New hypertension guideline: background and implications

Clinicians are trained to “treat the patient and not the number” in most situations. Most clinical practice and medical content recommendations are driven by professional society guidelines. According to Collins English Dictionary, a guideline is “something that can be used to help you plan your actions or to form an opinion about something.”(1) For most physicians, these are guides for practice, but final decisions are based on individual patients’ needs.

In November 2017, a new practice guideline on hypertension was published by the American College of Cardiology and the American Heart Association Task Force on Clinical Practice Guidelines.(2) This 283-page guideline calls for treatment at blood pressure levels of 130/90 mm Hg or higher, rather than the previous threshold of 140/90 mm Hg. The result is that now 46% of adults have hypertension, versus 32% under the old definition. In addition to changing the classifications of blood pressure levels, the new guideline focuses on patient blood pressure measurements at home, proper blood pressure measurement techniques, and the use of single-pill combination medications. It also emphasizes the importance of cardiovascular risk assessment when determining treatment. The hope is that with more attention on cardiovascular risk factors and a change in the definition, outcomes will improve.

This all sounds great, but before endorsing the guideline, it is important to analyze the methods used to develop it. The recommendation statements were graded; however, the individual studies and systematic reviews used were not. The tool used to assess cardiovascular risk has not been validated, making it unclear whether more aggressive treatment will ultimately improve outcomes. All of these issues raise concerns about the conclusions.

The American Association of Family Practice has decided not to endorse this guideline.(3) In addition to the lack of evidence-based rigor, the AAFP is concerned that, without compelling evidence that outcomes are better, strict adherence would result in treating people for hypertension who don’t need it. One experienced, practicing family physician remembers when prehypertension was defined at 120/80 mm Hg. “Trying to get patients below that goal often resulted in a poor quality of life,” she says. “Patients developed near syncope and other unintended side effects. Medicine is an art, and treatment must be individualized.” She adds, “Many patients have the perception that doctors just put everyone on more pills, and this makes that worse. But it probably will benefit the bottom line of the drug companies.” No medication is without side effects, and the more medications patients take, the higher the risk of drug interactions.

The guideline does highlight proper technique for measuring blood pressure, including the importance of home measurements. Also, recommending lifestyle improvements to patients when their blood pressures start to creep up is a great preventive measure.

When developing content like the Clinical Overviews on ClinicalKey,(4) our physician editors consider multiple sources when making recommendations, including more than one guideline, and they recognize that there is controversy in defining acceptable targets. We also address blood pressure goals in different contexts, considering patient age and various comorbidities. Ultimately, however, treatment for patients must be individualized and not based on a number alone.

 

Sources:

  1. Collins English Dictionary. Accessed April 11, 2018. https://www.collinsdictionary.com/dictionary/english/guideline
  2. Whelton PK et al: 2017 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 7. pii: S0735-1097(17)41519-1. doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print] https://www.sciencedirect.com/science/article/pii/S0735109717415191?via%3Dihub
  3. Crawford C: AAFP decides to not endorse AHA/ACC hypertension guideline. AAFP website. Published December12, 2017. Accessed April 11, 2018. https://www.aafp.org/news/health-of-the-public/20171212notendorseaha-accgdlne.html
  4. Elsevier Point of Care Clinical Overview. Hypertension. ClinicalKey website. Updated February 28, 2018. Accessed April 11, 2018. https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-85a2df82-8c01-418c-96d9-519f811389bc
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