Cardiovascular outcomes are significantly improved by intensive blood pressure (BP) lowering efforts in adults with hypertension, according to a recent systematic review — an opinion that is reflected in the updated 2020 recommendations from the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DOD).
“Overall, current clinical literature supports intensive BP lowering in patients with hypertension for improving cardiovascular outcomes. In most subpopulations, intensive lowering was favored over less-intensive lowering, but the data were less clear for patients with diabetes mellitus or cardiovascular disease,” concluded Kristen E. D’Anci, PhD, ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, PA, and fellow researchers in the Annals of Internal Medicine.
D’Anci and colleagues sought to assess the effects of intensive, targeted lowering of both systolic (SBP) and diastolic BP (DBP) with pharmacologic treatment on cardiovascular outcomes in hypertensive adults. Their systematic review was prepared for the 2020 VA/DOD Guidelines, which were updated in Jan. 2020.
For this review, D’Anci and colleagues used multiple databases, including MEDLINE and EMBASE, to identify eight systematic reviews of randomized controlled trials that assessed either a standardized SBP target of −10 mmHg or BP lowering below a target threshold.
They found high-strength evidence of the benefits of a 10-mmHg reduction in SBP for cardiovascular outcomes in the general population, as well as in patients with chronic kidney disease and those with heart failure. A 10-mmHg reduction in SBP reduced major CVD events compared with control (RR: 0.80; 95% CI: 0.77-0.83), and this was based on 55 randomized controlled trials and included 265,578 patients (adjusted relative risk [ARR]: 22 per 1,000 patients; 95% CI: 19-25 per 1,000 patients; number needed to treat [NNT]: 46; 95% CI: 40-54).
Results were similar across all baseline BPs, as follows:
- SBP ˂130 mmHg: RR: 0.63 (95% CI: 0.50-0.80); ARR: 51 per 1,000 patients (95% CI: 27-68 per 1000 patients); NNT: 20 (95% CI: 15-37).
- SBP 130-139 mmHg: RR: 0.87 (95% CI: 0.82-0.92); ARR: 16 per 1,000 patients (95% CI: 10-22 per 1000 patients); NNT: 62 (95% CI: 45-101).
- SBP 140-149 mmHg: RR: 0.79 (95% CI: 0.72-0.87); ARR: 30 per 1,000 patients (95% CI: 18-40 per 1000 patients); NNT: 34 (95% CI: 25-54).
- SBP 150-159 mmHg: RR: 0.80 (95% CI: 0.71-0.91); ARR: 13 per 1,000 patients (95% CI: 6-18 per 1000 patients); NNT: 80 (95% CI: 55-178).
- SBP >160 mm Hg: RR: 0.74 (95% CI: 0.69-0.79); ARR: 19 per 1,000 patients (95% CI: 15-22 per 1000 patients); NNT: 53 (95% CI: 45 to 66).
Evidence was mixed and of moderate strength, supporting the benefits of reducing SBP to a targeted point for cardiovascular outcomes in patients with a history of cardiovascular disease. For example, in patients with a history of cardiovascular disease, evidence supporting the benefits of a 10-mmHg reduction in SBP decreased major cardiovascular disease events compared with control was of moderate strength (RR: 0.77; 95% CI: 0.71-0.81) based on 18 randomized, controlled trials that included 83,125 patients. However, in those with diabetes, evidence was high-strength, and in those with a history of stroke, it was of low-strength.
Finally, D’Anci and colleagues found that safety results were either inconclusive or mixed. The rates of serious adverse events were similar between patients treated to strict BP targets and those treated to standard BP targets (RR: 1.01; 95% CI: 0.94-1.08]). Patient withdrawals due to adverse events favored less strict lowering (RR: 8.16; 95% CI: 2.06-32.28), as did the number of medications needed (1.9 versus 2.4).
In an accompanying article, CDR Mark P. Tschanz, DO, MACM, of the Naval Medical Center, San Diego, CA, and coauthors offered a synopsis of some of the key recommendations that came from the Jan. 2020 update to the 2014 joint clinical practice guideline from the VA and DOD for the diagnosis and management of patients with hypertension in the primary care setting.
In this guideline, hypertension is defined as a BP of ≥130/90 mmHg. This is consistent with the latest guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines but differs from the definition put forth in both the European Society of Cardiology (ESC)/European Society of Hypertension (ESH) and the National Institute for Health and Care Excellence (NICE) guidelines (≥140 mmHg).
In this latest update, the VA/DOD guidelines and current evidence support the periodic screening of adults for elevated BP, but specific screening intervals for BP are not evidence based and are, therefore, still unknown.
Regarding treatment goals and management, the VA/DOD work group found evidence that suggests that systolic BP (SBP) should be lowered to below 130 mmHg in all adult patients, although there were inconsistencies in existing data.
They also found strong evidence for treating patients age 30 years and over to a DBP goal of ˂90 mmHg. In patients age 60 years and over, evidence is also strong for an SBP goal of ˂150 mmHg, with added benefits for further BP reduction to between 130 and 150 mmHg. In those who are age 60 years and over who have type 2 diabetes, an SBP goal of ˂140 mmHg is recommended, with additional benefits to SBP lowered to between 130 and 140 mmHg.
As far as nonpharmacologic treatment for hypertension, the updated guidelines also call for aerobic exercise for at least 120 minutes/week, adherence to a dietitian-led Dietary Approaches to Stop Hypertension (DASH) diet, and limiting sodium intake to no more than 2,300 mg/d. Evidence supporting all of these recommendations is strong.
For the pharmacologic treatment of hypertension, the VA/DOD recommendations include the following, all of which are backed by strong evidence:
- Primary pharmacologic therapy consisting of a thiazide-type diuretic, calcium-channel blocker, or either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB).
- ACE inhibitors and ARBs should not be used as monotherapy in African American patients with hypertension.
- Treatment with more than one medication from the ACE, ARB, or direct renin inhibitor drug classes should not be used together in the same patient.
“In summary, the VA/DoD guideline provides evidence-based recommendations for outpatient evaluation and management of hypertension in adults, with the goal of successful patient-centered management to improve clinical outcomes,” concluded Tschanz and colleagues.
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A recent systematic review and the updated VA/DOD clinical practice guidelines both support intensive lowering of BP in patients with hypertension to improve cardiovascular outcomes.
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January 2020 update to VA/DOD clinical practice guidelines include key recommendations in defining hypertension, targeting treatment goals, and pharmacologic and nonpharmacologic management of hypertension.
E.C. Meszaros, Contributing Writer, BreakingMED™
The systematic review was funded by the VA, Veterans Health Administration, and development of the VA/DOD guidelines was supported by the Office of Quality, Safety and Value of the DOD.
D’Anci and Tschanz reported no conflicts of interest.
Cat ID: 6
Topic ID: 74,6,730,6,192,916
