Many guidelines take four to six years to be understood and implemented, but at the Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine, Thiruvinvamalai S. Dharmarajan, MD, cautioned against any further delay in implementing the 2017 Hypertension Clinical Practice Guidelines, which recommend lower blood pressure targets and more intensive treatment for most patients with hypertension.
“For those with high [cardiovascular] risk, which is 90% of your patients, try to get them toward 130 [mm Hg]” using lifestyle and pharmacologic therapy, said Dr. Dharmarajan in his review of the guidelines. “In practice,” he added, “if you’ve got them to 140, you’re in great shape. And 130 will be wonderful if tolerated.”
The new guidelines — developed by the American Heart Association, the American College of Cardiology, and eight other professional societies, including the American Geriatrics Society — define hypertension as an average systolic blood pressure (SBP) of 130 mm Hg or greater and an average diastolic blood pressure (DBP) of 80 mm Hg or greater, with hypertension stage 1 being 130–139 SBP or 80–89 DBP and hypertension stage 2 being ≥140 SBP or ≥90 DBP. Normal blood pressure is now defined as <120 mm Hg systolic and <80 mm Hg diastolic.
The landmark Systolic Blood Pressure Intervention Trial (SPRINT), which helped inform the 2017 guidelines, showed that achieving a lower blood pressure goal of 120 mm Hg (instead of 140 mm Hg) reduced the rate of cardiovascular events by about 25% and overall mortality by 27% after four to five years of therapy (New Engl J Med 2015:373;2103–2116). Last year, investigators reported less cognitive impairment (“probable dementia”) in the intensively treated group at about seven years of follow-up observation (JAMA 2019;321:553–561).
Despite SPRINT’s limiting exclusion criteria — living in a nursing homes or having diabetes, dementia, or a low glomerular filtration rate — the opportunity to substantially reduce adverse cardiovascular outcomes and mortality is a real one, said Dr. Dharmarajan.