The Optimal Blood Pressure Target

Medscape Cardiology > Black on Cardiology
Not Too High, Not Too Low: The Optimal Blood Pressure Target

Henry R. Black, MD Disclosures November 14, 2014


I am Dr Henry Black, adjunct professor of medicine at the Langone New York University School of Medicine. I want to talk about the J-shaped (or U-shaped) curve, an issue that has been bothering clinicians and epidemiologists who are interested in hypertension. The J- or U-shaped curve means that people at the top of the curve have the most risk. This concept is relevant to blood pressure and cholesterol. People at the lowest end of the curve are also at risk. We would like to find the optimal target for the treatment and epidemiologic study of high blood pressure, and the optimal cholesterol level as well, and data have now been provided in a very interesting study from the Southern California Kaiser Group.[1]

They looked at more than 3.4 million patients and identified approximately 500,000 who were being treated for hypertension, of whom approximately 460,000 had blood pressure measurements. They were trying to determine the optimal blood pressure in the treated group. Epidemiologic predictions are different, because rather than being based on treated people, they are based on untreated people, in whom the risk is linear: The lower you go, the better you are. But in treated patients, we are not sure what blood pressure is best. These investigators selected deciles of systolic blood pressure, from < 100 mm Hg to 110 mm Hg, and up to 170 mm Hg. They also analyzed diastolic blood pressures but focused primarily on systolic.

The optimal blood pressure turned out to be 137/71 mm Hg, and the optimal level to treat to was the lowest decile (130-139 mm Hg). They compared that decile with all of the others, and in every case, as the systolic blood pressure went up, so did the risk. As the blood pressure went down, the risk increased as well.

The so-called JNC 8 guidelines[2] recommend aiming for a systolic blood pressure < 150 mm Hg. That wasn't an evidence-based recommendation, although the title of the guidelines suggests that they are evidence-based. That recommendation was expert opinion–based. The finding that 130-139 mm Hg is the optimal target for treatment differs from what might be considered optimal epidemiologically, but those of us who are treating patients are more interested in the best treatment target. Our take-home message from this trial, published in the Journal of the American College of Cardiology, is that the optimal target for treatment is between 130 and 139 mm Hg systolic. Thank you very much.