Dr. Bray Links

Sunday, September 20, 2015

Conflicting targets for BP control in elderly

If your blood pressure is high. The clinical investigation should target what factors are causing this and fixing these - whether it is due to overexposure to processed foods, oxidized polyunsaturated and processed fats and oils, hormone disruptors or other chemicals, obesity, inactivity, poor resiliency to stress, heavy metals, or nutritional deficiencies. There is a fair amount of risk associated with syncope, dizziness, falls, and vascular hypoperfusion of the brain in patients over 60 y/o and this is one of the main reasons for balancing the "need" for lowering blood pressure (and vascular risk) with the risks associated with hypotensive episodes.



"More intensive management of high blood pressure, below a commonly recommended blood pressure target, significantly reduces rates of cardiovascular disease, and lowers risk of death in a group of adults 50 years and older with high blood pressure. This is according to the initial results of a landmark clinical trial sponsored by the National Institutes of Health called the Systolic Blood Pressure Intervention Trial (SPRINT). The intervention in this trial, which carefully adjusts the amount or type of blood pressure medication to achieve a target systolic pressure of 120 millimeters of mercury (mm Hg), reduced rates of cardiovascular events, such as heart attack and heart failure, as well as stroke, by almost a third and the risk of death by almost a quarter, as compared to the target systolic pressure of 140 mm Hg."


"In patients 60 years of age or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mmHg

Results of 5 key trials--HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative--informed the changes in the new guidelines. In these trials, patients between the ages of 30 and 69 received medication to lower DBP to a level <90 mmHg. Results showed a reduction in cerebrovascular events, heart failure, and overall mortality in patients treated to the DBP target level.   The data were so compelling that some members of the JNC 8 panel wanted to keep DBP <90 mmHg as the only goal among younger patients, citing insufficient evidence for benefits of an SBP goal lower than 140 mmHg in patients under the age of 60. However, more conservative panelists pushed to keep the target SBP goal as well as the DBP goal.   In younger patients without major comorbidities, elevated DBP is a more important cardiovascular risk factor than is elevated SBP. The JNC 8 panelists are not the first guideline authors to recognize this relationship. The JNC 7 guideline authors also acknowledged that DBP control was more important than SBP control for reducing cardiovascular risk in patients <60 years of age. However, in patients 60 years of age and older SBP control remains the most important factor.   Other recent evidence suggests that the SBP goal <140 mmHg recommended by the JNC 7 guidelines for most patients may have been unnecessarily low. The JNC 8 guideline authors cite 2 trials that found no improvement in cardiovascular outcomes with an SBP target <140 mmHg compared with a target SBP level <160 mmHg or <150 mmHg. Despite this finding, the new guidelines do not disallow treatment to a target SBP <140 mmHg, but recommend caution to ensure that low SBP levels do not affect quality of life or lead to adverse events.   The shift to a DBP-based goal may lead to use of fewer medications in younger patients with a new diagnosis of hypertension and may improve adherence and minimize adverse events associated with low SBP, such as sexual dysfunction."



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