(JATOS) or 140– 149 mm Hg (VALISH). The ages of the populations included in the trials the JNC 8 panel cited were ≥ 80 years in HYVET, 70–< 85 years in VALISH, 65–85 years in JATOS, ≥ 60 years in SHEP and Syst-Eur, and ≥ 55 years in Cardio-Sis. The mean BP measurements achieved in the active and/or more intensive treatment groups of these studies were 143.5/77.9 mm Hg, 136.6/74.8 mm Hg, 135.9/74.8 mm Hg, 143/68 mm Hg, 150.8/78.5 mm Hg, and 136/79.2 mm Hg, respectively. The JATOS and VALISH studies—which the JNC 8 panel referred to as showing no additional benefit with lower targets—were statistically underpowered to detect such a benefit due to the very low rates of stroke and CHD reported during follow-up. The majority of these trials suggest that a systolic BP goal of < 140 mm Hg is safe in non-frail, relatively healthy older patients. FEVER (Liu 2005)—a large trial with 9,711 Chinese patients aged 50–79 years that was not included in the JNC 8 review—indicated that a difference in systolic/diastolic BP as small as 4/2 mm Hg (induced by adding low-dose felodipine to low-dose hydrochlorothiazide in the trial) is associated with significant reductions in the incidence of stroke, all CVD, CHD, heart failure, and total mortality. The mean BP achieved at study end (60 months) with the addition of felodipine was 138.1/82.3 mm Hg versus 141.6/83.9 mm Hg with the addition of a placebo. A subgroup analysis for patients aged > 65 years showed a 44% reduction in all strokes (Zhang 2011). 2. The JNC 8 panel did not disallow treatment to < 140 mm Hg systolic BP. In a corollary recommendation, the panel indicated that treatment for hypertension does not need to be adjusted if the treatment results of SBP < 140 mm Hg are not associated with adverse effects on health or quality of life. 3. The JNC 8 panel recommendation for raising the target BP in patients aged ≥ 60 years was not based on a unanimous agreement. Some members argued that there was insufficient evidence to raise the target to 150 mm Hg in high-risk groups such as black persons, those with CVD including stroke, and those with multiple risk factors. This minority group explained that increasing the target would probably reduce the intensity of antihypertensive treatment in a large population at high risk for CVD. The panel agreed that more research is needed to identify optimal goals, yet they still raised the goal for those ≥ 60 years of age. 4. The American Society of Hypertension/International Society of Hypertension 2014 (Weber 2014), Canadian CHEP 2013, European ESC/ESC Task Force 2013, ICSI 2012, and NICE 2011 13 guidelines all recommend a BP goal of < 140/90 mm Hg for the general population aged < 80 years, and < 150/90 mm Hg for those aged 80 years or over. 5. There is a concern that the higher SBP goal for patients aged ≥ 60 years may increase their risk of stroke. 6. The risk of cardiovascular events increases with age, and raising the BP goal for patients aged ≥ 60 years will result in inadequate treatment for some higher-risk patients and deprive others of therapy. This would reduce all the benefits gained in the last few years from reducing blood pressure. Why do we recommend a lower BP target for patients with CKD and albuminuria? The JNC 8 panel recommended a goal of < 140/90 mm Hg for patients aged ≥ 18 years with CKD, based on expert opinion. The guideline panel, however, suggested that patients > 70 years with CKD or albuminuria should receive treatment based on comorbidity, frailty, and other patient-specific factors. They indicated that there was insufficient evidence to support a goal BP of < 140/90 mm Hg in patients > 70 years with CKD or albuminuria. The JNC 8 panel’s evidence review did not include meta-analyses or observational studies. The initial literature search was conducted through December 31, 2009. A second search made through August 2013 was restricted to multicenter RCTs with at least 2,000 participants. More recent evidence from meta-analyses (Lv 2012 and 2013) not reviewed by the JNC 8 panel suggests that intensive blood pressure lowering for patients with chronic kidney disease and proteinuria reduces their risk of major cardiovascular events, composite kidney failure events, and end-stage kidney disease. The most aggressive trials had an SBP target of < 120 mm Hg (in three of the trials included in the analysis) and < 130 mm Hg (in one). The DBP target was < 75 mm Hg in one trial and < 80 mm Hg in two trials. Antihypertensive pharmacological therapies · There is evidence from a large meta-analysis (Law 2009) that lowering systolic blood pressure by 10 mm Hg and/or diastolic blood pressure by 5 mm Hg using any of the five classes of antihypertensive drugs leads to similar risk reduction for CHD and stroke. The more recent Blood Pressure Lowering Treatment Trialists’ Collaboration meta-analysis (2013) also showed that the effects of BP lowering on reducing cardiovascular risk were similar irrespective of the antihypertensive drugs or regimens used (ACE inhibitors, calcium channel blockers, or diuretics/beta- blockers). · There is supporting evidence that: thiazides and ACE inhibitors used as first-line therapy for hypertension reduce the risk of morbidity and mortality due to CHD, stroke, and other cardiovascular events; CCBs reduce the risk of stroke but not of CHD events or mortality; and beta-blockers