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How Do the Latest Blood Pressure Guidelines Affect Primary Care Practice?

On November 13, 2017, the American Heart Association (AHA) and the American College of Cardiology (ACC) jointly announced new clinical practice guidelines for the management of high blood pressure (HBP) in adults. These guidelines claim that HBP is the number one contributing cause of mortality worldwide and that, after tobacco smoking, HBP is the next most common modifiable risk factor in cardiovascular disease (CVD).

By far the most dramatic change in these guidelines is in the definition of hypertension, with “stage 1 hypertension” being declared for repeated measures of either arterial systolic blood pressure (SBP) over 130 mm Hg or diastolic blood pressure (DBP) over 80 mm Hg. This change from the longstanding 140 mm Hg and 90 mm Hg has instantly created millions of new “hypertensives” in our practices. The authors claim that this change is justified based on a review of numerous prospective studies that show that: risk of CVD is approximately doubled for every increase of 10 mm Hg for DBP over 75 mm Hg and for systolic blood pressure (SBP) over 115 mm Hg; and that interventions that reduce blood pressure, even at those newly defined lower levels, does significantly reduce the risk of CVD. This guideline recommends a workup for all newly diagnosed hypertensives to differentiate primary from secondary hypertension and a CVD risk assessment including evidence of current end organ damage and use of the online AHA ten year event risk calculator. For stage 1 hypertension the guidelines suggest that a trial of lifestyle modification including weight management, sodium restriction, and exercise be instituted before pharmacologic therapy is initiated.(1) The ACC has listed “key points to remember” about these guidelines at the following website. http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

This is not the first AHA/ACC HBP clinical practice guidelines likely to provoke controversy.(2,3) The 2017 guidelines do acknowledge that CVD is a multifactorial disease and that hypertension often occurs with hyperlipidemia, diabetes, abdominal obesity, substance abuse, obstructive sleep apnea, hyperuricemia, or inflammatory biomarkers. They further acknowledge that because CVD risk is proportional to the elevation over normal, treating stage 1 hypertension may show less immediate benefit but that it is intended to prevent progression of CVD. Although lifestyle modification is an attractive approach to almost all the known risk factors of atherosclerotic CVD, it has a considerable cost in time and effort much of which resides in the primary care setting. A further concern is that, as a byproduct of decades of assiduous blood pressure measurement, we are faced with substantial numbers of patients whose prior management for “pre-hypertension” was annual assessment and patient education and, now labeled “hypertensive”, will require immediate evaluation, treatment, and more intensive monitoring. Because management of hypertension is almost a universal quality measure, primary care practices will be at risk of adverse action by payers and even subject to claims of malpractice by anyone who experiences an adverse outcome during this transition. Among the societies representing primary care practice, as of this writing only the American Academy of Physician Assistants has formally endorsed these new guidelines. The American Academy of Family Physicians states that AAFP will continue to endorse the 2014 JNC8 guideline while it reviews the 2017 guideline. http://www.aafp.org/news/health-of-the-public/20171115ahaacchbpguideline.html.

References:

  1. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 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: Executive Summary: 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)41518-X. https://doi.org/10.1161/HYP.0000000000000065
  2. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. https://jamanetwork.com/journals/jama/fullarticle/1791497
  3. Sneiderman CA. Integrating new cardiovascular guidelines in primary care practice part 2 Hypertension and Joint National Committee 8. Primary Issues. July 15, 2014. https://www.primarycarenetwork.org/acc-guidelines-part2/

Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA
csneiderman@culmoreclinic.org

Published on 12/4/17


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