BUSM’s Chobanian in NEJM: Time to Reassess Blood-Pressure Goals

High blood pressure or hypertension is a major health problem that affects more than 70 million people in the U.S., and over one billion worldwide. Despite being a critically important risk factor for heart and kidney disease, defining the “optimal” blood pressure has been a challenge.

In a perspective in this week’s New England Journal of Medicine, Aram Chobanian, MD, President Emeritus, Boston University, comments that recent findings from the SPRINT (Systolic Blood Pressure Intervention Trial) trial suggest that lowering systolic blood pressure to less than 120 was associated with a much lower incidence of cardiovascular disease as well as a reduction in overall mortality by 25 percent, compared to a target of 140.  While the results are not applicable to every patient, Chobanian states that the results suggest that the target blood pressure in treating hypertension should be lower than is currently recommended. Based on the evidence, he would now advocate a target level of 130 for most non-diabetic individuals above age 50 who have hypertension.

The trial, which began in 2009, included more than 9,300 participants age 50 and older (the study did not include patients with diabetes, prior stroke, or polycystic kidney disease).  SPRINT investigators divided the participants in two groups and assigned one group to achieve a target of less than 140mmHg and the other to a target of less than 120 mmHg. The 140mmHg group generally needed two blood pressure medications while the 120mmHg group needed three.  The results of the study reported a more aggressive stance on blood pressure to 120mmHg reduced the risk of death by almost 25 percent and reduced the rate of overall cardiovascular problems by almost one third.

Chobanian  acknowledges that this aggressive management of hypertension will “create major challenges for physicians.” He explains that this target will “probably require more careful titration of medications, greater use of combination drug preparations, more monitoring for adverse effects and more frequent patient visits than currently occur.” While the reports are exciting, Chobanian remains concerned by the “continued increase in prevalence of hypertension… and is disappointed by weak national efforts to prevent hypertension.” He believes that this issue “will require a broad-based national effort with strong political support.”

Submitted by Hannah K. Steere, MD