How early should blood pressure control be achieved for optimal cardiovascular outcomes?

Abstract

As a consequence of the aging population and the increasing prevalence rates for conditions such as type 2 diabetes and chronic kidney disease (CKD), management of hypertension will be focusing more and more on the high-risk patient. Clinical practice guidelines for managing hypertension in the United States recommend a target blood pressure (BP) o130/80 mm Hg in patients with diabetes or CKD, notably lower than the 140/90-mm Hg threshold for the general hypertensive population. However, the optimal timeframe from initiation of antihypertensive therapy to attaining these levels of BP control and influencing cardiovascular outcomes is not as well defined. Overall, a series of landmark BP intervention trials in patients with hypertension and additional cardiovascular risk factors collectively support that achieving prompt BP control, ideally within 1-3 months, translates into improved cardiovascular outcomes. Although the consistency of the findings is encouraging, the strength of this conclusion is limited by the available data, which were derived from studies not designed to determine the definition or benefits of early BP reduction. In several of these studies, using a treatment approach with initial monotherapy or combination therapy has clearly demonstrated pronounced BP lowering and high BP control rates within an intensive timeframe of 3-6 months of therapy. Although these studies were not conducted exclusively in high-risk patients, subgroup analyses have demonstrated that the observed outcomes in the overall study populations apply to the diabetic and CKD subsets.

Early combination therapy with telmisartan plus amlodipine for rapid achievement of blood pressure goals

“…While these trials were not designed to investigate speed of BP lowering or time to BP goal, there would appear to be some correlation between BP reduction within a certain time frame (1–6 months) and CV outcomes. It has also been suggested that early control of BP may impart a physiological memory that results in outcomes benefits over the long term . This is supported by the results of the Aliskiren and the Calcium Channel Blocker Amlodipine Combination as an Initial Treatment Strategy for Hypertension (ACCELERATE) trial.…”

Nifedipine plus candesartan combination increases blood pressure control regardless of race and improves the side effect profile

“…Fast and sustained blood pressure (BP) control in the management of hypertension is paramount [1,2]. To achieve this objective, many guidelines recommend initial combination therapy, as this approach has advantages related to compliance, efficacy and safety [3–5].…”

Hypertension management initiative prospective cohort study: comparison between immediate and delayed intervention groups

“…This has been associated with improved outcomes in studies of high-risk patients. 26 The mechanism of BP lowering is likely to be a combination of changes in prescriptions of lifestyle and medications as well as changes in adherence to therapy. 27 The use of the hypertension flow sheet may have contributed to the improved documentation and potentially improved assessment of medication therapy as well as a patient-selected lifestyle goal as the flow sheet included a field to document a patient-selected lifestyle goal.…”