Should we change the target blood pressure?

In this exclusive video, Harlan Krumholz, MD, SM, of Yale School of Medicine and Yale New Haven Hospital in Connecticut, reviews current research on intensive blood pressure (BP) treatments. It also offers advice on how to rethink patients’ BP goals.

Krumholz is the director of the Center for Outcomes Research and Evaluation; the Harold H. Hines Jr. Professor of Medicine; and professor at the Institute of Social and Political Studies, Investigative Medicine and Public Health.

Here is a transcript of his remarks:

I think many of us still have questions about what the right blood pressure goal should be.

Hello, I’m Harlan Krumholz from Yale School of Medicine and Yale School of Public Health. I’m a cardiologist and I’ve thought a lot about this blood pressure problem. Hey, I grew up in a time when we thought 140 out of 90 was the target. In fact, in the beginning, maybe when I was in medical school, people even said that normal blood pressure was 100+.

So the SHEP trial came out — it was actually before I was in medical school — but the SHEP trial came out and kind of disabused us of the idea that older people could tolerate higher blood pressure, and said we really needed to focus on controlling blood pressure on everyone. But that level of 140 out of 90 has always been our goal.

Then there were a series of studies that came out, the SPRINT trial in particular, that showed that more intensive blood pressure treatment was actually beneficial. The SPRINT trial, as a reminder, studied nearly 10,000 people and randomized people to intensive treatment. That is, looking at a target of around 120 versus a target of 140. They recruited people who didn’t have severe hypertension, but they wanted to see whether or not it would be better to push people lower , acknowledging that there might be adverse effects of treatment, but perhaps a net benefit of lower blood pressure. Admittedly, epidemiological studies had suggested so.

What they found was a marked benefit associated with this intensive treatment. There was a benefit in terms of mortality, there was a benefit in terms of cardiovascular events, there was a slight increase in drug-related complications, but the net benefits seemed very clear.

The net benefit was enough to cause the guidelines to lower the recommended level from 140 to 130. They didn’t go all the way to the SPRINT trial recommendation of 120 – and there are several reasons for that, possibly even The way blood pressure was measured in the SPRINT trial led them to be a little more conservative – but the target was pushed back further. But for the most part, I think those recommendations were ignored. Most people still think 140 over 80; fewer people focus on 130.

By the way, another study published later in China and looking at older patients also tested this hypothesis that lowering people would be better, and again showed that lower was better.

Now I want to move on to a study that just came out in JAMA Cardiology who looked at the question of: What about the long-term effects? What happened after the end of the trial? What happened when people returned to the wild and were no longer under trial protocol? In particular, the intensive group was no longer treated according to strict protocols to lower their blood pressure. In SPRINT, they were very successful in creating a blood pressure separation between the traditional group and the intensive group. Presumably after the trial, this pressure would no longer exist.

So what did they find? Well, with a median of about 9 years, with some people followed for up to 10 years, there was no significant difference between the two groups in terms of cardiovascular disease or all-cause mortality. That is, the benefits seemed to disappear at the end of the trial. So that’s actually very interesting and I think it also kind of validates the approach that they took in the trial: highly formal, trying to get people down in the intensive group. As soon as this trial was over, the benefits seemed to disappear.

So I think that again shows the importance for us to rethink those levels and go back to those studies that show us that lower levels seem to be better. If people are adequately monitored, we can also be alert to any adverse drug reactions, but it looks like we can help people reduce their risk. And then the importance of the long-term vigilance of this strategy. Again, this must be done in partnership with patients; they need to understand the risks and benefits of such an approach.

But when it comes to reducing major cardiovascular events and all-cause mortality, there’s a lot to be gained. But we have to think about how we’re going to implement systems in real-world practice that replicate what was achieved in the trial, and how we can sustain it long term, if we’re going to get the benefits that it was suggested to achieve in this essay, and if we want to achieve them in the long term.

I think the main message is to get us to think about ‘Less is more’; the trials that demonstrate and validate it, and then the importance of persistence and vigilance if we are to continue this benefit for our patients, in partnership with them, as we seek to reduce their risk and make the most of evidence that is out there in the literature.