Multisociety guidelines released accounting for SPRINT data
by Crystal Phend Crystal Phend, Senior Associate Editor, MedPage Today November 13, 2017
This article is a collaboration between MedPage Today® and: American College of Cardiology
ANAHEIM — After years of contention among professional societies over raising blood pressure targets, national guidelines have reduced the goal from 140/90 mm Hg to 130/80 mm Hg for the general population, including community-dwelling seniors.
The American Heart Association and American College of Cardiology, which took over from the NHLBI’s Joint National Commission in 2013, released the 2017 guideline with endorsement from nine other groups with key changes to the threshold and treatment algorithm.
BP Classifications
Normal blood pressure remains below 120 mm Hg, but hypertension has been split into stage 1 (130/80 to 139/89 mm Hg) and stage 2 (140/90 mm Hg and higher) with different implications for treatment.
With the new target, the overall prevalence of hypertension among U.S. adults will jump to 45.6% compared with 31.9% based on the JNC7’s 140/90 mm Hg threshold. That represents an additional 31.1 million people — based on National Health and Nutrition Examination Survey data through 2014 — for a total prevalence of 103.3 million, a simultaneously published study in Circulation indicated.
The targets were the same for older and younger adults, with the caveat that treatment decisions should be individualized for seniors with a high comorbidity burden and limited life expectancy.
The change was largely based on the SPRINT trial’s finding that a target below 120 mm Hg reduced heart attack, stroke, or death in higher-risk older adults, with clear benefit and no evidence of increased risk of falls or orthostatic hypertension in elderly individuals in the trial.
But the SPRINT researchers have cautioned that the blood pressure measurements were taken with a careful automated process and in a clinical trial setting with a motivated population that differs from most clinical settings, such that their findings should not be directly applied to usual practice.
The guideline writing committee selected 130/80 mm Hg as an intermediate target balancing the risk tradeoffs for the general population, Bob Carey, MD, vice-chair of the writing committee explained at a press conference.
“It’s much less evidenced-based than JNC8, but it’s important to give advice. You can’t study everything. There will never be another SPRINT,” commented Suzanne Oparil, MD, who was a reviewer for the new guideline but had co-chaired the JNC8 effort that resulted in unofficial recommendations after being disbanded by the NHLBI.
That controversial guideline had recommended looser thresholds for most hypertensive individuals 60 or older, starting pharmacologic treatment when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
“You can’t get a direct conversion,” agreed ACC immediate-past president Richard Chazal, MD, “but it’s about as ‘science-y’ as one can get.”
BP Treatment
The blood pressure target for treatment also shifted to less than 130/80 mm Hg. However, there were key differences in recommended treatment by hypertension category.
- Stage 1 hypertension in the 130/80 to 139/89 mm Hg range was recommended for nonpharmacologic (predominantly lifestyle) therapy only unless the patient has clinical cardiovascular disease or at least a 10% 10-year risk of it based on the ACC/AHA atherosclerotic cardiovascular disease risk calculator already in use for cholesterol treatment decisions
- Stage 2 hypertension is recommended for blood pressure medication regardless of 10-year risk or cardiovascular disease status
- Elevated blood pressure in the 120-129 mm Hg systolic range was recommended for non-pharmacologic attention to lifestyle therapy
Lifestyle measures are weight loss, the DASH diet, reducing sodium, increasing potassium through diet, physical activity, and moderate alcohol consumption (limit one drink per day for women, two for men).
Lifestyle change is challenging, acknowledged Paul Whelton, chair of the guidelines writing committee, also speaking at the press conference. However, “we have to come to grips with it, whether we can achieve it or not.”
Carey suggested “this guideline may be a can opener” to force change and a re-commitment to lifestyle improvements.
Donald Lloyd-Jones, MD, of Northwestern University in Chicago, predicted it will be a paradigm shift in how blood pressure is treated in the U.S.
Adoption
The guideline itself was published in Hypertension, as a rambling, 192-page document that might be too much for many physicians to comb through, commented William Cushman, MD, a key SPRINT investigator.
Still, “I generally think it is a very good guideline. I agree with most of recommendations,” he told MedPage Today. “I do think more emphasis could be made that the <130/80 mm Hg goal is reasonable, but SBP <120 mm Hg may be more appropriate if BP is taken properly with an automated manometer (not with how BPs are often measured in practice).
“Realize the diastolic BP goal is based on expert opinion, not evidence. We need to continue to emphasize how BP is measured in most settings should change. You can’t use a conversion factor since the difference in a sloppy BP reading and a correct technique is unpredictable in the individual patient. I think the goals are very feasible — they are already being achieved in a high percentage in some practice settings, e.g., Kaiser. ”
“It’s long because it’s comprehensive,” Whelton said.
Endorsing organizations were the American Academy of Physician Assistants, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society of Preventive Cardiology, Association of Black Cardiologists, National Medical Association, and the Preventive Cardiovascular Nurses Association.
While the American Medical Association wasn’t a party to the guidelines, it is a “close” partner and will help disseminate them along with a public service advertising campaign, Whelton said.
Conflict Ahead?
Notably, primary care and diabetes care organizations that have clashed with cardiologists over blood pressure guidelines did not sign on to the ACC/AHA 2017 guideline. The American College of Physicians and American College of Family Physicians, for instance, released guidelines earlier this year loosening thresholds to 150 mm Hg systolic for people 60 and older.
While the AHA/ACC have embraced their role as setting the national guideline from the government’s perspective, “I think it would be naïve for us to say we are the only guideline. We are the people that NHLBI asked to do this, so here we are. But the others exist,” Chazal told MedPage Today.
Oparil cautioned that it may be hard for physicians to shift practice quickly. “There’s not enough emphasis placed on hypertension. People will settle on any old number you get any old way, and that’s not appropriate.”
In order for this to really take hold it’s going to have to be established as a standard for payment, she suggested.
What the timeline might be for adopting these guidelines into the performance standards of the Centers for Medicare and Medicaid Services, insurers, and even the AHA/ACC’s own programs is unclear, Chazal said.
- Primary Source
Hypertension
- Secondary Source
Circulation