Yet Another Set of Hypertension Guidelines Sow Confusion Surrounding BP Targets in Older Patients

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have added their two cents to the management of patients with high blood pressure, publishing a new set of recommendations for the treatment of hypertension in patients 60 years and older.

The ACP and AAFP recommend physicians start treatment in older individuals with a systolic blood pressure persistently at 150 mm Hg or higher. In these patients, the target systolic blood pressure of less than 150 mm Hg can reduce the risk of mortality, stroke, and cardiac events and is a “strong” recommendation based on high-quality evidence, according to the ACP/AAFP.

For individuals with a history of stroke or transient ischemic attack, as well as those at high risk for cardiovascular events, it is recommended physicians start or intensify treatment to achieve a target systolic blood pressure of less than 140 mm Hg. These are “weak” recommendations, according to the ACP/AAFP, since there is less solid evidence to support treatment to this lower threshold.

The new recommendations, which were published January 16, 2017, in the Annals of Internal Medicine, add to an already bewildering array of blood pressure guidelines from various organizations, some with different targets and pharmacological approaches for managing hypertension.

For example, the American Heart Association (AHA), American Society of Hypertension/International Society of Hypertension (ASH/ISH), and the European Society of Cardiology/European Society of Hypertension (ESC/ESH) recommend a treatment target of 140/90 mm Hg or less (with the AHA, AH/ISH specifying that this applies to patients up to age 80). By contrast, the Eighth Joint National Committee (JNC-8) takes a similar approach to the ACP/AAFP guidelines, urging physicians to get their patients 60 years and older to a softer systolic blood pressure target of less than 150 mm Hg.

This glut of advice is simply “confusing for the practicing physician,” according to hypertension expert Franz Messerli, MD (University of Switzerland, Bern and Icahn School of Medicine at Mount Sinai, New York, NY). Despite the availability of guidelines from different societies—five different guidelines have emerged in the last 3 years—none have the National Heart, Lung, and Blood Institute (NHLBI) seal of approval, said Messerli.

Messerli was particularly dismayed by the relaxed blood-pressure target advocated by the ACP/AAFP. For him, a systolic blood pressure target of less than 150 mm Hg is unacceptable and inappropriate. In such individuals, there is an increased risk of stroke, one of the most devastating complications of hypertension.

“The idea that in patients older than 60 years, you should only treat if the blood pressure is greater than 150 [mm Hg], and that you should be happy if it is below this, is pathetic,” said Messerli. “It’s absolutely too high.”

Speaking with TCTMD, AHA president Steven Houser, PhD (Lewis Katz School of Medicine at Temple University, Philadelphia, PA), said they are “on record” for treating 60-year-old men and women with systolic blood pressure greater than 140/90 mm Hg.

“There is substantial data, and substantial new data, that lowering blood pressure below 140/90 [mm Hg] provides benefit,” he said. “What I think patients need to hear and know is that hypertension puts them at risk for stroke, heart attack, and heart failure—major health problems. Keeping blood pressure at a ‘normal’ level reduces those risks.”

For the AHA, “normal” means less than 140/90 mm Hg.

Too Many Cooks in the Kitchen

The new ACP/AAFP recommendations are based on a review and meta-analysis of 21 randomized controlled trials comparing blood pressure targets or treatment intensity—including ACCORD, HOT, HYVET, SHEP, and SPRINT, among others—and three observational studies assessing harm.

According to the reviewers, led by Jessica Weiss, MD (Oregon Health and Science University, Portland), nine clinical trials provided “high-strength evidence” supporting blood pressure control to less than 150/90 mm Hg. Overall, treatment to this goal significantly reduced the risk of mortality by 10%, cardiac events by 23%, and stroke by 26%. There were six trials that showed treatment to less than 140/85 mm Hg significantly reduced the risk of cardiac events by 18% and stroke by 21% but did not result in any reduction in mortality risk.

The benefit of the lower target was largely driven by the SPRINT trial, according to the researchers, a trial that showed an advantage for aggressive blood pressure-lowering in high-risk patients.

In an editorial, Michael Pignone, MD (University of Texas, Austin), and Anthony Viera, MD (University of North Carolina, Chapel Hill), write that the management of patients with systolic blood pressure between 140 and 150 mm Hg is “controversial.” SPRINT, for example, showed a benefit with more intensive lowering, but the generalizability of that trial remains a challenge. On aggregate, though, the editorialists take the stance that individuals 60 years and older with blood pressure greater than 140 mm Hg “may benefit from additional treatment, especially those at increased cardiovascular risk.”

To TCTMD, Messerli noted he has polled rooms full of cardiologists and hypertension physicians over the years, asking them what they’d choose if they had to “wake up tomorrow morning with either a stroke or a heart attack.” The answer is always unanimous—nobody ever chooses stroke. He pointed out the ACP/AAFP recommend physicians consider treating to less than 140 mm Hg in a 60-year-old patient with a previous history of stroke or transient ischemic attack in order to reduce the risk of recurrence.

“Wouldn’t it perhaps be better to do so before such a devastating complication has taken place?” asked Messerli.   

Hypertension Causes Major Health Problems

In 2013, the JNC-8 decision to relax the treatment threshold to 150/90 mm Hg in those 60 years and older, which was a key departure from JNC-7, was contentious. After the publication, five members of JNC-8 wrote an editorial in the Annals of Internal Medicine expressing concerns about increasing the target systolic blood pressure from 140 mm Hg to 150 mm Hg in patients 60 years and older. They argued the evidence supporting the more lax target was insufficient and inconsistent and might have the unintended effect of reversing declining cardiovascular disease rates.

The AHA and American College of Cardiology (ACC) are currently reviewing the hypertension guidelines and data supporting the blood pressure targets. In the meantime, the AHA recommends physicians follow a treatment algorithm they developed with the ACC and Centers for Disease Control and Prevention (CDC). Only in 80-year-old men and women is the target relaxed to less than 150/90 mm Hg.  

From a personal standpoint, Houser said he wouldn’t wait for his blood pressure to reach 150 mm Hg before starting treatment.

“I think the data is so strong, saying that there is significant benefit in keeping your blood pressure lower, that I’d personally want mine under 140 [mm Hg],” he said. Regarding the multitude of clinical recommendations, he added these are likely to cause confusion for doctors, stating it would be better if the different groups could have come together to develop joint guidelines.

On the whole, though, Houser and Messerli both stressed individualized patient care.

“This is really the issue,” said Messerli. “When you think about it, when you have a patient in front of you, you never ask, ‘What is the target?’ You just try to lower their blood pressure and see how the patient tolerates it. If you can get to less than 130 mm Hg over time, even in an 80-year-old, that’s perfectly acceptable and fine. Obviously, you want to check there is no hypotension, no dizziness, that the creatinine remains normal, and so on, but I personally have many octogenarians who are at 130 [mm Hg], even in the high 120 [mm Hg] range, on triple therapy who are doing exceedingly well.”

Finally, Messerli noted that beta-blockers are recommend by the ACP/AAFP on an “equal basis” with other agents, such as thiazide-type diuretics, ACE inhibitors, angiotensin receptor blockers, and calcium-channel blockers. Messerli said beta-blockers lower blood pressure but added that they have never been shown to reduce the risk of MI, stroke, or death in hypertensive patients 60 years and older.