Truisms — What We All Think We Know About High Blood Pressure May Not Be True

Truisms — What We All Think We Know About High Blood Pressure May Not Be True

BP thresholds and targets in the treatment of hypertension. An evidence-based approach

Montreal April 2015 James (Jim) Wright Therapeutics Initiative (TI)

Declaration No financial competing interests. Professor University of BC Co-Managing Director of TI Editor-in-Chief, Therapeutics Letter Coordinating Editor, Cochrane Hypertension Group Half-day a week outpatient Clinical Pharmacology practice.

An evidence-based approach to practical clinical scenarios  What is the evidence for treating moderate to severe hypertension (>160/100 mmHg)?

 What is the optimal target blood pressure?  Treatment of hypertension in the very elderly (>80 yrs).

 What is the evidence for treating mild elevations in blood pressure (140-159/90-99 mmHg)?

Clinical Implications  Relevant to people 60 and over with moderate to severe elevations of BP (>160/100 mmHg).

 Most patients were primary prevention and treated with stepped care therapy starting with a thiazide.

 40% of patients failed to achieve target diastolic of 160 mmHg. (Threshold for treatment).

 Total mortality – self evident

I–

 SAEs include any untoward medical occurrence that

Antihypertensive drug treatment.

C – Placebo or no treatment. O – Hierarchy of clinically important outcomes.

 Total serious adverse events (SAEs) results in death, is life-threatening, requires hospitalization or prolongation of hospitalization, or results in persistent or significant disability.*

S – Randomized clinical trials (at least 1 year duration).

Total Mortality and SAEs provide a measure of net effect.

Hierarchy of health outcomes  Total mortality  Total people with at least one serious adverse event

Benefit

 Total cardiovascular SAEs (fatal and non-fatal stroke, fatal and non-fatal MI and fatal and non-fatal CHF)

 Achieved differences in blood pressure.

Harm

264

Truisms — What We All Think We Know About High Blood Pressure May Not Be True

Cochrane Library  Musini VM, Tejani AM, Bassett K, Wright JM.  Pharmacotherapy for hypertension in the elderly.  Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000028. DOI: 10.1002/14651858.CD000028.pub2.

ARR = 1299/11166 (0.1) (100) =1.2%, NNT=83 for 5 yrs.

Clinical Implications  Relevant to people 60 and over with moderate to severe elevations of BP (>160/100 mmHg, including isolated systolic hypertension.

 Most patients were primary prevention and treated with stepped care therapy starting with a thiazide.

 40% of patients failed to achieve target diastolic of