Lower Blood Pressure Goals for Cardiovascular and Renal Risk Reduction: Are They Defensible?

Most guidelines in the Western world uniformly recommend two blood pressure (BP) goals, <140 ⁄90 mm Hg for the general population and <130 ⁄80 mm Hg for those with diabetes or chronic kidney disease (CKD). These recommendations for a lower BP goal in these specific groups stem from retrospective data analyses that suggest a slower decline in CKD and greater cardiovascular disease (CVD) risk reduction when BP is <130 ⁄80 mm Hg. The question to be addressed: are these more aggressive BP goals defensible based on appropriately powered prospective outcome trials? Meta-analyses of all clinical trials, to date, demonstrate that reducing BP reduces risk for stroke and coronary heart disease. However, none have achieved a mean BP goal of <130 ⁄80 mm Hg. This lack of lower BP goal achievement is even true in CVD outcome trials of diabetes. In trials such as the United Kingdom Prospective Diabetes Study (UKPDS) and the Hypertension Optimal Treatment Trial (HOT), the systolic BP was more than 10 mm Hg higher than this lower goal. Nevertheless, a benefit occurred on CVD reduction. One prospective study that achieved this lower BP goal in patients with diabetes and no overt nephropathy was the Appropriate Blood Pressure Control in Diabetes (ABCD) trial. This trial demonstrated reduced CV risk, but there was no difference between the groups with a mean systolic pressure of 138 mm Hg vs the intensive group at 132 mm Hg. A summary of large CVD outcome trials during the past decade with the relative CVD risk reduction and achieved mean systolic BP are presented in the Figure. It is clear that none of the trials achieved a systolic BP below 130 mm Hg. The definitive answer regarding whether lower levels of systolic BP further reduce CVD risk will come from the results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial within the year. If negative, the BP goal of <130 ⁄80 mm Hg will be clearly indefensible.