By Robert Walton
In this blog for people with cardiovascular disease taking treatment for high blood pressure, Robert Walton, a Cochrane UK Senior Fellow in General Practice, looks at the latest Cochrane evidence on what blood pressure targets to aim for, balancing the benefits of treatment against the risk of side effects.
Originally published: 5 October 2018. Revised and republished: 13 April 2023 to reflect the latest guidance and Cochrane evidence.
Take-home points
So you want to stay healthy and live to a ripe old age? But the doctor says your blood pressure is too high and you have started taking medication to bring it down. What should your blood pressure be and when do you stop trying to make it lower?
These are really important questions but until recently there was very little evidence on which to base your decision. Now there is an updated Cochrane Review that could help you to decide what your blood pressure target should be (Saiz et al. 2022), so you know what goal you need to achieve to reduce the chances of problems in the future.
But first, let’s have a look at existing recommendations for blood pressure targets and then see where the new review takes us.
A US perspective on blood pressure
An influential report by the American College of Cardiology and American Heart Association a few years ago reflected the views of some doctors both in the US and in Europe that blood pressure targets are currently set too high (Whelton et al, 2017). So, experts were thinking that many people would benefit from lower blood pressure than they are currently achieving.
Aiming for lower blood pressure seems to make sense because we know from large studies in different populations that the risk of heart disease and stroke rises steadily as blood pressure increases and, although there has been some debate on the subject, people with the lowest blood pressures generally are at lowest risk (Rapsomaniki et al, 2014).
So, does all that apply to people who have already had problems with cardiovascular disease who are taking blood pressure treatment? Well, the US guidelines presume that it does and suggest that blood pressure should be kept below 130/80. This new guidance (2022) caused a stir since doctors and patients alike began to wonder how the targets can be achieved.
Many people already take two or more drugs to control their blood pressure and would need higher doses or extra medication to move their blood pressure below the new target. With the increased medication load comes an increased risk of side effects and people may want to balance the benefits in the reduction of cardiovascular disease against the unwanted effects of drugs.
Is Europe in agreement with lower blood pressure targets?
Having previously recommended much higher targets than the USA, European guidelines (2021) have now become much more ambitious. Whilst agreeing with the US position that 130/80 should be a general target, the Europeans go further saying that in people under the age of 66 efforts should still be made to reduce blood pressure, acknowledging that many people can achieve systolic blood pressure less than 120mmHg without unwanted effects.
What about the guidance in the UK?
The National Institute for Health and Care Excellence (NICE) recently updated its advice (2022) which is neatly summarised in this visual summary. Perhaps as a result of the Covid pandemic most people in the UK tend to take their own blood pressure at home now and NICE has set the target for home blood pressure at 135/85, so somewhat higher than Europe and the USA.
So where does that leave us?
This helpful Cochrane Review, updated in November 2022, looks specifically at whether risk of death is lower in people with cardiovascular disease who achieve lower blood pressure targets. In this review, the lower target blood pressure was defined as 135/85. The review went on to assess the risk of unwanted effects from blood pressure treatment by looking at the number of people who dropped out of trials because of drug side effects.
Interestingly there was probably little or no difference in risk of death in people in the lower blood pressure target group compared to those in the standard target group. More people may have needed to leave the studies because of unwanted effects when they tried to achieve the lower blood pressure targets although there may be no increase in serious side effects.
Currently, then, there is no Cochrane evidence to suggest a benefit in aiming for lower blood pressure as suggested by the US and the EU. But several trials are in progress that will give us more detailed information on this important issue.
Join in the conversation on Twitter with @CochraneUK or leave a comment on the blog.
Robert Walton has nothing to disclose.
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About Robert Walton
Robert Walton is a Cochrane UK Senior Fellow in General Practice. Robert qualified in medicine in London in 1983, having taken an intercalated degree in human pharmacology and immunology. He trained at St Georges Hospital, London and became a member of the Royal College of Physicians in 1986. His work applying computerised decision support to prescribing drugs in the Department of Public Health and Primary care in Oxford led to a doctoral thesis in 1998. Robert was elected a Fellow of the Royal College of General Practitioners in 1999 and the Royal College of Physicians in 2001. He became a Senior Investigator in the National Institute for Health Research (NIHR) in 2016. Robert is Clinical Professor of Primary Medical Care at Queen Mary and was joint lead of the NIHR Research Design Service east London team. His research interests are in primary care, genetics, clinical trials and personalised medicine. Robert led a five-year NIHR funded programme developing a novel training intervention to promote smoking cessation in pharmacies in east London which included a substantive Cochrane review and meta analysis on behaviour change interventions in community pharmacies and a large scale cluster-randomised clinical trial. His research team is also developing a smartphone game to promote smoking cessation and researching a personalised/stratified medicine approach to tobacco dependence using computerised decision support. He sat on the NIHR Programme Grants for Applied Research sub panel A and worked as an evaluator for the European Union Horizon 2020 programmes Global Alliance for Chronic Diseases and New Therapies for Rare Diseases and as a monitor for EU projects. Robert contributes to UK national guidance, and has served on the National Institute for Health and Care Excellence (NICE) Outcome Indicator and Technology Appraisals Committees
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This post was previously published on evidentlycochrane.net and is republished here under a Creative Commons license.
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