Techniques for blood pressure control -
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Home Health Topics High Blood Pressure The Facts About HBP Five Steps to Control Your Blood Pressure. Your HBP deserves your attention. Work with your health care professional Your health care professional will help you make a plan to lower your blood pressure.
Make a few lifestyle changes In many cases this will be your health care professional's first recommendation, likely in one of these areas: Maintain a healthy weight.
If you are overweight or obese, weight loss will help reduce your blood pressure. Eat healthier. Eat lots of fruit, veggies and low-fat dairy and less saturated and total fat. The DASH diet is geared toward reducing blood pressure.
Reduce sodium. Ideally, stay under 1, mg a day, but aim for at least a 1, mg per day reduction. Get active. Limit alcohol. Drink no more than one to two drinks a day one for most women, two for most men.
Uncontrolled high blood pressure can be fatal. Your health Techniques for blood pressure control professional can tell pressure your Technisues target blood pressure. In many cases this will be your health care professional's first recommendation, likely in one of these areas:. Written by American Heart Association editorial staff and reviewed by science and medicine advisors. See our editorial policies and staff.Video
6 Ways to Prevent High Blood PressureTechniques for blood pressure control -
The "routine" method that is typically used worldwide to measure blood pressure should ideally not be used for clinical decision-making. A variety of methods and equipment are used to measure blood pressure in clinical practice; all methods of measurement, in particular office measurements, should follow specific standards see "Blood pressure measurement in the diagnosis and management of hypertension in adults" :.
It is likely that such routine measurements are highly variable from office to office and from one care provider to the next. The device is activated by a care provider, who then can leave the room. AOBPM requires specialized equipment. Typically, multiple readings are obtained daily over several consecutive days and then these readings are averaged to guide clinical decision-making.
A common scenario is to instruct patients to take two to four daily readings for five to seven days before attending the clinic. Proper technique should be followed table 1. The auscultatory method of measurement using a manual cuff is the most common technique employed in clinical practice and, in addition, was the technique used in most early clinical trials of antihypertensive therapy.
In newer trials, oscillometric devices have been used. In all trials, standardized preparation and technique were followed table 1. AOBPM attended and unattended is less frequently employed in clinical practice but was the technique that was used in the Systolic Blood Pressure Intervention Trial SPRINT and the Action to Control Cardiovascular Risk in Diabetes ACCORD trial.
Goal blood pressure trials that used home blood pressure measurement or ABPM are lacking. On average, systolic pressure readings are typically 5 to 15 mmHg lower with non-routine compared with routine measurement because the "white coat" effect may be absent and because routine measurements are performed without proper patient preparation and technique [ ].
Some studies have reported even more dramatic differences between non-routine and routine measurement [ 13 ]. However, it is critical to realize that this average difference in blood pressure between measurement methodologies applies to the population and not the individual. Some patients do not experience a white coat effect, and there is therefore some uncertainty in setting goals according to the method of measurement.
See "Blood pressure measurement in the diagnosis and management of hypertension in adults" and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".
Why baseline risk matters: Absolute versus relative risk — The management of adults diagnosed with hypertension depends in part upon the patient's risk for future cardiovascular events.
See 'Goal blood pressure in higher-risk patients' below and 'Goal blood pressure in lower-risk patients' below. In general, therapeutic decisions should be made based upon the absolute benefits and harms of a particular treatment and not the relative benefits and harms. Now suppose there are two hypertensive patients:.
This patient has a predicted year risk of having a major atherosclerotic cardiovascular event of 3 percent calculator 1. This patient has a predicted year risk of having a major atherosclerotic cardiovascular event of 20 percent calculator 1.
Usually, the relative risk reduction of a treatment is similar across different patients and populations with different baseline risk [ 16 ]. Thus, for both patients presented above, antihypertensive therapy would reduce the relative risk of cardiovascular events by 20 percent.
However, the first patient would have an absolute risk reduction of 0. In a population similar to the first patient, patients would need antihypertensive therapy for 10 years to prevent one major cardiovascular event; in a population similar to the second patient, 25 patients would require therapy for 10 years to prevent one event.
The conclusion from this hypothetical example, that the absolute benefit from therapy is larger among higher-risk as compared with lower-risk patients despite similar reductions in relative risk, is supported by various studies [ 17,18 ]. As an example, in a meta-analysis of 11 randomized trials comparing antihypertensive therapy with placebo, patients were risk stratified according to their estimated five-year risk of having a major cardiovascular event ie, myocardial infarction, stroke, heart failure using information in addition to their blood pressure, which included their age, sex, body mass index, and prior history of cardiovascular disease, smoking, and diabetes [ 18 ].
The relative risk of major cardiovascular events was significantly reduced by antihypertensive therapy to a similar degree regardless of the overall five-year risk.
However, the absolute benefit varied significantly, for example:. Goal blood pressure in higher-risk patients — In general, more aggressive blood pressure goals are appropriate for higher-risk patients.
These types of blood pressure measurements are defined and discussed above. See 'Importance of how blood pressure is measured' above.
The best data come from SPRINT, a multicenter, randomized, open-label trial performed in the United States [ 19,20 ]. SPRINT enrolled patients aged 50 years or older, more than 90 percent of whom were on antihypertensive therapy, who had a systolic blood pressure of to mmHg.
Clinical or subclinical cardiovascular disease was present in 22 percent of patients. Blood pressure during the trial was measured using attended or unattended AOBPM. AOBPM is discussed in detail elsewhere.
See 'Importance of how blood pressure is measured' above and "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Type of measurement devices'. Antihypertensive therapy consisted of an angiotensin-converting enzyme ACE inhibitor or angiotensin receptor blocker ARB; but not both , a long-acting dihydropyridine calcium channel blocker typically amlodipine , or a thiazide-like diuretic ie, chlorthalidone rather than hydrochlorothiazide or a combination of these drugs to achieve the blood pressure target; other antihypertensive medications were added if needed.
Medications were actively withdrawn in the standard treatment group if systolic blood pressure was below to mmHg, even in asymptomatic patients.
In both groups, medications were altered or discontinued if patients developed adverse effects, and, at one year, approximately one-half of the patients in the intensive-treatment arm attained a systolic pressure less than mmHg; the mean systolic pressures in the two groups at one year were and mmHg, and the mean number of antihypertensive medications used were 2.
The trial was halted early for benefit after a median follow-up of 3. This difference was due to differences in the rates of heart failure 1. Among those with known cardiovascular disease at baseline, the risk of the primary endpoint was also lower However, in the majority of patients, AKI was either mild 61 percent overall had stage 1 AKI or moderate 17 percent had stage 2 , and AKI completely or partly resolved in approximately 95 percent of patients.
Mild to moderate AKI does not typically warrant reduction of antihypertensive therapy unless hyperkalemia is also present [ 22 ].
However, this excess of new-onset CKD in the intensive group was accompanied by decreased, rather than increased, levels of kidney injury biomarkers [ 24 ]. This suggests that an increase in creatinine during intensive blood pressure lowering may reflect a benign functional and reversible change in GFR due to reduced blood flow rather than parenchymal kidney damage [ ].
Syncope 3. In addition, there were no differences between treatment groups with respect to physical and mental health-related quality of life, symptoms of depression, or satisfaction with care [ 27 ]. There was also no increase in the development of dementia; conversely, intensive blood pressure lowering reduced the rate of mild cognitive impairment 6.
However, a variety of factors are likely to affect the applicability of the findings:. Thus, the rate of adverse events reported in SPRINT may be an underestimate of the adverse event rate that would be seen with intensive treatment in routine practice.
In addition, patients in routine practice may require more antihypertensive medications than participants in SPRINT the average was three in the intensive treatment group, and approximately one-fourth required four or more medications , and this could increase risk of adverse events.
Routine systolic pressure measurements are usually higher than AOBPM measurements by 5 to 15 mmHg. By contrast, many older adults with isolated systolic hypertension have low diastolic pressure ie, less than 60 to 65 mmHg at baseline; such patients may not tolerate aggressive lowering of the systolic pressure, particularly those who have existing coronary artery disease.
See 'Older adults with isolated systolic hypertension' below. In addition, high-quality meta-analyses found that more versus less intensive blood pressure lowering produced cardiovascular benefits [ ]. As an example, a meta-analysis of 19 goal blood pressure trials excluding SPRINT combining 44, patients found a significant reduction in major cardiovascular events with more intensive as compared with less intensive blood pressure lowering RR 0.
Evidence supporting lower blood pressure targets also comes from trials that examined the effects of adding an antihypertensive medication, as compared with placebo, to the existing regimen among patients with known cardiovascular disease and a baseline blood pressure that was already below mmHg using routine measurements.
Most, but not all, of these placebo-controlled trials, including Heart Outcomes Prevention Evaluation HOPE , European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease EUROPA , Prevention of Events with Angiotensin-Converting Enzyme Inhibition PEACE , Comparison of Amlodipine vs Enalapril to Limit Occurrences of Thrombosis CAMELOT , Telmisartan Randomised Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease TRANSCEND , and Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research NAVIGATOR , evaluated the hypothesis that ACE inhibitors or ARBs might have a direct and clinically significant cardiovascular benefit [ ].
A meta-analysis focused on seven trials that limited therapy to either an ACE inhibitor or an ARB versus placebo in patients with ischemic heart disease and preserved left ventricular systolic function [ 47 ].
In six trials, ACE inhibitor therapy including HOPE, EUROPA, CAMELOT, and PEACE significantly reduced both total mortality RR 0. A limitation to this meta-analysis is that it did not distinguish between angiotensin inhibition and lower attained blood pressure as the mechanism of benefit.
This limitation was overcome in a meta-analysis that included 25 placebo-controlled trials with more than 63, patients in which active treatment consisted of all major classes of antihypertensive drugs, including ACE inhibitors, ARBs, beta blockers, calcium channel blockers, diuretics, or combination therapy [ 48 ].
Drug therapy significantly lowered the risks of all-cause mortality and myocardial infarction to the same degree as in the earlier meta-analysis pooled RR 0. Rather, the benefit seen likely resulted from blood pressure lowering. The absolute risk reductions in all-cause mortality and myocardial infarction were 14 and 13 per persons treated.
However, recommendations based upon SPRINT and these meta-analyses should not necessarily be applied to patients who are at low risk of having a cardiovascular event. See 'Goal blood pressure in lower-risk patients' below. Prior history of ischemic stroke or transient ischemic attack — Our suggestions for target blood pressure in patients with a prior ischemic stroke or TIA are, for the most part, the same as in other patients with established cardiovascular disease.
See 'Patients with established atherosclerotic cardiovascular disease' above. However, some patients, such as those with uncorrected hemodynamically significant large artery disease ie, of the internal carotid, middle cerebral, vertebral, or basilar artery , may develop ischemic symptoms with intensive blood pressure lowering and are at higher risk for recurrent stroke [ 50,51 ].
Such patients require a less intensive goal. See "Antihypertensive therapy for secondary stroke prevention" and "Evaluation of carotid artery stenosis". The main trial evaluating specific blood pressure targets in patients with ischemic stroke was the Secondary Prevention of Small Subcortical Strokes SPS3 study, which randomly assigned patients mean age of 63 years with recent two weeks to six months lacunar ie, small vessel infarction to a systolic blood pressure target of either to mmHg or less than mmHg using routine measurements [ 52 ].
Treatment was open label, using drugs from each of the major classes of antihypertensive medications prescribed by the local clinician. At one year, the achieved average systolic blood pressures for the higher- and lower-target groups were and mmHg, respectively, and the mean 11 mmHg difference between the groups was sustained for the duration of the study.
Patients assigned to the lower blood pressure target group were treated with a greater number of antihypertensive medications compared with the higher-target group mean of 2.
The following outcomes were reported [ 52 ]:. Similarly, the rate of a composite outcome of myocardial infarction or vascular death was nonsignificantly reduced in the lower blood pressure group.
Thus, the SPS3 results suggest, but do not establish, that a systolic blood pressure target of less than mmHg using routine blood pressure measurement is beneficial and safe for preventing recurrent stroke in patients with small vessel ischemic stroke.
In addition to SPS3, findings from other trials also suggest that lower blood pressures are associated with better outcomes. This trial had many limitations, including a nearly 30 percent drop-out rate, a low number of events, and a minimal systolic pressure separation between the intensive and standard groups versus mmHg, respectively.
However, the rate of major cardiovascular events was nonsignificantly lower in the intensive treatment group 1 versus 5 events. A variety of other trials in patients with prior stroke examined attained rather than target blood pressure; most, but not all, found that lower achieved blood pressure was associated with fewer recurrent strokes [ ].
However, such patients are often prescribed multiple specific drugs to improve survival and reduce morbidity, independent of the blood pressure, including inhibitors of the renin-angiotensin system eg, ACE inhibitors, ARBs, or ARB-neprilysin inhibitors , beta blockers, diuretics, and, in selected patients, mineralocorticoid receptor antagonists and sodium-glucose co-transporter 2 SGLT2 inhibitors.
Thus, achieved blood pressure in these patients is frequently much lower than these thresholds. Many experts consider the goal of therapy to be the lowest blood pressure that is not associated with symptoms of hypotension or evidence of hypoperfusion eg, worsening azotemia.
In some patients with severe HFrEF, this may be a systolic pressure as low as 90 mmHg. See "Overview of the management of heart failure with reduced ejection fraction in adults".
These goals are consistent with those for other patients at high cardiovascular risk. See "Treatment of hypertension in patients with heart failure". Although various trials and meta-analyses have found that more intensive blood pressure lowering can reduce incident heart failure and heart failure-associated morbidity, there are no specific trials of goal blood pressure in patients with HFrEF or HFpEF.
Thus, our suggested targets in patients with heart failure are based upon low-quality data. Routine and non-routine blood pressure measurements are defined and discussed above.
Support for our recommendations comes from randomized trials, meta-analyses, and large observational studies [ , ]. The largest trial ACCORD was a goal blood pressure trial that found no benefit from a more intensive goal systolic blood pressure less than mmHg as compared with a less intensive goal systolic blood pressure less than mmHg , other than a 53 percent relative reduction in the risk of stroke [ 59 ].
However, patients in ACCORD were also randomized to intensive or standard glycemic control ie, it was a two-by-two factorial trial , and, in the standard glycemic control arm, the more intensive blood pressure group had fewer major cardiovascular events [ 64 ]. The ACCORD trial enrolled patients with type 2 diabetes and either known cardiovascular disease or at least two additional cardiovascular risk factors; patients were randomly assigned to either systolic blood pressure goal less than mmHg or a systolic blood pressure goal less than mmHg.
Blood pressure was measured with AOBPM. Intensive therapy was also associated with a significantly higher rate of an increase in serum creatinine of more than 1.
Although the results from ACCORD found that intensive blood pressure lowering did not reduce cardiovascular events apart from stroke, patients were also randomized to intensive or standard glycemic control ie, it was a two-by-two factorial trial , and the effect of intensive blood pressure lowering can also be analyzed according to glycemic control assignment [ 64 ].
This result is important because the intensive glycemic goal implemented in the ACCORD trial is not recommended owing to a higher rate of cardiovascular disease and mortality.
Nevertheless, the benefits of a lower goal blood pressure may not extend to patients with relatively strict glycemic control. In addition, three high-quality meta-analyses found that more intensive blood pressure lowering produced cardiovascular benefits in diabetic patients [ ].
As an example, a meta-analysis of 19 goal blood pressure trials including 5 trials of diabetic patients combining 44, patients found a significant reduction in major cardiovascular events with more intensive as compared with less intensive blood pressure lowering RR 0.
The effect of intensive blood pressure lowering in the 5 trials of diabetic patients was similar RR 0. All-cause mortality was also lower with intensive treatment, but this was not statistically significant RR 0. Based upon data from goal blood pressure trials in diabetic patients, plus indirect data from SPRINT which included patients who, like those with diabetes, have a high cardiovascular risk [ 19,20,65 ], we suggest a goal systolic pressure of to mmHg if non-routine readings are used or to mmHg if routine measurements are used to measure blood pressure, rather than a goal systolic pressure of less than mmHg.
These recommendations are broadly consistent with those made by the American Diabetes Association ADA , which suggests attaining a lower blood pressure to a systolic of to mmHg among those who can tolerate such therapy [ 66,67 ].
We recognize that, even with the large number of trials and total patients studied, the blood pressure goals we propose are based upon studies with a variety of patient populations, treatment goals, treatment approaches, and primary endpoints. Overall, however, the available data suggest important benefits from intensive blood pressure control, despite the risk of modest adverse events.
The different types of blood pressure measurement are defined and discussed above. Our advice is broadly consistent with guidelines from the Kidney Disease: Improving Global Outcomes KDIGO clinical practice statement [ 68 ] and is mainly justified by a reduction in cardiovascular disease and mortality and not by a reduction in CKD progression [ 69 ].
The mortality benefit from aggressive blood pressure lowering is most evident when patients are followed over the long term ie, during post-trial follow-up , although an early reduction in mortality was noted in SPRINT. Several meta-analyses have synthesized the effects of more intensive blood pressure lowering on the progression of CKD, as well as the risk of death, in patients with and without proteinuria [ ].
Proteinuria was variably defined in these studies as a protein-to-creatinine ratio greater than 0. The following examples are illustrative:. More intensive blood pressure control was associated with reduced overall mortality HR 0.
Aggressive blood pressure lowering also reduced the progression to ESKD HR 0. However, long-term post-trial follow-up of those patients with proteinuria revealed a benefit on the incidence of ESKD RR 0. The investigators did not report the risk of death during long-term follow-up.
The three major goal blood pressure trials of patients with CKD AASK, MDRD, and SPRINT included different patient populations, examined different blood pressure targets, and used different methodology to measure blood pressure. Yet, as noted above, all three reached similar conclusions about the benefit of more intensive blood pressure lowering:.
At a mean follow-up of approximately four years, the mean rate of change in GFR and other kidney parameters was not different between the two groups. The use of ACE inhibitors and ARBs was similar in the two groups.
As was observed during the trial phase, there was no difference between groups in the progression of kidney disease defined as doubling of the serum creatinine, a diagnosis of ESKD, or death.
However, among patients with a baseline urine protein-to-creatinine ratio of greater than 0. By contrast, patients with urine protein-to-creatinine ratios less than 0. After the cohort phase was complete, AASK participants were followed for a median of 14 years for the occurrence of ESKD and death using the United States Renal Data System USRDS , the national ESKD registry, and the Social Security Death Index [ 72 ].
The effect of more intensive blood pressure control on the incidence of ESKD depended upon whether or not patients had proteinuria HR 0.
By contrast, the benefit of aggressive blood pressure lowering on mortality did not vary according to proteinuria HR 0. A subsequent study reported the long-term outcomes of patients enrolled in the initial MDRD study [ 78 ].
After the study was completed in , all participants were passively followed until for the incidence of kidney failure defined as dialysis or kidney transplantation and all-cause mortality.
The mean difference in blood pressure between the two groups during the trial phase was 7. On intention-to-treat analysis, patients in the aggressive control group were significantly less likely to experience kidney failure adjusted HR 0.
Kidney failure accounted for approximately 90 percent of events, and a hazard ratio was not provided for mortality alone. The following findings were noted among SPRINT participants who had CKD at baseline:. However, the result in the CKD subgroup was nonsignificant, possibly because of reduced statistical power.
By contrast, intensive blood pressure lowering increased the risk of a 30 percent or greater decline in eGFR. However, this decline principally occurred in the first six months of the trial, suggesting an acute hemodynamic effect of a lower blood pressure; after six months, the rate of change in eGFR differed only slightly annual decline of 0.
However, we suggest a less aggressive systolic goal blood pressure of to mmHg routine measurements or to mmHg nonroutine measurements in patients with a reduced life expectancy, for example, because of a high burden of comorbidity.
Individualization of blood pressure management is key in this population since the clinical benefit from intensive control is unlikely to be realized within one to two years [ 79 ]. Goal blood pressure in older adults, measured using AOBPM, was examined in SPRINT [ 80 ]. The benefit from more intensive blood pressure control was present in both fit and frail older adults.
Serious adverse events were similar in the two treatment groups and did not depend upon frailty. A meta-analysis of 10, hypertensive adults aged 65 years or older combined these results from SPRINT with three other large randomized goal blood pressure trials [ 81 ].
After a mean follow-up of 3. Rates of stroke and myocardial infarction were also lower, but the results were not statistically significant. Achieved systolic blood pressure, assessed using standardized office-based blood pressures table 1 , was mmHg in the more intensive group and mmHg in the less intensive group.
All-cause mortality was not significantly different 1. Hypotension was more common in the intensive group, but other major adverse events eg, syncope, fracture, worsening kidney function were similar between the groups.
The findings from this trial are generally consistent with those from SPRINT, although the population studied was lower risk at baseline and the difference in attained systolic blood pressure was smaller than in SPRINT.
Blood pressure goals may not be easy to achieve in older adults, particularly in those with a baseline systolic pressure greater than mmHg. If attaining goal blood pressure proves difficult or overly burdensome for such patients, the systolic pressure that is reached with two or three antihypertensive agents even if above target may be a reasonable interim goal.
Once maximally tolerated therapy is reached and blood pressure control remains suboptimal, then additional efforts to engage older adults in healthful lifestyle change can facilitate better blood pressure control. One potential limitation to achieving goal blood pressure is that lowering the blood pressure may impair mental function, leading to manifestations such as confusion or sleepiness.
In such patients, antihypertensive therapy should be reduced, and the systolic pressure should be allowed to rise to a level at which these symptoms resolve.
More gradual and much slower lowering of blood pressure may then be pursued in an attempt to attain goal blood pressure [ 28 ]. Older adults with isolated systolic hypertension — When treating older patients with isolated systolic hypertension, we and others suggest a minimum on-treatment diastolic pressure of 55 to 60 mmHg using office-based blood pressure [ ].
In such cases, the level of systolic blood pressure that is reached with two or three antihypertensive agents even if greater than the goal presented above may be a more reasonable goal [ 87 ].
See "Treatment of hypertension in older adults, particularly isolated systolic hypertension". A concern when treating older adult patients with isolated systolic hypertension is that the low diastolic pressure after therapy may impair tissue perfusion particularly coronary perfusion and possibly increase cardiovascular risk ie, the "J-curve" figure 3 and figure 4 [ ].
Various long-term observational studies in patients with hypertension have reported a nadir of cardiovascular complications at a diastolic pressure of approximately 80 mmHg. Thus, the incidence of cardiovascular complications is higher among those who achieve diastolic pressures greater than 80 to 85 mmHg, as well as among those who achieve diastolic pressures less than 75 to 80 mmHg and particularly below 70 mmHg [ 85,91, ].
Although lower attained diastolic pressures are associated with worse outcomes both cardiovascular and noncardiovascular in these studies, this finding is present in both treated and untreated ie, placebo-treated patients and also in trial patients assigned to less intensive blood pressure goals figure 5 [ , ].
These findings suggest that the worse outcomes at lower diastolic pressures are probably explained by poor health in patients who have lower diastolic pressures and not necessarily an adverse effect of antihypertensive therapy.
See "Treatment of hypertension in older adults, particularly isolated systolic hypertension", section on 'Importance of diastolic pressure'. Nevertheless, there may be a threshold diastolic blood pressure below which adverse cardiovascular outcomes might increase in older adult patients, particularly in those with coronary heart disease because much of coronary filling occurs during diastole.
Non-routine and routine blood pressure measurements are defined and discussed above. The best data come from SPRINT, which are presented above in detail. One inclusion criteria in SPRINT was an estimated year risk for a future cardiovascular event of 15 percent or greater; patients met this criteria 76 percent of those enrolled [ 19,20 ].
In this subgroup, intensive blood pressure lowering significantly reduced the rate of myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death 4.
A subsequent meta-analysis of 16 goal blood pressure trials and 52, patients examined the relative and absolute effects of more versus less intensive blood pressure lowering [ 17 ]. Nonsignificant relative risk reductions were found for heart failure 0.
However, absolute benefits from blood pressure lowering were greater among patients who were higher risk at baseline. Thus, patients with an estimated year cardiovascular disease event risk of 10 percent or greater appear to derive an important benefit from intensive blood pressure lowering, although it is likely that the benefit is greater among those whose risk is 15 percent or greater compared with those whose risk is 10 to 14 percent.
However, there is some disagreement among UpToDate authors and editors. Some experts suggest that lower-risk patients with stage 2 hypertension ie, patients with systolic pressure at least mmHg or diastolic pressure at least 90 mmHg and who therefore qualify for antihypertensive therapy should have the same goal blood pressure as patients who are higher risk.
The absolute benefit of blood pressure lowering is much lower in lower-risk as compared with higher-risk patients, although relative risk reductions are similar.
See 'Why baseline risk matters: Absolute versus relative risk' above. There are no goal blood pressure trials ie, trials that compared different target blood pressures in lower-risk patients. However, there are three large trials of lower-risk patients that compared antihypertensive therapy with placebo.
All three trials performed standardized office blood pressure measurement. However, among the subgroup whose initial systolic pressure was in the highest tertile ie, greater than mmHg , antihypertensive therapy reduced the incidence of major cardiovascular events 5.
There was no effect on all-cause mortality. The treated groups had significantly lower rates of all cardiovascular events 6. The main endpoint was total mortality at five years, which was significantly lower with stepped care 5. The magnitude of benefit was similar but not quite significant for the almost patients with an entry diastolic pressure of 90 to 94 mmHg absolute benefit 1.
The average attained diastolic pressure was 85 to 90 mmHg in the stepped care; systolic pressures were not given. Because blood pressure lowering in such patients is likely to reduce the relative risk, and because blood pressure is unlikely to spontaneously decrease, treatment to below this threshold may eventually produce an important absolute risk reduction over the long term.
Thus, some expert contributors to UpToDate, as well as some guideline statements [ 1 ], suggest the more intensive blood pressure goal for lower-risk in addition to higher-risk patients. See 'Overview of our approach' above. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Hypertension in adults". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.
There are two ways to performed high-quality, standardized office blood pressure measurement: automated oscillometric blood pressure monitoring AOBPM , which requires specialized equipment, and standardized office-based measurement using proper technique table 1 , which requires only ordinary equipment.
These two methods of measuring blood pressure in the office provide readings that approximate daytime ambulatory blood pressure using ambulatory blood pressure monitoring [ABPM] and self-measured home blood pressure monitoring. These four methods, while superior, are uncommonly performed and therefore are referred to as "non-routine.
Although it is an inferior method of measurement, it is faster and potentially less cumbersome and is the one primarily used in clinical practice and therefore is referred to as "routine" measurement.
See 'Prior history of ischemic stroke or transient ischemic attack' above. See 'Patients with heart failure' above. See 'Patients with diabetes mellitus' above. See 'Patients with chronic kidney disease' above. See 'Older adults' above. However, we suggest a less aggressive systolic goal blood pressure of to mmHg routine measurements or to mmHg non-routine measurements in patients with a high burden of comorbidity and also in older adults with postural hypotension.
See 'Patients with multiple cardiovascular risk factors' above. See 'Goal blood pressure in lower-risk patients' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in.
Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Goal blood pressure in adults with hypertension. Formulary drug information for this topic.
No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Authors: Johannes FE Mann, MD Karl F Hilgers, MD Section Editors: George L Bakris, MD William B White, MD Scott E Kasner, MD David M Nathan, MD Deputy Editors: John P Forman, MD, MSc Karen Law, MD, FACP Contributor Disclosures.
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Feb 08, OUR APPROACH TO GOAL BLOOD PRESSURE Overview of our approach — A variety of randomized trials have addressed the issue of goal blood pressure in patients with hypertension.
At a mean follow-up of 4. Hypertension ; e Muntner P, Carey RM, Gidding S, et al. Circulation ; Egan BM, Zhao Y, Axon RN.
US trends in prevalence, awareness, treatment, and control of hypertension, JAMA ; Bakris G, Sorrentino M. Redefining Hypertension - Assessing the New Blood-Pressure Guidelines. N Engl J Med ; Bress AP, Tanner RM, Hess R, et al.
Generalizability of SPRINT Results to the U. Adult Population. J Am Coll Cardiol ; Bress AP, Bellows BK, King JB, et al. Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control. Moise N, Huang C, Rodgers A, et al. Comparative Cost-Effectiveness of Conservative or Intensive Blood Pressure Treatment Guidelines in Adults Aged Years: The Cardiovascular Disease Policy Model.
Hypertension ; Richman IB, Fairley M, Jørgensen ME, et al. Cost-effectiveness of Intensive Blood Pressure Management. JAMA Cardiol ; Bress AP, Kramer H, Khatib R, et al. Potential Deaths Averted and Serious Adverse Events Incurred From Adoption of the SPRINT Systolic Blood Pressure Intervention Trial Intensive Blood Pressure Regimen in the United States: Projections From NHANES National Health and Nutrition Examination Survey.
Pappaccogli M, Di Monaco S, Perlo E, et al. Comparison of Automated Office Blood Pressure With Office and Out-Off-Office Measurement Techniques. Bakris GL. The Implications of Blood Pressure Measurement Methods on Treatment Targets for Blood Pressure. Myers MG, Kaczorowski J, Dawes M, Godwin M.
Automated office blood pressure measurement in primary care. Can Fam Physician ; Filipovský J, Seidlerová J, Kratochvíl Z, et al. Automated compared to manual office blood pressure and to home blood pressure in hypertensive patients.
That could be enough to hide high blood pressure, start you on a drug you don't really need, or lead your doctor to incorrectly adjust your medications. National and international guidelines offer specific instructions for measuring blood pressure.
If a doctor, nurse, or medical assistant isn't doing it right, don't hesitate to ask him or her to get with the guidelines. The best position to take your blood pressure is seated in a chair with your feet on the floor and your arm supported so your elbow is at about heart level.
You should remain in this position throughout the measurement. It's a good idea to have your blood pressure measured in both arms at least once, since the reading in one arm usually the right may be higher than that in the left. In general, the arm-to-arm difference in systolic blood pressure is 5 points or less.
If the difference is consistently greater than 10 points between the two arms, let your doctor know. This could be a sign that you have more than expected arterial plaque buildup. There are times to break these rules.
If you sometimes feel lightheaded when getting out of bed in the morning or when you stand after sitting, you should have your blood pressure checked while seated and then while standing to see if it falls from one position to the next.
Blood pressure is now categorized as follows :. Because blood pressure varies throughout the day, your doctor will rarely diagnose hypertension on the basis of a single reading.
Instead, he or she will want to confirm the measurements on at least two occasions in the office, or have you measure your blood pressure yourself with a home monitor.
Howard E. LeWine, MD , Chief Medical Editor, Harvard Health Publishing. As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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I'm Dr. Leslie Thomas, a nephrologist at Mayo Glutathione natural sources. And I'm cotnrol to pgessure some of the important questions you might have about hypertension. Measuring your blood pressure at home is a straightforward process. Many people have a slightly higher blood pressure in one arm versus the other. So it's important to measure the blood pressures in the arm with the higher readings. New Techniques for blood pressure control shows little risk Technques infection Techjiques prostate biopsies. Discrimination at work is linked to high blood pressure. Boost energy for better concentration fingers and Techniques for blood pressure control Poor circulation or Conrol phenomenon? To determine whether Tefhniques have hypertensiona medical professional will take a blood pressure reading. That could be enough to hide high blood pressure, start you on a drug you don't really need, or lead your doctor to incorrectly adjust your medications. National and international guidelines offer specific instructions for measuring blood pressure. If a doctor, nurse, or medical assistant isn't doing it right, don't hesitate to ask him or her to get with the guidelines.
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