Is it Time to Rethink Your High Blood Pressure Treatment?

'Standard' medical treatment for hypertension might be changing

Blood pressure gauge in Doctors surgery
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Besides being a huge risk factor for heart disease, strokes, etc, high blood pressure can also lead to kidney disease. Not only that, patients with existing chronic kidney disease (CKD), are at a higher risk of progression to end-stage kidney disease (when they would need either dialysis or a kidney transplant), should their blood pressure stay high/uncontrolled. After diabetes, high blood pressure is the commonest reason that people develop kidney failure.

The Difference Between Complete Kidney Failure and Mild Disease

In the long run, achieving and maintaining "target blood pressure" is one of the basic tenets of preventing CKD progression. It could prevent you from potentially getting to the point where you will be dialysis-dependent. But what is this so-called target blood pressure?

The Way We Treat Blood Pressure Is Not a Matter of One Physician's Opinion

Well, not always! It is actually determined by a bunch of smart physicians who sit around a table, look at the current body of evidence, and tell the rest of us how we should do it! That is a group called the Joint National Committee (JNC) and is set up by the National Institutes of Health (NIH). Their latest set of recommendations came out in February 2014, and are often referred to as the "JNC 8."  It is the JNC who will often have the last word on not only what drugs we should be using to treat high blood pressure, but also what our target goal blood pressure should be.

Why the Target Blood Pressure Changed 

In general, before JNC 8, we tended to be more aggressive about blood pressure treatment goals, often treating patients to targets under 130/80. However, just to make things confusing, let me mention that JNC is not the only official body making recommendations about blood pressure management. Take a look at Table 6 here.

You might notice that earlier guidelines from around 2010-2011 and before seem to recommend a more aggressive control of blood pressure to lower targets. That, in fact, was the accepted gospel truth for most primary physicians, cardiologists, and nephrologists, till very late. However, in 2010 we had a major study on high blood pressure that was reported in the hallowed pages of the New England Journal of Medicine (NEJM). This study called the ACCORD trial showed that there was no benefit to treating high blood pressure to an aggressive low of systolic 120 mm versus the more relaxed target of 140 mm. This flew in the face of "accepted" wisdom in the medical community, which tended to believe that low blood pressure is always good and high is bad! This trial was, however, not a flash in the pan, since earlier, we had seen another study called the INVEST trial that also reported no benefit of treating blood pressure too aggressively.

(I would like to emphasize though that just like in any other field of medicine, hypertension treatment is an area of great controversy and things keep changing. No two guidelines seem to agree with each other and even the JNC has received its fair share of barbs).

Current Treatment Targets 

JNC has basically recommended targets based on age for the general population:

  • Age < 60 yrs: target is to keep them under 140/90
  • Age > 60 yrs: target is to keep them under 150/90

Targets Are Different for People With Kidney Disease 

Blood pressure targets that apply to the average hypertensive person might not apply to the hypertensive patient who also has kidney disease. In fact, we have even more organizations that specifically deal with kidney diseases like the Kidney Disease Improving Global Outcomes (KDIGO) that have recommended lower treatment goals. But as far as the JNC 8 goes, the target is to keep everyone with kidney disease, regardless of age treated to a blood pressure < 140/90. And you shouldn't need medical treatment if you tend to stay under this level on an average. If you are close to this number, you might get away with diet/lifestyle modifications alone.

It's Also About How You Treat it

What I have described above is what targets you treat BP to. But an up-to-date physician will also keep in mind what specific drugs to use to get you to goal. The end does not always justify the means with hypertension treatment. I won't go into its specifics here but you could go through the details of JNC 8 if you really want to know.

We often also have something called "compelling indications" when it comes to hypertension treatment. For instance, someone with an excessive amount of protein in the urine might be put on lisinopril (a blood pressure pill), even if the blood pressure is under this goal. In this case, the blood pressure pill is being used for other indications.

To summarize, for most patients with kidney disease, a target goal pressure to optimize kidney function and reduce their chances of progression to end-stage kidney disease would be <140/90. At least that's where we stand until JNC 9!