This article elaborates on the clinical practice guideline from the American Academy of Family Physicians (AAFP) which recently outlined new blood pressure targets for adults who have hypertension. 

Hypertension is one of the most often treated conditions, therefore one may assume that definitive recommendations would have been established long ago.

1. JNC 8 advised in 2014 that the target blood pressure (BP) should be:

1. For people under the age of 60 be less than 140/90.
2. More than 60 be less than 150/90.

2. The American Heart Association revised their hypertension guidelines in 2017 

1. It recommends keeping blood pressure below 130/80 for most people, primarily on the basis of the SPRINT study (which included only persons with or at significantly higher risk for atherosclerotic cardiovascular disease).
2. Currently, the AAFP advises a blood pressure reading of less than 140/90. This is not a modest shift because lowering blood pressure objectives frequently necessitates the use of additional medications, and extra medications might have negative side effects.
3. Adults with hypertension, whether or not they have cardiovascular disease, are covered by the AAFP recommendation. In the thorough evaluation of the literature, the studies lasted an average of 3.7 years, and around 75% of the participants had no history of cardiovascular disease.

Their conclusions' primary finding is that total mortality did not statistically significantly decrease at target blood pressures lower than 140/90. Lower targets, however, resulted in a nominal rise in significant adverse events that didn't achieve statistical significance. Serious adverse events were those that resulted in death, the need for hospitalisation, or major impairment.

The requirement of additional medication on average in order to achieve low blood pressure targets was another potential drawback. According to one systematic analysis, the lower target BP groups had an eightfold greater withdrawal rate as a result of unfavourable outcomes.

While there was no change in mortality or stroke with lower blood pressure targets, according to the AAFP guidelines, a minor additional benefit was seen in myocardial infarction, which had a 16% lower incidence and a number needed to treat 137 over 3.7 years.

The AAFP recommendations

1. They continue by stating that while treating to a lower blood pressure target does not provide additional mortality benefit, a target blood pressure of less than 135/85 can be taken into consideration to reduce the risk for MI, noting that lower blood pressure may increase harm. This statement is graded as a weak recommendation. According to them, the lower BP target might be taken into account based on the preferences and values of the patient.
2. The AAFP recommendation is really beneficial. The American Heart Association (AHA) and AAFP, two major groups, have different guidelines as a result of two factors. While the American Heart Association (AHA) appears to have prioritised composite endpoints in trials like SPRINT, which enrolled only high-risk patients, the American Academy of Family Physicians (AAFP) appears to have chosen mortality as the primary endpoint in a more diverse patient population that included both high- and low-risk individuals.
3. Furthermore, it seems the two groups place distinct emphasis on bad events when reaching their respective conclusions. Evidently, more bad events occur while attempting to reduce BP, and in clinical practice, patients are very concerned about such occurrences.
4. It's interesting to note that the International Society of Hypertension advises most people to aim for a blood pressure of 140/90 as their "essential" target, while those under 65 might choose to aim for 130/80 as their "ideal" target. Always keep in mind that there may be alternative recommendations for specific comorbidities.
5. Guidelines from the AHA/American Stroke Association in 2021 advocate a BP of 130/80 for the prevention of recurrent stroke, while both the International Society for Hypertension and the AHA recommend a BP of 130/80 for those with established atherosclerotic cardiovascular disease. The American Diabetes Association amended their target BP for those with diabetes to 130/80 this year.

Two suggestions are included in the clinical practice guideline for hypertension

1. First, in order to lower the risks of both cardiovascular and all-cause mortality, the AAFP advises that doctors treat people with hypertension to a standard blood pressure goal of less than 140/90 mm Hg. This is a strong suggestion supported by credible evidence. Based on patient choices and values, treatment to a lower blood pressure goal of less than 135/85 mm Hg may be considered; nevertheless, the lower target does not provide any significant advantage for reducing death.
2. Second, to lessen the risk of myocardial infarction, the AAFP advises doctors to treat people with hypertension to a lower blood pressure goal of fewer than 135/85 mm Hg. Based on data of mediocre quality, this is a weak recommendation. Although lowering blood pressure to the conventional goal of less than 140/90 mm Hg decreased the risk of MI, there was only a small incremental benefit shown with a lower blood pressure target; there was no further benefit seen in avoiding a stroke.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.