There are some discrepancies among several international guidelines. I summarise the discrepancies among these guidelines for patients with diabetes, CKD and old age, and describe how-to reconcile.
A very controversial topic involves controlling the blood pressure target for hypertension with diabetes. In the treatment for the hypertension with diabetes, until 2012, it was almost universally accepted that the blood pressure control target should be below 130/80 mmHg. However, recent guidelines have increased the target blood pressure to 140 mmHg in systolic blood pressure. Very important evidence to support this change is from the results of ACCORD-BP. In ACCORD-BP, the ratio of stroke/myocardial infarction was 0.3. However, in Japanese epidemiological studies showed a two-fold higher incident rate in strokes than myocardial infarction. Thus, the background of cardiovascular disease is very different between European countries or the United States, and Japan. This point should be considered in each country guidelines.
As the risk of cardiovascular accidents is high in patients with CKD, their early detection is extremely important. KDIGO 2012 indicated the recent stratification for the treatment of hypertension with CKD. The goal of blood pressure lowering therapy in the case of CKD with proteinuria, are achievement of the blood pressure control target of below 130/80 mmHg. However, in CKD without proteinuria, the target blood pressure is 140/90 mmHg. The difference between KDIGO and other guidelines should be discussed.
Considerable evidence has been accumulated from elderly hypertension. HYVET indicated a target blood pressure of 140 to 150 mmHg in patients 80 years and older. Both JATOS and VALISH conducted in Japan indicated no significant differences in groups with blood pressure below 140 mmHg and those with blood pressure below 150mmHg. However, definition of the age of elderly is different among each guidelines.
Recent SPRINT results indicated different pressure goal in CKD and elderly patients. The situation of SPRINT is also discussed.