Recent guidelines have lowered the target threshold for defining blood pressure (BP) control during antihypertensive therapy (Table 4.1) [178, 185, 253, 254]. The most striking evidence directly influencing the 2017 AHA/ACC guidelines [178] was the results of the Systolic Blood Pressure Intervention Trial (SPRINT) study [179] . This trial clearly demonstrated the benefit of strict BP lowering to a systolic blood pressure (SBP) target of <120 mmHg in patients with hypertension. Rates of cardiovascular events and all‐cause mortality were lower in the strict BP control group than in the standard BP control group (SBP <140 mmHg). After this intervention study, the direction of BP management has been clearly set. However, the evidence from SPRINT was obtained using automated office blood pressure (AOBP) measurement, which is different from routine office BP measurement. AOBP measurement uses an automated device and readings are taken after the patient has been in a sitting position for five minutes since the physician left the office. AOBP values for SBP are about 10–15 mmHg lower than those measured using standard office BP techniques. The AOBP approach may exclude the physician‐associated white‐coat effect but cannot eliminate the pressor effect of the office setting [180] . A recent meta‐analysis of data from 123 studies (n = 613 815) showed that, regardless of baseline BP, a 10‐mmHg reduction in SBP significantly reduced the rate of major cardiovascular events by 20%, coronary heart disease by 17%, stroke by 27%, heart failure by 28%, and all‐cause of death by 13%. No effect of BP reduction on chronic kidney disease was identified (Figure 4.1) [285] Table 4.1 Guideline‐defined office blood pressure targets (mmHg) during antihypertensive therapy. Source: Kario K. Essential Manual of 24 Hour Blood Pressure Management: From Morning to Nocturnal Hypertension, Second Edition. Wiley, 2022. ACC, American College of Cardiology; AHA, American Heart Association; CAD, coronary artery disease; CKD, chronic kidney disease; ESC, European Society of Cardiology; ESH, European Society of Hypertension; HOPE, Hypertension Cardiovascular Outcome Prevention and Evidence. Hypertension develops with advancing age. The predominant pressor effect in younger patients is neurohumoral activation, which is related to obesity and metabolic factors. Structural changes in both small and large arteries and increased salt sensitivity due to reduced renal function are important causes of hypertension as age increases (Figure 4.2) [286] . Lifestyle modification is the first intervention to target BP and should be stated when office BP is 130/80 mmHg or morning home BP is 125/75 mmHg. Strict BP control at the early stage of hypertension is important to prevent cardiovascular remodeling, organ damage, and cardiovascular events. For example, in patients with atrial fibrillation (AF), history of hypertension, and poor BP control before the onset of AF are significant risk factors for the occurrence of cardiovascular events after AF onset (Figure 4.3) [287] . The benefits of BP‐lowering interventions are due to the reductions in BP per se, regardless of the methods used to achieve these decreases (including lifestyle modifications, drug therapy, and device usage) (Figure 4.4). This means that real‐world management of hypertension can include options based on patient preference to maximize the BP reductions achieved during therapy. Figure 4.1 Percentage risk reduction associated with a 10‐mmHg decrease in SBP during antihypertensive therapy (meta‐analysis data; n = 613 815). CHD, coronary heart disease; CVD, cardiovascular disease; HF, heart failure. Source: Created based on data from Ettehad et al. Lancet. 2016; 387(10022): 957–967 [285] . Figure 4.2 Age‐related timing of antihypertensive therapy initiation (renin‐angiotensin system inhibitors for younger patients with metabolic hypertension, and calcium channel blockers for older patients with structural and salt‐sensitive hypertension. eGFR, estimated glomerular filtration rate; HIT, health information technology; HTN, hypertension; OSA, obstructive sleep apnea. Source: Republished with permission of Bentham Science Publishers, from Kario. Curr Hypertens Review. 2018; 14: 2–5 [286] ; permission conveyed through Copyright Clearance Center, Inc. Salt restriction is the most effective nonpharmacological treatment approach in patients with hypertension, regardless of antihypertensive medication. A recent intervention study demonstrated that strict salt restriction prescribed by a nutritionist lowered salt intake (estimated by 24‐hour urine sodium excretion) by an additional 1.8 g/day in medicated patients with hypertension compared with conventional education by physicians. As a result, morning home SBP was marginally reduced (Figure 4.5), and ambulatory BP was significantly reduced throughout the 24‐hour period, including daytime, nighttime, and morning (Figure 4.6) [288] . The between‐group difference in the reduction of 24‐hour SBP was at least 7 mmHg.
CHAPTER 4
BP targets, when to initiate antihypertensive therapy, and nonpharmacological treatment
Clinical implications of antihypertensive treatment
SPRINT and automated office BP
Meta‐analysis of antihypertensive trials
JSH 2019 [253]
ACC/AHA 2017 [178]
ESC/ESH 2018 [254]
HOPE Asia Network [185]
Young, middle‐aged, and early elderly patients
<130/80 (age <75 years)
<130/80 (age <65 years)
SBP <130, ≥120 (age <65 years)
<130/80
Late‐elderly patients
<140/90 (age ≥75 years)
<130/80 (age ≥65 years)
SBP <140, ≥130 (age ≥65 years)
<140/90 (elderly)
Patients with diabetes
<130/80
<130/80
SBP <130, ≥120
<130/80
Patients with CAD
<130/80
<130/80
SBP <130, ≥120
—
Patients with cerebrovascular disease
<130/80
<130/80
SBP <130, ≥120
—
Patients with CKD
<130/80 (proteinuria positive)
<140/90 (proteinuria negative)
130/80 (with/without proteinuria)
SBP <140, ≥130
—
When to initiate antihypertensive therapy
Patient preference
Sodium intake
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
