AAFP Says It Cannot Endorse New Hypertension Guideline

The American Academy of Family Physicians (AAFP) announced last week that it has decided to not endorse the new hypertension guideline from the American College of Cardiology (ACC), the American Heart Association (AHA), and nine other partnering bodies.

Instead, the organization continues to endorse guidance released at the end of 2013 by a group originally empaneled as the Eight Joint National Committee (JNC8), which declined to join the ACC/AHA process for developing guidelines after the National Heart, Lung, and Blood Institute handed over responsibility for doing so.

“Based on the methodology, applicability, and consistency within the JNC8 guideline, the AAFP felt strongly that the JNC8 upheld the scientific rigor that provided strong recommendations to family physicians and patients on appropriate treatment of hypertension,David O'Gurek, MD, chair of the AAFP's Commission on Health of the Public and Science, said in AAFP News, a publication produced by the association.

The ACC/AHA hypertension guideline, released during the AHA 2017 Scientific Sessions last month to largely positive reviews, made two major changes: lowering the recommended treatment goal to less than 130/80 mm Hg across patient groups and reclassifying hypertension so that treatment with lifestyle changes and/or medication is recommended beginning when blood pressure is 130/80 mm Hg or higher. When the guidance was first released, experts who spoke with TCTMD emphasized that “buy-in” from primary care physicians would be essential for the new document to have a meaningful impact.

Now, having reviewed the guideline, the AAFP says it falls short of their standards for endorsement for the following reasons:

• Most of the recommendations were not based on a systematic review of the evidence. Although a systematic review was performed, it addressed only four key questions and did not assess harms associated with aiming for lower blood pressure goals.
• Assessments of the quality of individual studies or systematic reviews were not provided.
• The SPRINT trial was given too much weight at the expense of other studies.
• The guideline recommends using the ACC/AHA atherosclerotic cardiovascular disease risk calculator to determine whether medication is needed in certain patients, despite the fact that evidence showing the tool improves outcomes is lacking.
• There are concerns about potential conflicts of interest, with the head of the SPRINT trial serving as chair of the writing committee for the new guideline and other guideline writers having intellectual conflicts of interest that were not addressed.

In January 2017, the AAFP and American College of Physicians (ACP) released their own guideline for patients 60 and older. Similar to what is recommended by JNC8, they advise starting treatment in patients with a systolic pressure of 150 mm Hg or higher and aiming for goal below that threshold. That is much less aggressive than the recommendation in the new ACC/AHA guideline.

Though systematic reviews suggest that going even lower with blood pressure reduces cardiovascular events, there are no benefits seen in terms of all-cause mortality, CV mortality, MI, or renal events.

“Therefore, the AAFP and ACP recommended considering treatment to lower targets for some patients in the context of shared decision-making,” according to the AAFP News publication.

The nine organizations that joined ACC/AHA in crafting the new guideline were the American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society for Preventive Cardiology, National Medical Association, and Preventive Cardiovascular Nurses Association.