Evidence to Maintain the Systolic Blood Pressure Treatment Threshold at 140 mm Hg for Stroke Prevention

Abstract

In 2014, the Eighth Joint National Committee revised the target maximum systolic blood pressure (SBP) from 140 to 150 mmHg in persons aged ≥60 years without diabetes mellitus (DM) or chronic kidney disease (CKD). The evidence from cohort studies supporting this change was sparse, particularly among U.S. minority populations. In the Northern Manhattan Study, 1,750 participants aged ≥60 years and free of stroke, DM, and CKD had SBP measured at baseline and were annually followed for incident stroke. Mean age at baseline was 72±8 years; 63% were women; 48% Hispanic, 25% non-Hispanic white, and 25% non-Hispanic black. Among all participants, 40% were on antihypertensive medications, and 43% had SBP <140 mmHg, 20% 140-149 mmHg, and 37% ≥150 mmHg. Over a median follow-up of 13 years, 182 participants developed stroke. The crude stroke incidence was greater among individuals with SBP ≥150 mmHg (10.8 per 1000 person-years) and SBP 140-149 (12.3) compared to those with SBP<140 (6.2). After adjusting for demographics, vascular risk factors, diastolic BP, and medication use, participants with SBP 140-149 mmHg had an increased risk of stroke (HR, 1.7; 95% CI, 1.2-2.6) compared with those with SBP <140 mmHg. The increased stroke risk was most notable among Hispanics and non-Hispanic blacks. Raising the SBP threshold from 140 to 150 mmHg as a new target for hypertension treatment in older individuals without DM or CKD could have a detrimental effect on stroke risk reduction, especially among minority U.S. populations.

Incidence of cardiovascular disease in individuals affected by recent changes to US blood pressure treatment guidelines

“…In a report from the Northern Manhattan Study, Dong et al demonstrated elevated risks of stroke in individuals with SBP 140-149 mm Hg compared with those with an SBP <140 mm Hg, consistent with our findings [17]. In their sample, the increased risk was especially profound among Hispanics and non-Hispanic blacks.…”

“…The most recent European Society of Hypertension/European Society of Cardiology Guidelines for the Management of Arterial Hypertension (last revised in 2013) [16] and National Institute for Health and Care Excellence (NICE, published in 2011) [17] both differ substantially from the JNC 8 guideline. Both consider BP treatment targets in the context of other cardiovascular risk factors and global CVD risk assessment.…”

Hypertension and Migraine in the Northern Manhattan Study

“…The association between migraine and uncontrolled hypertension based on the JNC-8 hypertension guidelines is also of interest. 33,34 Lastly, the findings should be confirmed in other diverse cohorts of diverse race/ethnicity with younger age ranges as our findings may not be generalizable to nonHispanic and younger populations.…”

Long-Term Mortality in Hypertensive Patients With Coronary Artery Disease

“…15 Data from the Northern Manhattan Study showed that raising the SBP threshold from 140 to 150 mm Hg as a new target for hypertension treatment in older individuals without diabetes or chronic kidney disease could have a detrimental effect on stroke risk reduction. 16 This observation is further supported among patients with diabetes in the long-term follow-up of the Action to Control Cardiovascular Risk in Diabetes Trial Follow-On Blood Pressure Study (ACCORDION). 17 Although the SPRINT showed that targeting a SBP <120 mm Hg, compared with <140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause in patients at high risk for cardiovascular events but without diabetes.…”