Specially invited interpretation experts: TEDA International Cardiovascular Disease Hospital Li Yuming Yang Ning
Strengthen blood pressure control
Chinese experts suggest
Recently, the Hypertension Group of the Cardiovascular Disease Branch of the Chinese Medical Association organized Chinese experts to formulate the "Chinese Expert Recommendations for Strengthening Blood Pressure Control", which was published in the Chinese Journal of Hypertension.
This recommendation summarizes evidence-based medical evidence on antihypertensive strategies in China and internationally in recent years, and makes recommendations on the management of blood pressure in patients with hypertension. In particular, for some special groups, such as the elderly, pregnant women's blood pressure problems, detailed analysis and recommendation have also been made.
This article invites the corresponding author Professor Li Yuming of TEDA International Cardiovascular Hospital and the author of TEDA International Cardiovascular Disease Hospital Professor Yang Ning to interpret the suggestions in depth for the benefit of readers.
Professor Li Yuming
Professor Yang Ning
Expert recommendations to develop the background
Hypertension is one of the most important risk factors for cardiovascular disease, and active prevention and treatment of hypertension is an important measure for the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD).
For nearly two decades, most guideline documents have recommended < 140/90 mmHg as a blood pressure control goal for patients with general hypertension.
For patients at high risk of cardiovascular disease such as diabetes, chronic kidney disease, and coronary heart disease, some guidelines recommend controlling blood pressure at <130/80 mmHg.
For older patients, most guidelines recommend a more relaxed target value of 150/90 mmHg <.
Both Chinese and international guidelines relied on evidence from clinical studies published at the time, as did blood pressure control goals for hypertensive patients.
In recent years, especially following the publication of the 2015 Systolic Blood Pressure Intervention Study (SPRINT study), the 2021 Elderly Hypertension Antihypertensive Target Target Study (STEP study), and the publication of the latest meta-analysis of the Antihypertensive Therapy Trials Collaborative Group (BPLTTC), more studies have suggested that further lowering the blood pressure control goals in hypertensive patients on the existing basis may help to more significantly reduce the occurrence of hypertension-related adverse events.
In this context, the Hypertension Group of the Cardiovascular Disease Branch of the Chinese Medical Association organized Chinese experts to formulate this expert recommendation.
The main recommendation among expert recommendations
Point 1
< 130/80 mmHg should be used as a blood pressure control target for most patients with hypertension (without cardiovascular comorbidities, or with coronary heart disease, chronic heart failure, stroke history, chronic kidney disease, diabetes, etc.) provided that the patient is able to tolerate it.
Point 2
It is recommended that the antihypertensive therapy in elderly patients with hypertension adopt a step-by-step strategy: first reduce their blood pressure to <140 to 150 mmHg, and if it is well tolerated, it can be further reduced to <130/80 mmHg.
Point 3
Hypertensive patients with advanced age and poor health, comorbid cognitive impairment, debilitation, and limited life expectancy should be individualized blood pressure control goals based on the patient's specific circumstances.
Point 4
In order to improve the tolerance of antihypertensive therapy in elderly patients with hypertension, especially patients over 80 years of age, the initial treatment should start from low intensity, and gradually increase the dose and type of drugs according to the patient's tolerance. Monitoring of adverse reactions and tolerance needs to be strengthened during treatment, and the intensity of treatment needs to be reduced if necessary.
Point 5
Hypertensive pregnant women with systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg are recommended to initiate antihypertensive therapy in conjunction with lifestyle interventions, with close monitoring of blood pressure and target organ damage during treatment. The buck target value is ≤135/85 mmHg.
Analysis of antihypertensive strategies for special populations
Hypertension in the elderly
The elderly are susceptible to hypertension, ≥ the prevalence of hypertension exceeds 50% in the elderly population aged 60.
For a long time, due to insufficient evidence in relevant studies, the optimal blood pressure control goal for elderly hypertension patients has been highly controversial, and many scholars believe that blood pressure control in the elderly should be appropriately relaxed, < 140 to 150/90 mmHg has been the target value of antihypertensive therapy recommended by most hypertension prevention and treatment guidelines.
However, in recent years, the RESULTS OF SPRINT, STEP, and the latest meta-analyses from BPLTTC have suggested that intensive antihypertensive therapy in older adults can benefit more.
In clinical practice, people's concerns about intensive antihypertensive therapy in the elderly are mainly twofold.
First, because the elderly often present with simple systolic hypertension, their diastolic blood pressure is generally normal or even low.
Lowering systolic blood pressure to a lower level (e.g., <130 mmHg) may result in diastolic blood pressure levels being too low, which can adversely affect coronary blood perfusion pressure.
However, a recently published large Mendelian randomized analysis showed that no J-curve relationship between blood pressure levels and adverse cardiovascular events was found when the diastolic blood pressure was as low as 50 mmHg.
Second, older people are often accompanied by orthostatic hypotension.
It is generally believed that patients with orthostatic hypotension should moderately reduce the intensity of antihypertensive therapy to alleviate the symptoms of orthostatic hypotension.
However, a systematic review and meta-analysis of the latest study shows that in hypertensive patients with orthostatic hypotension, intensive hypotension not only does not aggravate orthostatic hypotension, but helps alleviate their clinical symptoms.
Based on this finding, orthostatic hypotension symptoms should not be a factor influencing aggressive antihypertensive therapy.
For ≥ 80-year-old elderly, there is a lack of targeted clinical randomized controlled trials.
Subgroup analysis of patients aged 75 years ≥ the SPRINT study showed a 37% reduction in the risk of compound endpoint events after intensive antihypertensive therapy, of which the intensive antihypertensive group and the control group were 79.8±3.9 years, 79.9±4.1 years, respectively.
The latest BPLTTC meta-analysis, published in 2021, included data from 358707 participants from 51 randomized clinical trials, excluded participants with a history of heart failure, randomized participants ranging from 21 to 105 years (median age 65), and placed participants by baseline age (<55, 55 to 64, 65 to 74, 75 to 84, and ≥85 years) and blood pressure categories (systolic blood pressure from <120 to ≥170 mmHg, And diastolic pressure from <70 to ≥110 mmHg, in 10 mmHg increments).
The primary endpoints were a combination of fatal or nonfatal stroke, fatal or nonfatal myocardial infarction or ischemic heart disease, death, or heart failure requiring hospitalization.
The results showed that active hypotensive reduction at 75-84 years of age reduced the risk of adverse endpoint events [risk ratio (HR) 0.91 (0.87-0.96); ≥ 85-year-old group did not achieve statistical significance, HR 0.99 (0.87-1.12)].
The researchers analyzed that the ≥ 85-year-old group did not show a benefit in active blood pressure reduction, which may be related to the small number of people included in this group (4788 cases), but throughout the study, there was a consistent benefit for active blood pressure reduction in all age groups.
Therefore, the study concluded that in order to more effectively reduce the risk of hypertension-related adverse events, different blood pressure control goals should not be set according to different ages in antihypertensive treatment guidelines.
Analysis of antihypertensive strategies for special populations
Hypertensive disorders of pregnancy
It is worth mentioning that in April 2022, following the publication of this recommendation in February 2022, another blockbuster clinical study (CHAP study) in the field of hypertension disorders in pregnancy published its results in the New England Journal of Medicine (NEJM).
The CHAP study included a total of 2408 women with chronic hypertension within 23 weeks' gestation with mildly elevated blood pressure and randomly divided them into two groups. The intensive antihypertensive group (1208 cases/laberolol or nifedipine extended-release agent of choice) controlled their blood pressure below 140/90 mmHg; the control group (1200 patients) was not routinely treated with antihypertensive drugs, and antihypertensive drugs were only given when blood pressure exceeded 160/105 mmHg.
The primary endpoint consisted of severe preeclampsia, preterm birth within 35 weeks, placental abruption, and fetal/neonatal death. The safety endpoint was in low-weight neonates.
The results showed that the average blood pressure of the intensive antihypertensive group and the control group during the follow-up period was 129.5/79.1 mmHg and 132.6/81.5 mmHg, respectively.
Compared with the control group, the incidence of primary endpoint events decreased by 18% (P<0.0001) in the intensive antihypertensive group, and there was no significant difference in the incidence of safety endpoint events between the two groups.
ChaP studies have three characteristics in design.
One was the inclusion of 2408 pregnant women, doubling the sample size from another related study in 2015 (chips, which eventually included 981 cases).
Second, the gestational age included in the study was before 23 weeks, and the group was relatively single, mainly pregnant women with chronic hypertension and pregnancy.
Third, in the process of research, attention was paid to the use of antihypertensive drugs.
The results of the CHAP study suggest that in pregnant women with chronic hypertension with mildly elevated blood pressure, controlling blood pressure at <140/90 mmHg can help improve maternal-fetal/maternal clinical outcomes. This is consistent with this recommendation for the treatment of hypertensive disorders in pregnancy.
Summary
Looking at the relevant research evidence on intensive antihypertensive and clinical outcomes in recent years, we can conclude that a more aggressive and rigorous management strategy should be adopted for patients with hypertension, regardless of age and whether or not they have cardiovascular disease.
Considering that there are certain differences in the patient management background in clinical practice and randomized clinical trials, it is also necessary to treat individually according to the tolerance of each patient, and the monitoring of patients with low blood pressure levels should be strengthened, and possible adverse reactions should be detected in time and treated accordingly.
In addition, it is important to note that the effect of blood pressure measurement techniques on blood pressure values cannot be ignored when discussing the target values for blood pressure.
While promoting the standardized measurement of blood pressure, we should also pay more attention to the role of home self-test blood pressure and ambulatory blood pressure monitoring, and use it as an important supplement to blood pressure in the clinic.