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Is 140/90 Low Enough for Nondiabetic Hypertensive Patients?

A study supports a more aggressive approach to BP reduction.

Most guidelines recommend 140/90 mm Hg as the blood pressure target for nondiabetic patients with hypertension. But, no randomized trials of systolic blood pressure (SBP) reduction to 130 mm Hg have been conducted in this population.

With funding from three pharmaceutical manufacturers, Italian investigators randomized 1111 nondiabetic hypertensive patients to tight (<130 mm Hg) or usual (<140 mm Hg) SBP control. Patients (age, 55) had baseline SBP levels of 150 mm Hg after receiving antihypertensive therapy for at least 12 weeks and had at least one other cardiovascular risk factor. Treatment was open-label and individualized and included previous (background) therapy plus various combinations of furosemide, hydrochlorothiazide, ramipril, telmisartan (Micardis), amlodipine, bisoprolol, and clonidine.

Clinicians measured blood pressure by auscultation every 4 months and reported the average of three seated readings after 10 minutes of rest. In the tight-control group, one SBP reading >130 mm Hg at any visit led to intensification of treatment; in the usual-control group, one SBP reading <130 at any visit led to down-titration of treatment. The primary endpoint was prevalence of electrocardiographic left ventricular hypertrophy (LVH), as assessed by blinded readers.

At baseline, blood pressures were equal in the two groups, and roughly 20% of patients in each group had LVH. After 2 years, 27% and 72% of patients in the usual- and tight-control groups, respectively, had SBP <130 mm Hg, and significantly more patients in the usual-control group than in the tight-control group (17.0% vs. 11.4%) had LVH. In addition, significantly more patients in the usual-control group than in the tight-control group (9.4% vs. 4.8%) reached a secondary composite endpoint that consisted of any of nine adverse clinical cardiovascular outcomes.

Comment: Left ventricular hypertrophy is not a clinical endpoint, but it is a powerful predictor of cardiovascular events. According to this study, an aggressive approach to blood pressure reduction can be well-tolerated and might lower the incidence of adverse cardiovascular outcomes. Larger and longer studies will be required to measure individual cardiovascular outcomes directly and to test this hypothesis in patients at lower baseline risk.

— Bruce Soloway, MD

Published in Journal Watch General Medicine August 27, 2009

Citation(s):

Verdecchia P et al. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): An open-label randomised trial. Lancet 2009 Aug 15; 374:525.

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• How low did diastolic pressures go?
  Kevin Parent, 3 Sep 2009 11:16 AM EST
  There is expressed concern in the literature that diastolic pressures less than 60mmHg may increase the risk of myocardial infarction.... [more]