Becoming Enlightened About More Stringent Blood Pressure Goals: Sapere Aude!

The skeptical cardiologist and many of his patients with hypertension have a decision to make: what should our BP goal be?

Given that we have data now on over 1 million patients one might think that the answer would be clear and that there would be a consensus amongst all the experts.

Messerli and Bangalore, writing in a recent special hypertension issue of JACC, however, clearly articulate the “blood pressure landscape schism” that currently exists.

This figure from their paper (subtitled “Schism Among Guidelines, Confusion Among Physicians, and Anxiety Among Patients”) shows the marked difference in BP goal and treatment recommendations for the same patient in recent American and  European Cardiology and American Family Practice Guidelines.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines—which aide approximately 25,000 cardiologists in the United States—indicate that her BP should be <130/80 mm Hg (1). The 2018 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines—which aide approximately 75,000 physicians—indicate that her BP should be <140/90 mm Hg (2). The 2017 American College of Physicians (ACP)/American Association of Family Physicians (AAFP) guidelines—which aide approximately 250,000 family practitioners and internists in the United States—indicate that her BP should be <150/90 mm Hg

 

 

 

 

 

 

 

 

 

 

 

Messerli and Bangalore use a second figure to graphically illustrate the potential consequences of the differing guidelines.

Stroke Mortality for Upper Limit of On-Treatment Systolic Target BP as per Various Guidelines Absolute risk of stroke mortality is 5% for the suggested on-treatment target BP of the ACC/AHA guidelines, 8% for target BP of the ESH/ESC guidelines, and 14% for target BP of the ACP/AAFP guidelines. Abbreviations as in

Cardiovascular death rates thus may vary three-fold depending on what BP goal we choose.

This marked variation in treatment recommendation highlights that they

are not only an evaluation and interpretation of evidence in question, but also a judgment weighted by personal, regulatory, and organizational preferences that can vary from physician to physician within a country and across geographical regions.

Physicians and patients (hopefully through shared decision making) are going to have to do some thinking on their own.

Messerli and Bangalore quote Immanuel Kant in this regard:

Enlightenment is man’s emergence from his self-imposed nonage. Nonage is the inability to use one’s own understanding without another’s guidance. This nonage is self-imposed if its cause lies not in lack of understanding but in indecision and lack of courage to use one’s own mind without another’s guidance. Dare to know! (Sapere aude.) “Have the courage to use your own understanding,” is therefore the motto of the enlightenment.

As a 64 year old who has emerged from his nonage with hypertension, I have carefully examined the latest American hypertension guidelines especially in light of the SPRINT study and elected to add a third anti-hypertensive agent to get my average BP below 130/80. It’s worked for me with minimal  side effects but I carefully monitor my BP.

If I notice any symptoms (light-headed, fatigued) suggesting hypotension associated with systolic BP <120 mm Hg I tweak my medical regimen to allow a higher BP.

Like all of my patients I would prefer to be on less medications, not more but when it comes to enlightenment about the effects of hypertension, it is now clear that lower is better for most of us in our sixties down to at least 130/80*.

Sapere Audaciously Yours,

-ACP

*N.B. In the SPRINT study the BP was obtained using an automatic BP cuff after 5 minutes of rest with the patient unobserved and averaging 3 recordings one minute apart.

This “research grade BP” averages about 12 mm Hg less than a routine single clinic obtained BP (see here.)

The BP Schism

9 thoughts on “Becoming Enlightened About More Stringent Blood Pressure Goals: Sapere Aude!”

  1. OMG: I could have written that phrase (“…As a 64 year old who has emerged from his nonage with hypertension…”), just changing the age to 63. I do exactly the same! I only take atenolol 25 mg/day, but will jump or halve a dose if I get too dizzy… On those days “without”, my aerobic training performance is better… give and take, i guess… Thank you for this very enlightening commentary.

  2. HBP at the 95% level is a “made to happen” condition that comes from what people do/don;t do what they should to cure it–at the 95% level. In that that same sense it can be made to “unhapppen” by changing what that person does. If guidance is needed, help is available.HRS, MD, FACC

  3. The best amount of medication to take continues to be an issue for me. I take 3 (resting) BP readings with an Omron twice daily. If my average systolic is under 120 bpm I don’t take anything. If it’s over 120 I take 2.5mg of amlodipine in the morning. Looking at data over the past month, with a number of missed days due to travel, the highest average was about 160. Almost all of my high readings are in the evening. Several times per month I will get BP systolic about 100, usually in the morning. I think the high variability is largely due to sodium intake, that largely due to my eating roughly one restaurant meal/day, usually midday (I live in a CCRC). I’m 76 and moderately active walking about 100 miles/month and climbing about 200 flights of stairs/month. One big issue with the elderly is lightheadedness due to a combination of meds, diet, and activity which can be the cause of falls resulting in serious injury. I haven’t fallen in years but am witness to many in my community who have suffered broken bones and worse. I do sometimes experience mild lightheadedness on walks but have not felt as if I might fall.

    1. As suggested above do what you should so u do not have HBP/need to take no meds/not experience hypotension from what would be unnecessary meds.

    2. In the SPRINT trial the group with SBP goal of 120 had more episodes of hypotension but no more frequent falls compared to the group with goal of 140. I routinely assess my hypertensive patients for any symptoms suggesting too low a BP and back off on BP meds if they occur and systolic BP <140. The European guidelines suggested loosening SBP to 150 for those over 75 but American guidelines did not.

      1. I am the Rodney Dangerfield on this site: I talk about cure/no needs for meds/no side effects from meds, & no one seems interested. “I don’t get no respect”

        1. “Made to happen”; “unhappen” is not enough information. Why not make that specific guidance available right here?

  4. I cheat… use fasting (and diet) to regulate weight which drives the rest of my markers.
    As a final tweak, I’ll base the BP meds dose on the amount and annoyance of “Karvezide Cough” and “Candesartan Croaking”
    My personal opinion is the race to the minimums is driven more by ve$ted interests than by science… or the patient’s overall benefit.

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