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Hypertension: delicate choice of blood pressure target

Aiming for blood pressure of 120 mm Hg presents advantages and risks, and should be discussed with some patients.

The cardiovascular risk increases continually as blood pressure rises over 115/75 mm Hg. The aim of blood pressure-lowering treatment is to reduce mortality and cardiovascular events. In healthy patients with no cardiovascular or renal damage and who are not diabetic, and apart from during pregnancy, some blood pressure-lowering drugs are justified when blood pressure is higher than 160/90 mm Hg. Then the first-choice treatment is a thiazidic diuretic or an angiotensin-converting enzyme inhibitor.

In the randomised, publicly funded Sprint trial, carried out in the USA, which received a great deal of media attention, lowering the target for systolic blood pressure to around 120 mm Hg reduced overall mortality compared with a target of around 135 mm Hg: 3.3% deaths in around 3 years in the "intensive" treatment group versus 4.5% in the "standard" treatment group.

But this was a non-blinded trial, and the patients involved were not representative of the majority of patients with hypertension: those in the trial were at high risk of a cardiovascular event, often overweight but not diabetic, with no history of stroke or symptomatic cardiac failure. The mortality benefit was obtained at the price of twice the number of severe adverse effects, especially renal. As a result of trying to achieve a systolic pressure of around 120 mm Hg, most patients had to take at least three antihypertensive drugs, thus increasing the risks of adverse effects and drug interactions. These results still remain to be confirmed by further trials.

It is advisable not to retain this target blood pressure of 120 mm Hg other than for patients who have been informed of the harm-benefit balance, and this target should be abandoned when the build-up of drugs exposes the patient to too many adverse effects.

©Prescrire 1 January 2017

"Hypertension. Targeting 120 mmHg: survival benefit after 3 years, but high renal risk" Prescrire Int 2017; 26 (178): 21-22. (Pdf, subscribers only).
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