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2014 Eighth Joint National Committee panel recommendation for blood pressure targets revisited: results from the
Sripal Bangalore1, Yan Gong2, Rhonda M Cooper-DeHoff3
1Division of Cardiology, New York University School of Medicine, New York, New York.
Insights
For older adults with coronary artery disease (CAD), a systolic blood pressure (BP) target below 140 mm Hg is more beneficial than the 140-150 mm Hg target recommended by JNC-8. Lower BP targets reduce cardiovascular mortality and stroke risk.
Area of Science:
- Cardiology
- Hypertension Management
- Clinical Trials
Background:
- The 2014 JNC-8 guidelines suggest a systolic blood pressure (BP) target <150 mm Hg for individuals aged 60 and older.
- This differs from previous recommendations of <140 mm Hg.
- The optimal BP target for patients with coronary artery disease (CAD) remains unclear.
Purpose of the Study:
- To evaluate the optimal systolic blood pressure (BP) target in patients aged 60 years and older with CAD.
- To compare the outcomes associated with different BP treatment strategies.
Main Methods:
- Analysis of data from the INternational VErapamil SR Trandolapril STudy (INVEST) trial.
- Patients (≥60 years, CAD, baseline systolic BP >150 mm Hg) were categorized into three groups based on achieved on-treatment systolic BP: <140 mm Hg, 140 to <150 mm Hg, and ≥150 mm Hg.
- Primary outcome: composite of all-cause death, nonfatal myocardial infarction (MI), or nonfatal stroke. Secondary outcomes included mortality, MI, stroke, heart failure, and revascularization.
Main Results:
- Among 8,354 patients, 57% achieved <140 mm Hg, 21% achieved 140 to <150 mm Hg, and 22% achieved ≥150 mm Hg.
- The group achieving <140 mm Hg had significantly lower rates of the primary outcome, all-cause mortality, cardiovascular mortality, MI, and stroke compared to the other two groups.
- Adjusted analyses showed increased risks for cardiovascular mortality and stroke in the 140 to <150 mm Hg group, and for multiple outcomes in the ≥150 mm Hg group, compared to the <140 mm Hg group.
Conclusions:
- In hypertensive patients aged 60 and older with CAD, a systolic BP target of <140 mm Hg is associated with better outcomes than a target of 140 to <150 mm Hg.
- The JNC-8 recommended target of 140 to <150 mm Hg offers less benefit than the previously recommended <140 mm Hg target for this population.
- These findings suggest a need to reconsider BP management guidelines for older adults with CAD.
Background:
The 2014 Eighth Joint National Committee panel recommendations for management of high blood pressure (BP) recommend a systolic BP threshold for initiation of drug therapy and a therapeutic target of <150 mm Hg in those ≥60 years of age, a departure from prior recommendations of <140 mm Hg. However, it is not known whether this is an optimal choice, especially for the large population with coronary artery disease (CAD).
Objectives:
This study sought to evaluate optimal BP in patients ≥60 years of age.
Methods:
Patients 60 years of age or older with CAD and baseline systolic BP >150 mm Hg randomized to a treatment strategy on the basis of either atenolol/hydrochlorothiazide or verapamil-SR (sustained release)/trandolapril in INVEST (INternational VErapamil SR Trandolapril STudy) were categorized into 3 groups on the basis of achieved on-treatment systolic BP: group 1, <140 mm Hg; group 2, 140 to <150 mm Hg; and group 3, ≥150 mm Hg. Primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction (MI), or nonfatal stroke. Secondary outcomes were all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, nonfatal stroke, heart failure, or revascularization, tabulated separately. Outcomes for each group were compared in unadjusted and multiple propensity score-adjusted models.
Results:
Among 8,354 patients included in this analysis with an accumulated 22,308 patient-years of follow-up, 4,787 (57%) achieved systolic BP of <140 mm Hg (group 1), 1,747 (21%) achieved systolic BP of 140 to <150 mm Hg (group 2), and 1,820 (22%) achieved systolic BP of ≥150 mm Hg (group 3). In unadjusted models, group 1 had the lowest rates of the primary outcome (9.36% vs. 12.71% vs. 21.32%; p < 0.0001), all-cause mortality (7.92% vs. 10.07% vs. 16.81%; p < 0.0001), cardiovascular mortality (3.26% vs. 4.58% vs. 7.80%; p < 0.0001), MI (1.07% vs. 1.03% vs. 2.91%; p < 0.0001), total stroke (1.19% vs. 2.63% vs. 3.85%; p <0.0001), and nonfatal stroke (0.86% vs 1.89% vs 2.86%; p<0.0001) compared with groups 2 and 3, respectively. In multiple propensity score-adjusted models, compared with the reference group of <140 mm Hg (group 1), the risk of cardiovascular mortality (adjusted hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.01 to 1.77; p = 0.04), total stroke (adjusted HR: 1.89; 95% CI: 1.26 to 2.82; p = 0.002) and nonfatal stroke (adjusted HR: 1.70; 95% CI: 1.06 to 2.72; p = 0.03) was increased in the group with BP of 140 to <150 mm Hg, whereas the risk of primary outcome, all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, and nonfatal stroke was increased in the group with BP ≥150 mm Hg.
Conclusions:
In hypertensive patients with CAD who are ≥60 years of age, achieving a BP target of 140 to <150 mm Hg as recommended by the JNC-8 panel was associated with less benefit than the previously recommended target of <140 mm Hg.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.