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Stricter Blood Pressure Guidelines Could Prevent Cardiovascular Events, but Debate Continues

Mary Caffrey
A 2015 study sponsored by the National Institutes of Health made a change in blood pressure guidelines seem inevitable. But there is disagreement between the standards promoted by societies for family physicians and those for cardiologists, leading to confusion for those in daily practice.
A year ago, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated new blood pressure guidelines that lowered the threshold at which some patients should be treated for hypertension, from 140/90 mmHg to 130/80 mmHg.

A new study, published today in the AHA journal, Circulation, finds that change could translate into 3 million fewer cardiovascular disease events over 10 years, compared with earlier guidelines.1 “Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans,” said lead author Adam Bress, PharmD, MS, assistant professor of Population Health Sciences at University of Utah Health, in a statement. “Achieving these lower goals will be challenging.”

But Bress’ study is just one among several that have come recently, along with commentary that show despite a landmark National Institutes of Health (NIH) study in 2015 that seemed like a mandate for lower blood pressure targets, not everyone is on board. The new study additionally says that for the highest-risk cardiovascular patients, the new guidelines could result in an increase of treatment-related serious adverse events, which suggest the need for personalized care.

One challenge is the Western diet, which is cited as the cause of rising levels of obesity and diabetes around the world. The assumption that blood pressure must rise with age may not be true, and it may be more closely connected to what we eat.

A study published last week in JAMA Cardiology compared blood pressure of 2 remote South American tribes, one which had no exposure to Western dietary patterns and the other which had some exposure to processed foods with higher levels of salt. Despite similar genetic backgrounds, the tribe that consumed saltier foods had higher blood pressure. Many believe the real key to treating heart disease and diabetes is getting serious about dietary and nutrition policy.

Bress and his team calculated fewer events in middle-aged adults based on the 2017 blood pressure goals when compared with guidelines in the seventh Joint National Committee, known as JNC7, as with the eighth Joint National Committee (JNC8), which put the cutoff for hypertension at 140/90 mmHg for patients younger than 60 years of age and 150/90 mmHg for those age 60 years and older.

Last month, Franz H. Messerli, MD, and Sripal Bangalore, MD, MHA, writing in the Journal of the American College of Cardiology explained how physicians are justifiably confused. They offer a case study of a 63-year-old female patient with blood pressure readings that average 148/86 mmHg. Guidelines between ACC/AHA, which cover 25,000 cardiologists, and those of the European Society of Hypertension and European Society of Cardiology, which cover 75,000 physicians, are not in alignment.2

ACC/AHA guidelines say her blood pressure should be 130/80 mmHg. The European guidelines say her blood pressure should be 140/90 mmHg. But guidelines for the American College of Physicians and the American Association of Family Physicians say she’s just fine at 150/90 mmHg. The guidelines don’t align on how many medications to use when starting treatment, either.

Ironically, all 3 guidelines are based on the same study; called SPRINT (Systolic Blood Pressure Intervention Trial), this was a large trial by the NIH that stopped early because it became clear that treating patients to a lower blood pressure target was resulting in fewer fatal cardiovascular events.

Despite this, the ACP guidelines insist that treating blood pressure to a target of 130/80 mmHg across a population of older adults will result in “low value care.”

Messerli and Bangalore see more frustration ahead. “The above hypertension guideline fiasco eloquently illustrates the potential shortcomings of dogmatic clinical directives and, if anything, is prone to increase the rift between those who preach, those who teach, and those who treat,” they wrote. 

“Unless we make a concerted effort to do so, as the number of guidelines is increasing more rapidly than does iron-clad evidence, we are prone to see more and more schism among recommendations, confusion among physicians, and anxiety among patients,” the authors concluded.

References
  1. Bress AP, Colantonio LD, Cooper RS, et al. Potential cardiovascular disease events prevented with adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline [published online November 19, 2018]. Circulation. doi: 10.1161/CIRCULATIONAHA.118.035640.
  2. Messerli FH, Bangalore S. The blood pressure landscape: schism among guidelines, confusion among physicians, and anxiety among patients. J Am Coll Cardiol. 2018;72(11):1313-1316. doi: 10.1016/j.jacc.2018.07.026.


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