🎯 Blood Pressure Targets

💪 SPRINT Trial - Intensive vs Standard

• Population: High-risk non-diabetic patients (N=9,361)
• Targets: <120 mmHg vs <140 mmHg systolic
• Primary Outcome: 25% relative risk reduction
• Absolute Benefit: 1.6% over 3.26 years (2.5% over 5 years)
• NNT: 61 to prevent one primary outcome event
• Mortality Benefit: 27% relative reduction, 1.2% absolute

👴 STEP Trial - Elderly Patients

• Population: Chinese adults age 60-80 years (N=8,511)
• Targets: <130 mmHg vs <150 mmHg systolic
• Primary Outcome: 26% relative risk reduction
• Absolute Benefit: 3.7% over 4 years
• Key Finding: SBP 130-140 mmHg similar outcomes to <130 mmHg
• Safety: Acceptable adverse event profile in elderly

🧠 SPRINT-MIND - Cognitive Outcomes

• Cognitive Focus: Mild cognitive impairment prevention
• Result: 19% reduction in mild cognitive impairment
• Brain Health: Intensive BP control preserves cognition
• Dementia: Trend toward reduced dementia risk
• Implications: Brain protection beyond cardiovascular benefits
• Age Consideration: Midlife hypertension particularly harmful

✅ Benefits of <120 mmHg Target

SPRINT Trial Results (5-year projected)

• All-cause mortality: ARR 1.5% (NNT 67)
• Cardiovascular events: ARR 3.1% (NNT 32)
• Heart failure: ARR 2.3% (NNT 43)
• Stroke: ARR 1.7% (NNT 59)
• Cognitive protection: ARR 1.9% for MCI (NNT 53)
• Renal outcomes: Slower eGFR decline

⚠️ Risks of <120 mmHg Target

SPRINT Trial Adverse Events (5-year projected)

• Syncope: ARI 2.3% vs 0.6% (NNH 59)
• Orthostatic hypotension: ARI 3.4% vs 1.2% (NNH 45)
• Acute kidney injury: ARI 3.8% vs 1.3% (NNH 40)
• Electrolyte abnormalities: ARI 4.9% vs 1.8% (NNH 32)
• Falls with injury: ARI 2.7% vs 1.5% (NNH 83)
• Medication discontinuation: ARI 11.4% vs 5.2% (NNH 16)

🌟 High-Risk Patients

Target: <130/80 mmHg (Class 1 Recommendation)

• Established CVD: CAD, stroke, PAD, heart failure
• Diabetes Mellitus: Type 1 or 2 with any complications
• CKD with Albuminuria: ≥30 mg/g albumin/creatinine ratio
• 10-Year CVD Risk ≥10%: Based on PREVENT calculator
• Evidence: Consistent benefit across multiple trials
• Monitoring: More frequent follow-up required

👴 Elderly Patients (>80 years)

Target: Individualized, Often 140-150 mmHg Systolic

• Frailty Assessment: Consider functional status and life expectancy
• Comorbidity Burden: Multiple conditions may limit benefit
• Fall Risk: Orthostatic hypotension prevention priority
• Cognitive Function: Severe dementia may preclude intensive targets
• Goals of Care: Quality of life vs longevity considerations
• Gradual Approach: Slow titration to avoid complications

🫀 Special Cardiac Conditions

Target: Condition-Specific Considerations

• CAD with Wide PP: Avoid diastolic <70 mmHg
• Heart Failure: <130/80 mmHg if tolerated
• Aortic Stenosis: Careful reduction to maintain perfusion
• Hypertrophic Cardiomyopathy: Avoid excessive reduction
• Post-MI: <130/80 mmHg for secondary prevention
• Atrial Fibrillation: Consider stroke risk in target selection

🫘 Chronic Kidney Disease

Target: <130/80 mmHg Across All CKD Stages

• Unified Approach: Same target regardless of CKD stage
• Albuminuria: RAAS inhibition mandatory if present
• eGFR Monitoring: 30% increase acceptable with RAAS inhibitors
• Progression Prevention: BP control slows CKD advancement
• CVD Protection: Reduced cardiovascular events
• Dialysis Patients: Individualized based on fluid status

📈 Age-Related Changes

• Young Adults (<50): Diastolic BP equally important predictor
• Middle Age (50-59): Systolic becomes predominant
• Elderly (≥60): Only systolic BP remains significant predictor
• Mechanism: Arterial stiffening with aging
• Pulse Pressure: Widens progressively with age
• Clinical Focus: Shift emphasis to systolic in elderly

⚠️ Wide Pulse Pressure Risks

• Definition: Pulse pressure ≥60 mmHg (some use ≥70 mmHg)
• Prevalence: 42% in patients ≥65 years with hypertension
• J-Curve Risk: Diastolic <70 mmHg with CAD increases events
• Coronary Perfusion: Occurs primarily during diastole
• High-Risk Groups: CAD, diabetes, age >75 years
• Management: Target systolic while avoiding low diastolic

📈 Stepwise Approach to Target Achievement

• Initial Goal: <140/90 mmHg for all patients
• Secondary Goal: <130/80 mmHg if tolerated
• Intensive Goal: <120 mmHg systolic in selected patients
• Monitoring Frequency: Every 2-4 weeks during titration
• Medication Adjustment: Add/increase every 2-4 weeks
• Plateau Phase: Monthly monitoring once stable

🏥 Clinical Monitoring Guidelines

• Home BP Monitoring: Essential for accurate assessment
• Laboratory Monitoring: Electrolytes, creatinine every 2-4 weeks
• Symptom Assessment: Dizziness, fatigue, syncope
• Adherence Evaluation: Pill counts, pharmacy records
• Lifestyle Reinforcement: Diet, exercise, weight management
• Complication Screening: Target organ damage assessment

⚠️ Absolute Contraindications

• Symptomatic Hypotension: Dizziness, falls, syncope
• Severe Orthostatic Hypotension: >20/10 mmHg drop
• Limited Life Expectancy: <2-3 years prognosis
• Severe Frailty: High fall risk, cognitive impairment
• Medication Intolerance: Multiple drug allergies/intolerances
• Patient Preference: Informed refusal of intensive therapy

🤔 Relative Contraindications

• Advanced Age: >85 years without clear benefit
• Multiple Comorbidities: Complex medical conditions
• Polypharmacy: >10 medications with interaction risk
• Cognitive Impairment: Moderate-severe dementia
• Recent Stroke: Within 3 months, individualize
• Social Factors: Poor follow-up, medication access issues