Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View

Abstract

Special Articles1 April 2014Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority ViewFREEJackson T. Wright Jr., MD, PhD, Lawrence J. Fine, MD, DrPH, Daniel T. Lackland, DrPH, Gbenga Ogedegbe, MD, MPH, MS, and Cheryl R. Dennison Himmelfarb, PhD, RN, ANPJackson T. Wright Jr., MD, PhDFrom Case Western Reserve University, Cleveland, Ohio; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Medical University of South Carolina, Charleston, South Carolina; New York University School of Medicine, New York, New York; and Johns Hopkins University School of Nursing, Baltimore, Maryland.Search for more papers by this author, Lawrence J. Fine, MD, DrPHFrom Case Western Reserve University, Cleveland, Ohio; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Medical University of South Carolina, Charleston, South Carolina; New York University School of Medicine, New York, New York; and Johns Hopkins University School of Nursing, Baltimore, Maryland.Search for more papers by this author, Daniel T. Lackland, DrPHFrom Case Western Reserve University, Cleveland, Ohio; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Medical University of South Carolina, Charleston, South Carolina; New York University School of Medicine, New York, New York; and Johns Hopkins University School of Nursing, Baltimore, Maryland.Search for more papers by this author, Gbenga Ogedegbe, MD, MPH, MSFrom Case Western Reserve University, Cleveland, Ohio; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Medical University of South Carolina, Charleston, South Carolina; New York University School of Medicine, New York, New York; and Johns Hopkins University School of Nursing, Baltimore, Maryland.Search for more papers by this author, and Cheryl R. Dennison Himmelfarb, PhD, RN, ANPFrom Case Western Reserve University, Cleveland, Ohio; National Heart, Lung, and Blood Institute, Bethesda, Maryland; Medical University of South Carolina, Charleston, South Carolina; New York University School of Medicine, New York, New York; and Johns Hopkins University School of Nursing, Baltimore, Maryland.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M13-2981 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The “2014 Evidence-Based Guideline for the Management of High Blood Pressure In Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)” recommends several major changes from the JNC 7 report (1, 2). The 2014 guideline is based on a systematic review of randomized, controlled trials (RCTs) by a multidisciplinary panel using a process informed by Institute of Medicine recommendations for guideline development (3). Although there was almost unanimous agreement on nearly all recommendations, a minority of the panel (the authors of this commentary) disagreed with the recommendation to increase the target systolic blood pressure (SBP) from 140 to 150 mm Hg in persons aged 60 years or older without diabetes mellitus (DM) or chronic kidney disease (CKD). This target guides both the initiation of therapy and treatment goals. Although this issue has major clinical and public health implications, the guideline only briefly summarized the concerns underlying the minority opinion to maintain the target of less than 140 mm Hg. The Institute of Medicine recommendation for guideline development encourages guidelines to provide “a description and explanation of any differences of opinion regarding the recommendation” (3). This summarizes the evidence and rationale underlying the minority opinion to maintain the SBP target of 140 mm Hg or lower in persons aged 60 years or older until there is greater certainty of the risks and benefits of a higher target.First, increasing the target will probably reduce the intensity of antihypertensive treatment in a large population at high risk for cardiovascular disease (CVD) (Table 1). The higher SBP goal would apply to some of the groups at highest cardiovascular risk, such as African Americans, hypertensive patients with multiple CVD risk factors other than DM or CKD, and those with clinical CVD. Second, the evidence supporting increasing the SBP target from 140 to 150 mm Hg in persons aged 60 years or older was insufficient and inconsistent with the evidence supporting the panel's recommendations for an SBP target of less than 140 mm Hg in persons younger than 60 years and those aged 60 years or older with DM or CKD. Third, the higher SBP goal in individuals aged 60 years or older may reverse the decades-long decline in CVD, especially stroke mortality (4). In the absence of definitive evidence defining the optimum SBP target, observational studies and RCT data that the panel did not systematically review more strongly support the SBP goal of less