Trending Clinical Topic: New Blood Pressure Targets

Ryan Syrek


February 17, 2023

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From 1990 to 2019, the worldwide incidence of hypertension doubled. Given the well-known and serious health concerns associated with elevated blood pressure (BP), various organizations have recently moved toward more aggressive targets. That updated guidance, along with recent key findings related to treatment compliance among hypertensive patients, resulted in the top trending clinical topic this week. Recently, the American Academy of Family Physicians (AAFP) and the American Diabetes Association (ADA) updated their BP targets for certain patients (see Infographic).

The new clinical practice guidelines from the AAFP were based on a review of randomized controlled trials which showed that a target of < 140/90 mm Hg had all-cause and cardiovascular mortality benefits. A small additional benefit in the reduction of myocardial infarction was shown with targets of < 135/85 mm Hg. The new guidelines also include a recommendation to standardize measurements by using an appropriate-sized cuff on a bare arm at heart level, with the patient's feet on the floor. The AAFP suggests that variability can be further reduced by taking measurements after at least 5 minutes of rest and 30 minutes without caffeine.

Neil Skolnik, MD, suggests that the new guidelines are incredibly helpful, but he cites concerns related to lowering BP further that include the potential for increased adverse events associated with treatment. "In my experience, patients care a lot about adverse events," Skolnik notes. He points out that the International Society of Hypertension also recommends an "essential" BP target of < 140/90 mm Hg for most individuals, with an "optimal" BP of < 130/80 mm Hg. That organization also recommends a BP of < 130/80 mm Hg for patients with confirmed atherosclerotic cardiovascular disease. The American Heart Association/American Stroke Association guidelines from 2021 recommend a BP target of < 130/80 mm Hg for prevention of recurrent stroke.

Like the AAFP, the ADA also recently adopted more aggressive BP targets. The new target is < 130/80 mm Hg, along with a LDL cholesterol target of < 70 mg/dL, or ≤ 55 mg/dL, depending on the patient's cardiovascular risk. Other changes include an emphasis on weight loss as a goal of therapy for patients with type 2 diabetes, guidance for screening and assessing peripheral arterial disease, use of finerenone in those with diabetes and chronic kidney disease, use of approved point-of-care A1c tests, and guidance on screening for food insecurity.

These new, lower targets require patient compliance with treatment, which is a major concern. One approach currently under investigation to help patients with hypertension is renal denervation or small interfering RNA (siRNA), which has a long half-life. A new therapeutic siRNA, zilebesiran, is currently the subject of a phase 2 clinical trial. Phase 1 studies with zilebesiran in patients with hypertension demonstrated a long-term effect, with a reduction of > 90% in circulating angiotensinogen over 6 months after a single subcutaneous dose (800 mg). The peak in reduction of circulating angiotensinogen occurs after approximately 3 weeks. Lasting reductions in BP have also been observed, with 24-hour ambulatory BP monitoring showing a reduction in systolic BP of > 15 mm Hg 8 weeks after administration of a single dose (800 mg). In the phase 2 trials, zilebesiran is being studied in patients with mild to moderate hypertension who are not taking antihypertensive drugs (KARDIA-1) and in patients whose BP is not controlled (KARDIA-2).

Of the myriad of factors that support BP control, concerns related to COVID loom large. The association between hypertension and severe COVID is well recognized, but a recent study may have identified the level at which high BP can predict a life-threatening infection. The greatest risk was among people whose systolic BP was > 150 mm Hg. The findings were based on data from 16,134 people in the United Kingdom who tested positive for COVID-19. Among them, 40% had high BP and 22% got severe COVID-19. The findings expand on a previous study, which showed that high BP more than doubles the risk for severe COVID, even among those who are vaccinated and boosted.

Given how common hypertension is, especially in certain patient populations, the new targets provided by key organizations have sparked a great deal of interest. Those changes, along with new information about siRNA treatment and COVID-related concerns, resulted in this week's top trending clinical topic.

Take a quiz about BP medication use.


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