Heart failure patients should have their systolic blood pressure controlled to under 130 mm Hg, and those at risk for the disease should target less than 130/80 mm Hg, updated guidelines recommended.
The American College of Cardiology/American Heart Association/Heart Failure Society of America focused guideline update cited the SPRINT data in making this change from the prior recommendation to follow JNC7, with its target of 140/90 mm Hg.
Although the landmark SPRINT trial had targeted under 120 mm Hg in people with increased cardiovascular risk (defined as over age 75, established vascular disease, chronic renal disease, or a Framingham Risk Score over 15%), it used a research protocol not typical of clinical practice.
"Blood pressure measurements as generally taken in the office setting are typically 5 to 10 mm Hg higher than research measurements; thus, the goal of <130/80 mm Hg is an approximation of the target blood pressure in conventional practice," said the guidelines published in Circulation, the Journal of the American College of Cardiology, and the Journal of Cardiac Failure.
The adjustment factor to use for SPRINT has been debated by hypertension specialists, as even the protocol for measuring blood pressure in the trial was unclear to many.
Although SPRINT and other trials haven't specifically addressed blood pressure targets in hypertension and heart failure (HF) with either preserved or reduced ejection fraction, the findings were extrapolated to patients with these conditions with a class I recommendation.
The prevention part of the guideline update is important, guideline chair Clyde Yancy, MD, of Northwestern University in Chicago, told MedPage Today. However, he declined to comment on other guidelines.
"I cannot speak for other ACC/AHA guidelines as each committee has a different perspective but for HF, preventing disease is of paramount importance," he said.
Beyond heart failure, an update to the AHA/ACC hypertension guidelines is already underway.
The update to the 2013 heart failure guideline follows another focused update released in 2016, which recommended the angiotensin receptor-neprilysin inhibitor (ARNI) valsartan/sacubitril (Entresto) and ivabradine (Corlanor).
Other changes in the update included:
- A new recommendation for natriuretic peptide biomarker screening for patients at risk of heart failure (class IIa)
- A clarification that the usefulness of those biomarkers to establish prognosis of acutely decompensated heart failure is at admission to the hospital
- Clarification of the medication choice recommendations for heart failure with reduced ejection fraction (HFrEF) now with the addition of ARNI
- Recommendation to replace ACE inhibitor or angiotensin receptor blockers with an ARNI in chronic, symptomatic, NYHA Class II or III HFrEF
- Addition of contraindications to ARNI use
- Recommendation of IV iron for NYHA Class II and III heart failure with iron deficiency as reasonable
- Recommendations on sleep apnea treatment
The update was done in collaboration with the American Academy of Family Physicians, the American College of Chest Physicians, the and International Society for Heart and Lung Transplantation.