What is the evidence for blood pressure (BP) targets below 140/90 mm Hg?
Evidence supports systolic BP (SBP) targets below 140 mm Hg for hypertension and subgroups with diabetes (DM) or renal disease. In patients with a 10-year risk of cardiovascular disease (CVD) of 20% or more, targets of about 120 mm Hg (or 125 to 130 mm Hg in office) can be considered. This does not include those with DM or previous stroke, and standing BP should be monitored.
Statistically significant outcomes include the following:
The SPRINT RCT1 (N = 9361, 10-year CVD risk of about 20%) compared target SBP below 140 versus below 120 mm Hg over 3.3 years; groups attained BPs of 136/76 and 121/68 mm Hg, respectively. The relative risk reduction (RRR) was 25% for CVD (NNT = 61) and 27% for mortality (NNT = 90). Similar benefits were seen for the elderly and other groups. Exclusion criteria were DM, stroke, ejection fraction below 35%, glomerular filtration rate below 20 mL/min, or standing SBP below 110 mm Hg.
-In 7 to 19 RCTs (22 089 to 44 898 patients) over 3.8 years, BP was 4/3 to 7/5 mm Hg lower for intensive versus standard targets. Smaller BP reductions did not reduce CVD.2 Larger reductions gave about a 14% RRR for CVD.3 If CVD risk was about 20% over 10 years, the NNT was 36. Some trials did not have intensive target groups.3
For DM, in 2 SRs of 5 RCTs (N = 7314) over 4.5 years,4,5 the SBP RCTs reported BPs of 119/64 versus 135/83 mm Hg and the diastolic BP RCTs reported BPs of 128/76 versus 133/70 mm Hg for intensive versus standard targets.
-There were no differences in mortality or CVD.
-There was an 18% RRR for renal dysfunction (NNT = 247).9
An SBP target of about 120 mm Hg is suggested in SPRINT for those with a 20% or greater 10-year CVD risk. Estimating risk is essential for lipid level and CVD screening.12 However, SPRINT used automated office BP monitors that read 5 to 10 mm Hg below actual BP. Office targets of 125 to 130 mm Hg might be appropriate. Lower targets do not apply to patients with DM. In SPRINT, diastolic BP was kept above 65 mm Hg and standing SBP was 110 mm Hg or greater.
Tools for Practice
Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to www.acfp.ca.. Archived articles are available on the ACFP website:
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.
- Copyright© the College of Family Physicians of Canada