Information sourced from NEJM Journal Watch:
New Multisociety Hypertension Guideline Is Released
The guideline lowers thresholds for categorizing people as having hypertension and for prescribing drug therapy.
Sponsoring Organizations: American College of Cardiology (ACC), American Heart Association (AHA), and nine other organizations
Target Audience: All clinicians
In 2003, the National Institutes of Health (NIH) issued its last guideline on hypertension (Seventh Joint National Committee [JNC7]; NEJM JW Gen Med Jun 15 2003 and JAMA 2003; 289:2560). In 2014, the JNC8 guideline — written by an expert panel no longer affiliated with NIH — was published (NEJM JW Gen Med Jan 15 2014 and JAMA 2014; 311:507). Now, the ACC and AHA have issued a new guideline, intended to be the U.S. standard of care.
Newly defined categories are “elevated blood pressure (BP)” (systolic BP, 120–129 mm Hg and diastolic BP, <80 mm Hg); stage 1 hypertension (systolic BP, 130–139 mm Hg or diastolic BP, 80–89 mm Hg), and stage 2 hypertension (systolic BP, ≥140 mm Hg or diastolic BP, ≥90 mm Hg).
For people with elevated BP (but not hypertension), lifestyle modification is recommended.
For people with stage 1 hypertension who have known atherosclerotic cardiovascular disease (CVD) or 10-year cardiovascular risk ≥10% (according to the ACC/AHA calculator, which also is used for cholesterol management), both lifestyle modification and drug therapy are recommended. Stage 1 patients with <10% 10-year risk should pursue lifestyle modification only.
All people with stage 2 hypertension should receive medication (in addition to lifestyle modification).
The treatment goal for everyone is <130/80 mm Hg.
Allan S. Brett, MD reviewing Whelton PK et al. J Am Coll Cardiol 2017 Nov 13.
COMMENT — GENERAL MEDICINE
Allan S. Brett, MD
This guideline is a 194-page document (currently online) that addresses a broad spectrum of topics, including BP measurement, secondary hypertension, and managing hypertension in patients with comorbidities. But the big changes — heavily influenced by results of the SPRINT study (NEJM JW Gen Med Dec 15 2015 and N Engl J Med 2015; 373:2103) — are those in the bulleted list above.
First, the new categories will label many more people as having elevated BP or frank hypertension. In JNC7, systolic thresholds for so-called prehypertension, stage 1 hypertension, and stage 2 hypertension were 120 mm Hg, 140 mm Hg, and 160 mm Hg, respectively; diastolic thresholds were 80 mm Hg, 90 mm Hg, and 100 mm Hg, respectively. The downstream consequences of telling people with BP of 120/70 mm Hg that their BP is “elevated” are unknown.
Second, in the new guideline, hypertension treatment is based on both BP thresholds and 10-year overall CV risk. Younger and middle-aged people without other substantial risk factors who are labeled as having stage 1 hypertension (130–139/80–89 mm Hg) generally will have estimated 10-year CVD risk <10%, and lifestyle modification (but not drug therapy) will be recommended for them. However, nearly all older people with BP in this range will be candidates for drug therapy, because the risk calculator gives them 10-year CV risk >10% based on age alone.
Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person, and, keep in mind, several studies have suggested that the ACC/AHA risk calculator overestimates risk in certain populations. In addition, a recent guideline from the American College of Physicians and the American Academy of Family Physicians (NEJM JW Gen Med Apr 15 2017 and Ann Intern Med 2017; 166:430) recommends — as did JNC8 — a systolic BP treatment threshold of 150 mm Hg for average-risk older people (age, ≥60).
In the new guideline, the authors discuss accurate measurement of BP in the office and encourage home or ambulatory monitoring to identify white-coat hypertension. Unfortunately, proper office measurement (e.g., seated position for at least 5 minutes in a quiet and relaxed setting, proper positioning of the arm, repeat measurements after several minutes in some cases) is the exception and not the rule in most primary care practices. BP lability is common with both office-based and home readings, making it difficult to say, “your blood pressure is X” (a single number that represents the patient’s “true” BP).
I’m not going to change my practice until I weigh responses to this guideline from a broad range of experts. In the end, initiating drug therapy in patients with BPs near treatment thresholds should reflect shared decision-making between clinicians and patients.
Karol E. Watson, MD, PhD, FACC
Comment — Cardiology The new hypertension guidelines have the potential to improve cardiovascular outcomes by shining a bright light on the dangers of even modest BP elevations and encouraging lifestyle management. These guidelines now label many more Americans as having hypertension, but this should be seen not as a mandate for more drug treatment but as a call to action for lifestyle changes and, if necessary, drug therapy.
Whelton PK et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017 Nov 13; [e-pub].
[Muntner P et al. Potential U.S. population impact of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline. J Am Coll Cardiol 2017 Nov 6; e-pub. PubMed® abstract]
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