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Published on: June 16, 2014
Intensive blood pressure lowering in chronic kidney disease: the time has come
Marcel Ruzicka1, Swapnil Hiremath
1Division of Nephrology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.
Insights
Intensive blood pressure lowering benefits patients with chronic kidney disease (CKD), reducing heart failure, mortality, and stroke. Careful patient selection and modern BP measurement methods are crucial for optimal outcomes.
Area of Science:
- Cardiology
- Nephrology
- Hypertension Research
Background:
- The Systolic Blood Pressure Intervention Trial (SPRINT) has prompted re-evaluation of intensive blood pressure (BP) management.
- Current national hypertension guidelines show limited changes, with ongoing debate on patient applicability for intensive BP lowering.
Purpose of the Study:
- To review the evidence and implications of intensive BP lowering, particularly in patients with chronic kidney disease (CKD).
- To explore the benefits of lower BP targets on cardiovascular outcomes and stroke.
- To address the heterogeneity in guidelines regarding intensive BP management.
Main Methods:
- Analysis of findings from recent hypertension trials, including SPRINT.
- Evaluation of evidence linking lower BP targets to specific cardiovascular benefits in CKD populations.
- Consideration of BP measurement techniques and their impact on trial interpretation.
Main Results:
- Robust evidence supports lower BP targets in non-diabetic CKD patients, leading to reduced heart failure and mortality.
- Similar benefits observed in diabetic CKD patients, with reduced stroke incidence.
- Differences in BP measurement methods across trials necessitate careful interpretation of results.
Conclusions:
- Intensive BP lowering in CKD patients yields significant cardiovascular benefits, contrary to the general 'less is more' therapeutic principle.
- Optimal application requires newer oscillometric BP devices, adequate patient rest periods, and careful patient selection.
- Further research and guideline refinement are needed to standardize intensive BP management strategies.
Purpose Of Review:
Release of the findings from the Systolic Blood Pressure Intervention Trial has resulted in a renewed examination of intensive blood pressure (BP) lowering. Only a few national hypertension guidelines (Canada and Australia) have changed recommendations, but considerable heterogeneity still exists with respect to the patient population to whom intensive BP lowering may apply.
Recent Findings:
There is fairly robust evidence that lower BP targets in nondiabetic chronic kidney disease (CKD) results in a decrease in heart failure and mortality. Similar data exist in patients with diabetes and CKD for reduction in stroke. Consideration of the differences in BP measurement methods in newer trials helps us understand and interpret the findings.
Summary:
Though often times less is more with respect to therapeutic measures, in patients with CKD, more BP lowering will result in more cardiovascular benefit. Use of newer oscillometric BP devices with adequate resting prior and judicious patient selection are the key aspects to be considered when applying intensive BP lowering.
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