Perspectives on Hypertension

This post was authored by Patrick T. O’Gara, MD, FACC, president of the ACC, and William J. Oetgen, MD, MBA, FACC, executive vice president of Science, Education and Quality of the ACC.

A State-of-the-Art paper published this week in the Journal of the American College of Cardiology (JACC) provides three perspectives on the recommendations for treatment of hypertension published in the Journal of the American Medical Association (JAMA) late last year by panel members appointed to the Eighth Joint National Committee. The recommendations garnered much attention in the lay press and physician community for several major changes from the previous guideline (JNC 7). In particular, the recommendations raised the systolic blood pressure threshold for treatment of hypertensive persons aged 60 years or older to 150 mm Hg. A target of 140/90 was maintained for other age groups and for patients with diabetes or chronic kidney disease.

The JACC paper outlines the impacts of these proposed recommendations on certain at-risk populations, namely African Americans and women. In one section, authors on behalf of the Association of Black Cardiologists Board of Directors, strongly opine that a systolic blood pressure treatment goal of 150 mmHg for those ≥60 years of age “may have a substantial negative impact on gains that have been made in the last several decades on the treatment of cardiovascular disease.” The authors urge clinicians who treat African Americans and other high-risk patient populations to await further recommendations from major professional organizations before departing from previously established guidelines and standards of care.

Another group of experts caution that the new recommendations will adversely affect all patients aged 60 years and older, but disproportionately affect women. “Cardiovascular disease in women has been understudied, under-recognized, and undertreated with consequent suboptimal outcomes in this population,” they write. “As most Americans ≥60 years old with hypertension are women, women will be differentially affected by the recommendation to relax the systolic blood pressure threshold for initiating treatment (to 150 mmHg) and to raise the treatment target (to 150 mmHg) for people ≥60 years old.” They caution that the new recommendations offer “no recognition of this majority female hypertensive population or the facts that older women have poorly controlled blood pressure, in general, and approximately 40 percent of those with poor control are African-American women, who have the highest risks for stroke, heart failure and chronic kidney disease.”

Meanwhile, Lawrence R. Krakoff, MD, writes in the first section of the paper that what is currently missing from the evidence “is a large, randomized controlled trial of those older than 60 years of age without diabetes or chronic kidney disease comparing a higher and lower goal.” He notes that two such trials – SPRINT and ESH-CHL-SHOT – are underway and could inform the discussion of the benefits of a lower goal.

It’s also important to note that the recommendations outlined by the panel members and discussed in the JAMA paper were not endorsed by any organized body – for some of the very reasons outlined in the new JACC paper. While often referred to as “guidelines,” these recommendations are not traditional practice guidelines in the sense that they were not promulgated or endorsed by the government or medical professional societies like the ACC and the American Heart Association (AHA). Moreover, in a remarkable turn of events, four months after the publication of the JAMA paper, five of its 17 authors published a “minority view” in the Annals of Internal Medicine which repudiated the blood pressure target and treatment recommendations of 150 mm Hg.

The ACC/AHA Task Force on Practice Guidelines is moving forward with developing a collaborative model in partnership with multiple other organizations to update the national hypertension guidelines along with the National Heart, Lung, and Blood Institute, which will support the necessary evidence reviews for the updated guideline. The model will include an extensive science and evidence review process, followed by draft recommendations that will undergo peer and stakeholder review, prior to the publishing of official guidelines in two years for clinicians to follow as the national standard for hypertension prevention and treatment.

In the short-term, the ACC, AHA and the Centers for Disease Control and Prevention released a scientific advisory on the effective approach to hypertension in November 2013 that encourages use of enhanced, evidence-based, blood pressure treatment systems for providers, including standardization of protocols and algorithms, incentives for improved performance based on achieving and maintaining patients at blood pressure goals, and technology-facilitated clinical decision support and feedback.

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