Long-Awaited Hypertension Guidelines Released at AHA

ANAHEIM, CA—(UPDATED) The wait is finally over: the comprehensive hypertension guidelines that have been in the works for more than 3 years are being released here at the American Heart Association (AHA) 2017 Scientific Sessions.

As expected, the findings from SPRINT and other recent trials have resulted in a lowering of the recommended treatment goal, which is now less than 130/80 mm Hg across patient groups.

Also changing is the classification of various blood pressure (BP) levels. What had been considered “prehypertension” according to the Seventh Joint National Committee (JNC 7) is now split into an “elevated BP” category for patients with systolic 120 to 129 mm Hg and diastolic less than 80 mm Hg and stage 1 hypertension for patients with systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg. Stage 2 hypertension now encompasses patients with a systolic BP of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg.

The consequence of that reclassification is that nearly half of all US adults (45.6%) are now deemed to have hypertension, up from 31.9% according to JNC 7 criteria.

“We’re excited about these guidelines,” writing committee chair Paul Whelton, MD (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), told reporters. “We think that they will empower clinicians. We think they’ll empower adults, especially those with elevated and high blood pressure, [but] also those with normal blood pressure who want to prevent going into that elevated sphere. . . . We’re confident that if the guideline is implemented it will improve the cardiovascular health of our adult community in the United States.”

Commenting for TCTMD, Steven Nissen, MD (Cleveland Clinic, OH), indicated that the guidelines will provide motivation for clinicians to redouble their efforts around hypertension control.

“There has been a certain complacency about blood pressure treatment,” he said. “We've done a better job of getting people on statins, and now the question is: can we get blood pressure treatment to be as good? It hasn’t been as good historically. A smaller percentage of people with hypertension are actually at goal than the groups that we treat for lipids, and I think we’re going to need to do better. It’s much harder to treat hypertension, and this will help people to be empowered to do a better job.”

The real impact of the new guidance, however, will be dependent on buy-in from patients and primary care physicians, according to Raymond Townsend, MD (Hospital of the University of Pennsylvania, Philadelphia), who estimated that as much as 90% of hypertension care is delivered in primary care. The guideline, weighing in at more than 100 recommendations and about 1,000 references, may be daunting in that setting.

This is pretty aggressive stuff. Raymond Townsend

“It’s a handful to manage this thing,” Townsend told TCTMD. “So is it reasonable to do this? I’ll tell you better once I see a little bit of where the ink goes in the next 2 weeks in a lot of journals that are going to look at the fact that we’re defining almost half of the adult US population as having hypertension right now.”

There could be pushback from patients who don’t want to start taking additional antihypertensive drugs to get to the lower treatment goal when they are already taking a lot of medications for other conditions, he said, adding, “This is pretty aggressive stuff.” Moreover, when aiming for a lower goal, clinicians will have to worry more about potential side effects, requiring “a little bit more pharmacovigilance in terms of laboratory monitoring until we straighten out someone at a new equilibrium,” he said.

Asked to predict what’s going to happen, Townsend said he thinks the new guideline will have a major impact and spur clinicians to aim for lower goals in their patients. He added that the first indication of how well this works will likely come from the Kaiser Permanente system, which has been able to achieve very high rates of blood pressure control.

Focusing on Lifestyle

Published online in Hypertension and the Journal of the American College of Cardiology, the guideline is the culmination of a process that started in 2013, when the National Heart, Lung, and Blood Institute handed off the responsibility of creating guidelines to the AHA and the American College of Cardiology (ACC). The societies created a writing group in 2014, setting off a 3-year review of close to 1,000 studies, with input from an independent evidence review committee.

The resulting document, which is approved by the AHA, ACC, and nine other partnering organizations, is comprehensive, covering the prevention, detection, evaluation, and management of high blood pressure in adults.

There is an emphasis on the importance of lifestyle modification throughout the guideline, regardless of levels of blood pressure and cardiovascular risk, according to writing committee vice chair Robert Carey, MD (University of Virginia School of Medicine, Charlottesville).

“We have lifestyle modification as the cornerstone of treatment for hypertension, and we expect that this guideline will cause our society and our physician community to really pay attention much more to lifestyle recommendations,” he said at a press conference.

Lowering the Goal

When the SPRINT trial was reported 2 years ago at this meeting, it fueled a debate about appropriate treatment goals and led many to call for more aggressive targets. The trial showed that treating to a systolic goal of less than 120 mm Hg, rather than a standard goal of less than 140 mm Hg, cuts the rate of adverse clinical outcomes in nondiabetic patients at high risk for cardiovascular events, albeit with an increase in some adverse events, including hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure.

The guideline authors recommend lowering blood pressure to less than 130/80 mm Hg for adults, even those with various comorbidities, who have confirmed hypertension and known cardiovascular disease or a high estimated risk. For those with confirmed hypertension without additional markers of cardiovascular risk, that same goal “may be reasonable.”

Less than 130 mm Hg was chosen as a middle ground between the standard goal of less than 140 and the intensive goal of less than 120 mm Hg studied in SPRINT due to a couple of considerations, Carey said. First, the method of blood pressure measurement used in SPRINT is not available in all practices. And second, the authors were concerned about possible side effects at a more aggressive goal if it were applied to the general population. The intermediate goal of less than 130 mm Hg strikes the appropriate balance between safety and efficacy as the field awaits more randomized evidence, Carey said.

There is a balance of benefits and harms from more aggressive blood pressure control, particularly in the elderly. Steven Nissen

The lower treatment goal also applies to older people (65 years and older), Whelton noted. He said the members of the writing committee were comfortable with that due to the fact that a large number of individuals have been enrolled in recent trials that showed the benefits of more aggressive control in older adults. He also pointed out that the benefits of aggressive treatment were obtained in the SPRINT subgroup of patients 75 and older.

Thus, a goal of less than 130 mm Hg is recommended for noninstitutionalized, ambulatory, community-dwelling, older adults. However, for those with hypertension, a high comorbidity burden, and limited life expectancy, “clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs,” the guideline states.

Nissen said he would have liked to see more discussion about managing this older population in the context of the new treatment goal.

“There is a balance of benefits and harms from more aggressive blood pressure control, particularly in the elderly,” he said. “I would have appreciated a little bit more guidance about assessing the fragility of patients and making a more careful determination, so that it’s really not one-size-fits-all.”

Even so, Nissen added: “Overall, I think treating blood pressure to lower targets is a reasonable thing to do. [The authors] make a reasonably good case for it, but I think it will require a lot of interpretation and thought about how to implement it.”

Eugenia Gianos, MD (NYU Langone Medical Center, New York, NY), told TCTMD that she is comfortable with the treatment goal of less than 130/80 mm Hg in older patients because of accumulated trial data showing that it is safe, even in those who are frail. She noted that older patients carry the highest risk of cardiovascular events to begin with. “So not being aggressive in treatment in these patients when we have more than enough data to suggest that it’s safe is not a wise approach,” Gianos said.

Calculating Risk

Another major change to the guidelines is the incorporation of the AHA/ACC risk calculator when making treatment decisions.

For patients with “normal” and “elevated” blood pressure, lifestyle modifications are recommended. Treatment of stage 1 hypertension, however, depends on the calculated 10-year risk of atherosclerotic cardiovascular disease. Patients with established cardiovascular disease or an estimated 10-year risk of at least 10% should be treated with lifestyle modification and antihypertensive medications. Those without cardiovascular disease or a high predicted risk should be treated with lifestyle interventions alone.

Incorporating a risk assessment into treatment decisions focuses therapy in patients with the most to gain, which prevents more cardiovascular disease events, saves more quality-adjusted life-years, and lowers the cost of care, Carey said.

Nissen had some concerns about using this risk calculator, pointing to a number of studies questioning how well it does in predicting risk. “I would have preferred if they had not done that,” Nissen said.

But Gianos, who noted that no risk prediction tool is going to be perfect, said the calculator “is a very simple, easy tool and a good starting point for most patients for risk assessment.” Plus, because it incorporates sex and race, it is better than some other tools for capturing risk for stroke, she said.

The Art and Science of Medicine

Martha Gulati, MD (University of Arizona College of Medicine, Phoenix), editor-in-chief of ACC’s CardioSmart, said the new guideline will hopefully spur greater attention to the treatment of hypertension.

Asked about the expanded number of adults considered to have hypertension under the new classification, she told TCTMD, “I think that it will get us to be more aggressive—hopefully—about treating blood pressure.” She said use of the term prehypertension may have allowed clinicians to not act on those blood pressure levels. Now that the terms have been changed, it should be an indication that some intervention—lifestyle modification or drug therapy—should be started when blood pressure is elevated.

There’s always that art along with the science. Martha Gulati

John Erwin, III, MD (Texas A&M College of Medicine/Baylor Scott & White Health, Temple, TX), agreed with the importance of focusing on risk at those levels of blood pressure.

“The medical community is constantly being criticized for ‘creating disease’ where there is none,” he commented in an email to TCTMD. “Based upon natural history data, these BPs in the lower range of the new classification system are not benign. We must always be careful not to overuse pharmaceuticals, but I think that these guideline writers amply promote the importance on nonpharmacological lifestyle modifications.”

Gulati and Erwin both said the lower treatment goal is supported by the evidence, with Gulati acknowledging that some might be critical of using that goal in older patients, for example. However, guidelines are meant to provide advice, allowing for clinicians to tailor treatment to individual patients, she said. “There’s always that art along with the science.”

Erwin concurred, saying, “Guidelines are just that. They are not meant to be inflexible algorithms. Shared decision-making and good clinical assessment of the individual's frailty and risk must be factored in to these decisions.”