Achieving optimal blood pressure goals -
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No potential conflicts of interest relevant to this article were reported. Centers for Disease Control and Prevention. Available from www. Accessed 23 December NCD Risk Factor Collaboration.
Worldwide trends in diabetes since a pooled analysis of population-based studies with 4. Search ADS. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes UKPDS 36 : prospective observational study.
Synergistic association of combined glycemic and blood pressure level with risk of complications in US veterans with diabetes. Diabetes, other risk factors, and yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial.
ACCORD Study Group. American Diabetes Association. Cardiovascular disease and risk management. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis.
SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program SHEP.
Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension: the Systolic Hypertension in Europe Syst-Eur trial investigators.
Department of Veterans Affairs. Department of Defense. Accessed 20 December Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment HOT randomised trial.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee; Cheng AY. Canadian Diabetes Association.
de Boer. Diabetes and hypertension: a position statement by the American Diabetes Association. Cicero AFG, et al. Nutrients and nutraceuticals for the management of high normal blood pressure: an evidence-based consensus document. Role of the renin-angiotensin-aldosterone system and its pharmacological inhibitors in cardiovascular diseases: complex and critical issues.
Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 14—effects of different classes of antihypertensive drugs in older and younger patients: overview and meta-analysis.
J Hypertens. New opportunities for monitoring blood pressure control and awareness in the population: insights from year editions of the World Hypertension Day. Wald DS, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11, participants from 42 trials.
Am J Med. SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. Tocci G, Volpe M. Modern clinical management of arterial hypertension: fixed or free combination therapies? Cuspidi C, et al. Incident left ventricular hypertrophy in masked hypertension.
Tadic M, Cuspidi C. Untreated masked hypertension and carotid atherosclerosis: a meta-analysis. Blood Press. Tientcheu D, et al. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension: analysis from the Dallas heart study.
J Am Coll Cardiol. Risk of new-onset metabolic syndrome associated with white-coat and masked hypertension: data from a general population. Mengden T, et al. Blood pressure control and cardiovascular risk in hypertensive patients with type 2 diabetes: The German T2Target registry.
CAS Google Scholar. Hänninen MR, et al. Metabolic risk factors and masked hypertension in the general population: the Finn-Home study. Franklin SS, et al. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Increased long-term risk of new-onset diabetes mellitus in white-coat and masked hypertension.
Presta V, et al. Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension. Satoh M, et al.
Long-term stroke risk due to partial white-coat or masked hypertension based on home and ambulatory blood pressure measurements: the Ohasama study.
Long-term risk of sustained hypertension in white-coat or masked hypertension. Personalised single-pill combination therapy in hypertensive patients: an update of a practical treatment platform. CAS PubMed PubMed Central Google Scholar. ARB-based single-pill platform to guide a practical therapeutic approach to hypertensive patients.
Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Giuliano Tocci. Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement. Supplementary file1 Flow-chart for the selection of the study population of hypertensive patients under monotherapies JPEG 64 kb.
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Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Abstract Introduction Despite hypertension guidelines suggest that the most effective treatment strategy to improve blood pressure BP target achievement is to implement the use of combination treatment, monotherapy is still widely used in the clinical practice of hypertension.
Aim To investigate BP control under monotherapy in the setting of real-life. Results From an overall sample of records we selected Conclusions Our data showed a persistent use of monotherapy in the clinical practice, though with unsatisfactory BP control, especially in light of the BP treatment targets suggested by the last hypertension guidelines.
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Table 1 General characteristics of the study population of hypertensive outpatients treated with monotherapies Full size table. Full size image. Table 2 Office, home and h blood pressure levels in hypertensive outpatients treated with monotherapies Full size table. References Dahlöf B, et al.
PubMed Google Scholar Julius S, et al. CAS PubMed Google Scholar ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group.
Google Scholar Jamerson K, et al. CAS PubMed Google Scholar Dahlöf B, et al. PubMed Google Scholar Chow CK, et al. CAS PubMed Google Scholar Borghi C, et al. PubMed Google Scholar Tocci G, et al.
CAS PubMed Google Scholar Geldsetzer P, et al. PubMed Google Scholar Volpe M, et al. CAS PubMed Google Scholar Williams B, et al. PubMed Google Scholar Volpe M, Gallo G, Tocci G.
PubMed Google Scholar Del Pinto R, et al. PubMed Google Scholar Torlasco C, et al. PubMed PubMed Central Google Scholar De Giusti M, et al. PubMed Google Scholar Rea F, et al. CAS PubMed Google Scholar Egan BM, et al.
CAS PubMed Google Scholar Tocci G, et al. Google Scholar Mancia G, et al. PubMed Google Scholar Expert Panel on Detection, and Treatment of High Blood Cholesterol in Adults.
However, a variety of factors are likely to affect the applicability of the findings:. Thus, the rate of adverse events reported in SPRINT may be an underestimate of the adverse event rate that would be seen with intensive treatment in routine practice.
In addition, patients in routine practice may require more antihypertensive medications than participants in SPRINT the average was three in the intensive treatment group, and approximately one-fourth required four or more medications , and this could increase risk of adverse events.
Routine systolic pressure measurements are usually higher than AOBPM measurements by 5 to 15 mmHg. By contrast, many older adults with isolated systolic hypertension have low diastolic pressure ie, less than 60 to 65 mmHg at baseline; such patients may not tolerate aggressive lowering of the systolic pressure, particularly those who have existing coronary artery disease.
See 'Older adults with isolated systolic hypertension' below. In addition, high-quality meta-analyses found that more versus less intensive blood pressure lowering produced cardiovascular benefits [ ]. As an example, a meta-analysis of 19 goal blood pressure trials excluding SPRINT combining 44, patients found a significant reduction in major cardiovascular events with more intensive as compared with less intensive blood pressure lowering RR 0.
Evidence supporting lower blood pressure targets also comes from trials that examined the effects of adding an antihypertensive medication, as compared with placebo, to the existing regimen among patients with known cardiovascular disease and a baseline blood pressure that was already below mmHg using routine measurements.
Most, but not all, of these placebo-controlled trials, including Heart Outcomes Prevention Evaluation HOPE , European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease EUROPA , Prevention of Events with Angiotensin-Converting Enzyme Inhibition PEACE , Comparison of Amlodipine vs Enalapril to Limit Occurrences of Thrombosis CAMELOT , Telmisartan Randomised Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease TRANSCEND , and Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research NAVIGATOR , evaluated the hypothesis that ACE inhibitors or ARBs might have a direct and clinically significant cardiovascular benefit [ ].
A meta-analysis focused on seven trials that limited therapy to either an ACE inhibitor or an ARB versus placebo in patients with ischemic heart disease and preserved left ventricular systolic function [ 47 ]. In six trials, ACE inhibitor therapy including HOPE, EUROPA, CAMELOT, and PEACE significantly reduced both total mortality RR 0.
A limitation to this meta-analysis is that it did not distinguish between angiotensin inhibition and lower attained blood pressure as the mechanism of benefit. This limitation was overcome in a meta-analysis that included 25 placebo-controlled trials with more than 63, patients in which active treatment consisted of all major classes of antihypertensive drugs, including ACE inhibitors, ARBs, beta blockers, calcium channel blockers, diuretics, or combination therapy [ 48 ].
Drug therapy significantly lowered the risks of all-cause mortality and myocardial infarction to the same degree as in the earlier meta-analysis pooled RR 0. Rather, the benefit seen likely resulted from blood pressure lowering. The absolute risk reductions in all-cause mortality and myocardial infarction were 14 and 13 per persons treated.
However, recommendations based upon SPRINT and these meta-analyses should not necessarily be applied to patients who are at low risk of having a cardiovascular event. See 'Goal blood pressure in lower-risk patients' below. Prior history of ischemic stroke or transient ischemic attack — Our suggestions for target blood pressure in patients with a prior ischemic stroke or TIA are, for the most part, the same as in other patients with established cardiovascular disease.
See 'Patients with established atherosclerotic cardiovascular disease' above. However, some patients, such as those with uncorrected hemodynamically significant large artery disease ie, of the internal carotid, middle cerebral, vertebral, or basilar artery , may develop ischemic symptoms with intensive blood pressure lowering and are at higher risk for recurrent stroke [ 50,51 ].
Such patients require a less intensive goal. See "Antihypertensive therapy for secondary stroke prevention" and "Evaluation of carotid artery stenosis". The main trial evaluating specific blood pressure targets in patients with ischemic stroke was the Secondary Prevention of Small Subcortical Strokes SPS3 study, which randomly assigned patients mean age of 63 years with recent two weeks to six months lacunar ie, small vessel infarction to a systolic blood pressure target of either to mmHg or less than mmHg using routine measurements [ 52 ].
Treatment was open label, using drugs from each of the major classes of antihypertensive medications prescribed by the local clinician.
At one year, the achieved average systolic blood pressures for the higher- and lower-target groups were and mmHg, respectively, and the mean 11 mmHg difference between the groups was sustained for the duration of the study. Patients assigned to the lower blood pressure target group were treated with a greater number of antihypertensive medications compared with the higher-target group mean of 2.
The following outcomes were reported [ 52 ]:. Similarly, the rate of a composite outcome of myocardial infarction or vascular death was nonsignificantly reduced in the lower blood pressure group.
Thus, the SPS3 results suggest, but do not establish, that a systolic blood pressure target of less than mmHg using routine blood pressure measurement is beneficial and safe for preventing recurrent stroke in patients with small vessel ischemic stroke.
In addition to SPS3, findings from other trials also suggest that lower blood pressures are associated with better outcomes. This trial had many limitations, including a nearly 30 percent drop-out rate, a low number of events, and a minimal systolic pressure separation between the intensive and standard groups versus mmHg, respectively.
However, the rate of major cardiovascular events was nonsignificantly lower in the intensive treatment group 1 versus 5 events. A variety of other trials in patients with prior stroke examined attained rather than target blood pressure; most, but not all, found that lower achieved blood pressure was associated with fewer recurrent strokes [ ].
However, such patients are often prescribed multiple specific drugs to improve survival and reduce morbidity, independent of the blood pressure, including inhibitors of the renin-angiotensin system eg, ACE inhibitors, ARBs, or ARB-neprilysin inhibitors , beta blockers, diuretics, and, in selected patients, mineralocorticoid receptor antagonists and sodium-glucose co-transporter 2 SGLT2 inhibitors.
Thus, achieved blood pressure in these patients is frequently much lower than these thresholds. Many experts consider the goal of therapy to be the lowest blood pressure that is not associated with symptoms of hypotension or evidence of hypoperfusion eg, worsening azotemia.
In some patients with severe HFrEF, this may be a systolic pressure as low as 90 mmHg. See "Overview of the management of heart failure with reduced ejection fraction in adults". These goals are consistent with those for other patients at high cardiovascular risk.
See "Treatment of hypertension in patients with heart failure". Although various trials and meta-analyses have found that more intensive blood pressure lowering can reduce incident heart failure and heart failure-associated morbidity, there are no specific trials of goal blood pressure in patients with HFrEF or HFpEF.
Thus, our suggested targets in patients with heart failure are based upon low-quality data. Routine and non-routine blood pressure measurements are defined and discussed above.
Support for our recommendations comes from randomized trials, meta-analyses, and large observational studies [ , ]. The largest trial ACCORD was a goal blood pressure trial that found no benefit from a more intensive goal systolic blood pressure less than mmHg as compared with a less intensive goal systolic blood pressure less than mmHg , other than a 53 percent relative reduction in the risk of stroke [ 59 ].
However, patients in ACCORD were also randomized to intensive or standard glycemic control ie, it was a two-by-two factorial trial , and, in the standard glycemic control arm, the more intensive blood pressure group had fewer major cardiovascular events [ 64 ].
The ACCORD trial enrolled patients with type 2 diabetes and either known cardiovascular disease or at least two additional cardiovascular risk factors; patients were randomly assigned to either systolic blood pressure goal less than mmHg or a systolic blood pressure goal less than mmHg.
Blood pressure was measured with AOBPM. Intensive therapy was also associated with a significantly higher rate of an increase in serum creatinine of more than 1. Although the results from ACCORD found that intensive blood pressure lowering did not reduce cardiovascular events apart from stroke, patients were also randomized to intensive or standard glycemic control ie, it was a two-by-two factorial trial , and the effect of intensive blood pressure lowering can also be analyzed according to glycemic control assignment [ 64 ].
This result is important because the intensive glycemic goal implemented in the ACCORD trial is not recommended owing to a higher rate of cardiovascular disease and mortality.
Nevertheless, the benefits of a lower goal blood pressure may not extend to patients with relatively strict glycemic control. In addition, three high-quality meta-analyses found that more intensive blood pressure lowering produced cardiovascular benefits in diabetic patients [ ].
As an example, a meta-analysis of 19 goal blood pressure trials including 5 trials of diabetic patients combining 44, patients found a significant reduction in major cardiovascular events with more intensive as compared with less intensive blood pressure lowering RR 0.
The effect of intensive blood pressure lowering in the 5 trials of diabetic patients was similar RR 0. All-cause mortality was also lower with intensive treatment, but this was not statistically significant RR 0. Based upon data from goal blood pressure trials in diabetic patients, plus indirect data from SPRINT which included patients who, like those with diabetes, have a high cardiovascular risk [ 19,20,65 ], we suggest a goal systolic pressure of to mmHg if non-routine readings are used or to mmHg if routine measurements are used to measure blood pressure, rather than a goal systolic pressure of less than mmHg.
These recommendations are broadly consistent with those made by the American Diabetes Association ADA , which suggests attaining a lower blood pressure to a systolic of to mmHg among those who can tolerate such therapy [ 66,67 ]. We recognize that, even with the large number of trials and total patients studied, the blood pressure goals we propose are based upon studies with a variety of patient populations, treatment goals, treatment approaches, and primary endpoints.
Overall, however, the available data suggest important benefits from intensive blood pressure control, despite the risk of modest adverse events. The different types of blood pressure measurement are defined and discussed above.
Our advice is broadly consistent with guidelines from the Kidney Disease: Improving Global Outcomes KDIGO clinical practice statement [ 68 ] and is mainly justified by a reduction in cardiovascular disease and mortality and not by a reduction in CKD progression [ 69 ].
The mortality benefit from aggressive blood pressure lowering is most evident when patients are followed over the long term ie, during post-trial follow-up , although an early reduction in mortality was noted in SPRINT. Several meta-analyses have synthesized the effects of more intensive blood pressure lowering on the progression of CKD, as well as the risk of death, in patients with and without proteinuria [ ].
Proteinuria was variably defined in these studies as a protein-to-creatinine ratio greater than 0. The following examples are illustrative:. More intensive blood pressure control was associated with reduced overall mortality HR 0. Aggressive blood pressure lowering also reduced the progression to ESKD HR 0.
However, long-term post-trial follow-up of those patients with proteinuria revealed a benefit on the incidence of ESKD RR 0. The investigators did not report the risk of death during long-term follow-up.
The three major goal blood pressure trials of patients with CKD AASK, MDRD, and SPRINT included different patient populations, examined different blood pressure targets, and used different methodology to measure blood pressure. Yet, as noted above, all three reached similar conclusions about the benefit of more intensive blood pressure lowering:.
At a mean follow-up of approximately four years, the mean rate of change in GFR and other kidney parameters was not different between the two groups. The use of ACE inhibitors and ARBs was similar in the two groups. As was observed during the trial phase, there was no difference between groups in the progression of kidney disease defined as doubling of the serum creatinine, a diagnosis of ESKD, or death.
However, among patients with a baseline urine protein-to-creatinine ratio of greater than 0. By contrast, patients with urine protein-to-creatinine ratios less than 0. After the cohort phase was complete, AASK participants were followed for a median of 14 years for the occurrence of ESKD and death using the United States Renal Data System USRDS , the national ESKD registry, and the Social Security Death Index [ 72 ].
The effect of more intensive blood pressure control on the incidence of ESKD depended upon whether or not patients had proteinuria HR 0. By contrast, the benefit of aggressive blood pressure lowering on mortality did not vary according to proteinuria HR 0.
A subsequent study reported the long-term outcomes of patients enrolled in the initial MDRD study [ 78 ]. After the study was completed in , all participants were passively followed until for the incidence of kidney failure defined as dialysis or kidney transplantation and all-cause mortality.
The mean difference in blood pressure between the two groups during the trial phase was 7. On intention-to-treat analysis, patients in the aggressive control group were significantly less likely to experience kidney failure adjusted HR 0. Kidney failure accounted for approximately 90 percent of events, and a hazard ratio was not provided for mortality alone.
The following findings were noted among SPRINT participants who had CKD at baseline:. However, the result in the CKD subgroup was nonsignificant, possibly because of reduced statistical power. By contrast, intensive blood pressure lowering increased the risk of a 30 percent or greater decline in eGFR.
However, this decline principally occurred in the first six months of the trial, suggesting an acute hemodynamic effect of a lower blood pressure; after six months, the rate of change in eGFR differed only slightly annual decline of 0. However, we suggest a less aggressive systolic goal blood pressure of to mmHg routine measurements or to mmHg nonroutine measurements in patients with a reduced life expectancy, for example, because of a high burden of comorbidity.
Individualization of blood pressure management is key in this population since the clinical benefit from intensive control is unlikely to be realized within one to two years [ 79 ]. Goal blood pressure in older adults, measured using AOBPM, was examined in SPRINT [ 80 ].
The benefit from more intensive blood pressure control was present in both fit and frail older adults. Serious adverse events were similar in the two treatment groups and did not depend upon frailty. A meta-analysis of 10, hypertensive adults aged 65 years or older combined these results from SPRINT with three other large randomized goal blood pressure trials [ 81 ].
After a mean follow-up of 3. Rates of stroke and myocardial infarction were also lower, but the results were not statistically significant. Achieved systolic blood pressure, assessed using standardized office-based blood pressures table 1 , was mmHg in the more intensive group and mmHg in the less intensive group.
All-cause mortality was not significantly different 1. Hypotension was more common in the intensive group, but other major adverse events eg, syncope, fracture, worsening kidney function were similar between the groups. The findings from this trial are generally consistent with those from SPRINT, although the population studied was lower risk at baseline and the difference in attained systolic blood pressure was smaller than in SPRINT.
Blood pressure goals may not be easy to achieve in older adults, particularly in those with a baseline systolic pressure greater than mmHg. If attaining goal blood pressure proves difficult or overly burdensome for such patients, the systolic pressure that is reached with two or three antihypertensive agents even if above target may be a reasonable interim goal.
Once maximally tolerated therapy is reached and blood pressure control remains suboptimal, then additional efforts to engage older adults in healthful lifestyle change can facilitate better blood pressure control.
One potential limitation to achieving goal blood pressure is that lowering the blood pressure may impair mental function, leading to manifestations such as confusion or sleepiness. In such patients, antihypertensive therapy should be reduced, and the systolic pressure should be allowed to rise to a level at which these symptoms resolve.
More gradual and much slower lowering of blood pressure may then be pursued in an attempt to attain goal blood pressure [ 28 ]. Older adults with isolated systolic hypertension — When treating older patients with isolated systolic hypertension, we and others suggest a minimum on-treatment diastolic pressure of 55 to 60 mmHg using office-based blood pressure [ ].
In such cases, the level of systolic blood pressure that is reached with two or three antihypertensive agents even if greater than the goal presented above may be a more reasonable goal [ 87 ]. See "Treatment of hypertension in older adults, particularly isolated systolic hypertension".
A concern when treating older adult patients with isolated systolic hypertension is that the low diastolic pressure after therapy may impair tissue perfusion particularly coronary perfusion and possibly increase cardiovascular risk ie, the "J-curve" figure 3 and figure 4 [ ].
Various long-term observational studies in patients with hypertension have reported a nadir of cardiovascular complications at a diastolic pressure of approximately 80 mmHg. Thus, the incidence of cardiovascular complications is higher among those who achieve diastolic pressures greater than 80 to 85 mmHg, as well as among those who achieve diastolic pressures less than 75 to 80 mmHg and particularly below 70 mmHg [ 85,91, ].
Although lower attained diastolic pressures are associated with worse outcomes both cardiovascular and noncardiovascular in these studies, this finding is present in both treated and untreated ie, placebo-treated patients and also in trial patients assigned to less intensive blood pressure goals figure 5 [ , ].
These findings suggest that the worse outcomes at lower diastolic pressures are probably explained by poor health in patients who have lower diastolic pressures and not necessarily an adverse effect of antihypertensive therapy. See "Treatment of hypertension in older adults, particularly isolated systolic hypertension", section on 'Importance of diastolic pressure'.
Nevertheless, there may be a threshold diastolic blood pressure below which adverse cardiovascular outcomes might increase in older adult patients, particularly in those with coronary heart disease because much of coronary filling occurs during diastole.
Non-routine and routine blood pressure measurements are defined and discussed above. The best data come from SPRINT, which are presented above in detail. One inclusion criteria in SPRINT was an estimated year risk for a future cardiovascular event of 15 percent or greater; patients met this criteria 76 percent of those enrolled [ 19,20 ].
In this subgroup, intensive blood pressure lowering significantly reduced the rate of myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death 4. A subsequent meta-analysis of 16 goal blood pressure trials and 52, patients examined the relative and absolute effects of more versus less intensive blood pressure lowering [ 17 ].
Nonsignificant relative risk reductions were found for heart failure 0. However, absolute benefits from blood pressure lowering were greater among patients who were higher risk at baseline. Thus, patients with an estimated year cardiovascular disease event risk of 10 percent or greater appear to derive an important benefit from intensive blood pressure lowering, although it is likely that the benefit is greater among those whose risk is 15 percent or greater compared with those whose risk is 10 to 14 percent.
However, there is some disagreement among UpToDate authors and editors. Some experts suggest that lower-risk patients with stage 2 hypertension ie, patients with systolic pressure at least mmHg or diastolic pressure at least 90 mmHg and who therefore qualify for antihypertensive therapy should have the same goal blood pressure as patients who are higher risk.
The absolute benefit of blood pressure lowering is much lower in lower-risk as compared with higher-risk patients, although relative risk reductions are similar. See 'Why baseline risk matters: Absolute versus relative risk' above. There are no goal blood pressure trials ie, trials that compared different target blood pressures in lower-risk patients.
However, there are three large trials of lower-risk patients that compared antihypertensive therapy with placebo. All three trials performed standardized office blood pressure measurement.
However, among the subgroup whose initial systolic pressure was in the highest tertile ie, greater than mmHg , antihypertensive therapy reduced the incidence of major cardiovascular events 5.
There was no effect on all-cause mortality. The treated groups had significantly lower rates of all cardiovascular events 6. The main endpoint was total mortality at five years, which was significantly lower with stepped care 5.
The magnitude of benefit was similar but not quite significant for the almost patients with an entry diastolic pressure of 90 to 94 mmHg absolute benefit 1. The average attained diastolic pressure was 85 to 90 mmHg in the stepped care; systolic pressures were not given.
Because blood pressure lowering in such patients is likely to reduce the relative risk, and because blood pressure is unlikely to spontaneously decrease, treatment to below this threshold may eventually produce an important absolute risk reduction over the long term. Thus, some expert contributors to UpToDate, as well as some guideline statements [ 1 ], suggest the more intensive blood pressure goal for lower-risk in addition to higher-risk patients.
See 'Overview of our approach' above. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Hypertension in adults". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.
You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest. There are two ways to performed high-quality, standardized office blood pressure measurement: automated oscillometric blood pressure monitoring AOBPM , which requires specialized equipment, and standardized office-based measurement using proper technique table 1 , which requires only ordinary equipment.
These two methods of measuring blood pressure in the office provide readings that approximate daytime ambulatory blood pressure using ambulatory blood pressure monitoring [ABPM] and self-measured home blood pressure monitoring.
These four methods, while superior, are uncommonly performed and therefore are referred to as "non-routine. Although it is an inferior method of measurement, it is faster and potentially less cumbersome and is the one primarily used in clinical practice and therefore is referred to as "routine" measurement.
See 'Prior history of ischemic stroke or transient ischemic attack' above. See 'Patients with heart failure' above. See 'Patients with diabetes mellitus' above. See 'Patients with chronic kidney disease' above. See 'Older adults' above. However, we suggest a less aggressive systolic goal blood pressure of to mmHg routine measurements or to mmHg non-routine measurements in patients with a high burden of comorbidity and also in older adults with postural hypotension.
See 'Patients with multiple cardiovascular risk factors' above. See 'Goal blood pressure in lower-risk patients' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in.
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Thank you for visiting nature. You are using a browser version with Efficient fat burning Achieving optimal blood pressure goals for CSS. To pressuree the best experience, we recommend you use presssure Achieving optimal blood pressure goals up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. Key Points Achieving optimal blood pressure goals Practice. Meta-analyses optimap Sweet and Tangy Fruits studies have shown that elevated blood pressure BP and hypertension are associated Endurance nutrition for GI distress prevention an goqls Sweet and Tangy Fruits optimzl cardiovascular ooptimal CVDend-stage renal opyimal, subclinical atherosclerosis, and all-cause mortality. A blooe risk of hypertension is influenced by various genetic and environmental factors, such as being overweight or obese; diet; alcohol intake; and fitness level. The American College of Cardiology ACC and American Heart Association AHA recently updated their guideline on the prevention, detection, evaluation, and treatment of high BP in adults. In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms? In adults with hypertension, does initiating treatment with antihypertensive pharmacologic monotherapy vs.
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