The National Institute for Health and Care Excellence (NICE) guidelines makes the point that hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.
Blood pressure is normally distributed in the population and there is no natural cut-off point above which ‘hypertension’ definitively exists and below which it does not.
The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke.
Routine periodic screening for high blood pressure is now commonplace in the UK, but still many cases go undetected, and many are undertreated.
The diagnosis, treatment and follow-up of people with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and is expensive.
In the recent Systolic Blood Pressure Intervention Trial (SPRINT), a large study funded by the National Institutes of Health (which was stopped early). It was found that a more intensive strategy of lowering blood pressure – one that aims to achieve a systolic blood pressure target of 120 mm Hg – reduces the risk of death and cardiovascular events when compared with a strategy that lowers systolic blood pressure to conventional targets. National Institutes of Health, Landmark study shows intensive blood pressure management may save lives (press release, September 11 2015).
This research suggests that current targets may be too high
Discrepancy now exists between published targets for this population
- 2009 NICE guideline for type 2 diabetes: 140/80 mmHg (and 130/80 mmHg for those with kidney, eye or cerebrovascular damage)
- 2010 Scottish Intercollegiate Guidelines Network (SIGN) guideline for diabetes: 130/80 mmHg
People with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg if aged under 80 years, or below 150/90 mmHg if aged 80 years and over.
- 2013 guideline from the European Society of Hypertension (ESH) and European Society of Cardiology (ESC): 140/85 mmHg
- 2014 Joint National Committee (JNC) 8 guideline: 140/90 mmHg
My policy is to discuss and agree with the patient an agreed target, and if possible encourage them to self- monitor, aiming for a systolic pressure of less than 130 unless there is a reason not to do so.
Professor Mike Kirby FRCP
University of Hertfordshire and The Prostate Centre, London