Primary care physicians cautious about new guidelines for high blood pressure

The lower threshold recommended by the American College of Cardiology and the American Heart Association classifies 46 percent of U.S. adults as having high blood pressure, compared with 32 percent under the previous definition.

Primary care faculty at UMass Medical School will continue counseling patients about lifestyle modifications as well as medication to manage blood pressure and reduce cardiovascular disease risk rather than striving to achieve a set point for all, despite stringent new guidelines from the American College of Cardiology and the American Heart Association.

19 nov 2017--Formerly called "prehypertensive," systolic blood pressure between 121 and 129 over diastolic pressure of between 80 and 89 is now defined as "elevated blood pressure." This lowered threshold classifies 46 percent of U.S. adults as having high blood pressure, compared with 32 percent under the previous definition.
"Cardiovascular disease is a public health problem and we should address it as such, recommending healthy lifestyles for everyone," said Ronald Adler, MD, associate professor of family medicine & community health. "Pushing to reach the same aggressive blood pressure target for all our patients will inevitably lead to the unintended consequences of medication adverse effects plus complications such as dizziness and falls from blood pressure that is too low."
The guidelines also call for providers to assess a patient's 10-year-risk for cardiovascular disease using the ASCVD Risk Calculator—also a source of debate—to guide doctor–patient conversations and shared decision making about how to manage elevated blood pressure.
"While I have many concerns about the calculator's ability to predict future disease, it does open up the opportunity for providers and patients to discuss risk modification when discussing blood pressure," said Frank Domino, MD, professor of family medicine & community health. "To that end, I tell patients if they do not want to take a blood pressure pill, they only need to get 20 minutes of aerobic exercise five days a week."
Other American and international health organizations define high blood pressure as more than 150/90 for those older than 60 years and more than 140/90 for everyone else, including diabetics, regardless of age.
"I worry that the new guideline doesn't account for the potential harms of overdiagnosis and overtreatment, especially in the elderly," said Dr. Adler. "Our medical care should focus on controlling those with more significantly elevated blood pressure and cardiovascular risk to ensure that we reach targets about which there is widespread consensus more reliably."
The new guidelines were announced Nov. 13 and published in the journal Hypertension.

More information: Paul K. Whelton et al. 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, Hypertension (2017). DOI: 10.1161/HYP.0000000000000065


Provided by University of Massachusetts Medical School

High blood pressure is redefined as 130, not 140: US guidelines (Update)

In this June 6, 2013, file photo, a patient has her blood pressure checked by a registered nurse in Plainfield, Vt. New medical guidelines announced Monday, Nov. 13, 2017, lower the threshold for high blood pressure, adding 30 million Americans to those who have the condition. 

High blood pressure was redefined Monday by the American Heart Association, which said the disease should be treated sooner, when it reaches 130/80 mm Hg, not the previous limit of 140/90.
Doctors now recognize that complications "can occur at those lower numbers," said the first update to comprehensive US guidelines on blood pressure detection and treatment since 2003.

19 nov 2017--A diagnosis of the new high blood pressure does not necessarily mean a person needs to take medication, but that "it's a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches," said Paul Whelton, lead author of the guidelines published in the American Heart Association journal, Hypertension, and the Journal of the American College of Cardiology.
Healthy lifestyle changes include losing weight, exercising more, eating healthier, avoiding alcohol and salt, quitting smoking and avoiding stress.
The new standard means that nearly half (46 percent) of the US population will be defined as having high blood pressure.
Previously, one in three (32 percent) had the condition, which is the second leading cause of preventable heart disease and stroke, after cigarette smoking.
The normal limit for blood pressure is considered 120 for systolic, or how much pressure the blood places on the artery walls when the heart beats, and 80 for diastolic, which is measured between beats.
Once a person reaches 130/80, "you've already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure," said Whelton.
"We want to be straight with people—if you already have a doubling of risk, you need to know about it."

People in 40s most affected

Once considered mainly a disorder among people 50 and older, the new guidelines are expected to lead to a surge of people in their 40s with high blood pressure.
"The prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45," according to the report.
Damage to the blood vessels is already beginning once blood pressure reaches 130/80, said the guidelines, which were based in part on a major US-government funded study of more than 9,000 people nationwide.
The category of prehypertension, which used to refer to people with systolic pressure of 120-139, no longer exists, according to the new guidelines.
"People with those readings now will be categorized as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89)."
Medication is only recommended for people with Stage I hypertension "if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk."
The proper technique must be used to measure blood pressure, and levels "should be based on an average of two to three readings on at least two different occasions," said the report.
"I absolutely agree with the change in what is considered high blood pressure because it allows for early lifestyle changes to be addressed," said Satjit Bhusri, a cardiologist at Lenox Hill Hospital in New York.
"It is important, however, to realize that the change in the definition does not give course to increase prescription of medications, rather that it brings to light the need to make lifestyle changes," Bhusri said in an email to AFP.
The new guidelines were announced at the American Heart Association's 2017 Scientific Sessions conference in Anaheim, California.

More information: Abstract/Full Text (subscription or payment may be required)
Guidelines Report

Resistant hypertension: A review for physicians

An infographic on resistant hypertension. Credit: Canadian Medical Association Journal

19 aug 2014--A new review article on resistant hypertension, which affects about 1 in 10 people with high blood pressure, is aimed at helping physicians assess and manage patients with the condition. The review, published in CMAJ(Canadian Medical Association Journal) includes information on emerging therapies for the condition.

The authors note that high-quality evidence is lacking. "We found few randomized controlled trials (RCTs) and no systematic reviews to guide decision-making. Thus, we have made management recommendations based primarily on expert consensus unless otherwise specified," writes Dr. Raj Padwal, Department of Medicine, University of Alberta, with coauthors.

About 20% of Canadian adults have hypertension (high blood pressure.) Resistant hypertension is defined as blood pressure levels that exceed the target level despite treatment with three or more hypertension drugs. Obesity, especially a large waist circumference, and sleep apnea are the top contributing factors to resistant hypertension. Patients with resistant hypertension are at higher risk of heart disease and death.

Before treating patients for resistant hypertension, physicians must rule out "pseudoresistance." Elevated blood pressure during physician visits ("white coat effect"), not taking recommended medications and inaccurate blood pressuremeasurements can contribute to apparently resistant hypertension.

The review recommends structured approaches to managing this condition:

• optimizing current medication regimen and strategies to improve adherence
• counselling patients to reduce salt intake, limit alcohol, exercise and strive for a healthy weight
• treating obstructive sleep apnea with continuous positive airway pressure
• adding drugs when current drugs are not effective—spironolactone, a-blockers, b-blockers and others
• referring patients to clinics with hypertension specialists

The authors close by emphasizing the need for more rigorous studies in the field to address knowledge gaps and clarify uncertainties.

More information: Canadian Medical Association Journal, www.cmaj.ca/lookup/doi/10.1503/cmaj.130764

Provided by Canadian Medical Association Journal

Cardiac Benefits with Hypertension Treatment Vary by Gender

By Todd Neale
NEW YORK, 5 july 2008--In patients receiving treatment for hypertension, women have less improvement in left-ventricular hypertrophy than men, a post hoc analysis revealed.
Among patients taking either losartan (Cozaar) or atenolol (Tenormin), women had significantly less reduction of left ventricular hypertrophy using two sets of criteria -- the Cornell product (P<0.001) and Sokolow-Lyon voltage (P=0.005) -- compared with men, Peter Okin, M.D., of Weill Cornell Medical College here, and colleagues reported in the July issue of Hypertension: Journal of the American Heart Association.
The gender differences remained after adjusting for several variables, including baseline severity of hypertrophy and blood pressure changes.
There are well-established gender differences in the electrocardiographic criteria for left-ventricular hypertrophy, the researchers said, although whether these differences are also found in the magnitude of regression of the condition during treatment for hypertension had been unclear.
So the researchers evaluated improvements in left-ventricular hypertrophy in 9,193 patients from the Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) study, a prospective, double-blind, randomized study that showed that treatment with losartan was associated with a greater reduction in hypertrophy and a lower rate of diabetes compared with atenolol.The LIFE study included patients ages 55 to 80 who had a systolic blood pressure of 160 to 200 mm Hg and a diastolic pressure of 95 to 115 mm Hg. Patients were given 50 mg of either losartan or atenolol.
Through a mean follow-up of 4.8 years, there were no gender differences in the change in systolic blood pressure.
There were, however, significant differences between the sexes in changes in diastolic blood pressure starting at four years and continuing through the end of the study, with women having slightly less change in pressure than men.
The researchers assessed changes in electrocardiographic left ventricular hypertrophy using both gender-adjusted Cornell product and Sokolow-Lyon voltage criteria throughout the five-year study.
Left ventricular hypertrophy was defined as >2,440 mm.ms using Cornell product criteria or >38 mm using Sokolow-Lyon voltage criteria.
Above-average regression of hypertrophy was defined as a reduction ³236 mm.ms or ³3.5 mm using the respective criteria.
Women had significantly less regression according to both Cornell product (-149 versus -251 mm.ms) and Sokolow-Lyon voltage (-3.0 versus -4.8 mm) criteria (P<0.001 for both).
After adjusting for baseline severity of hypertrophy, baseline levels of and changes in blood pressure, hypertension medication, age, and other baseline gender differences, the disparity between the sexes in degree of regression remained (P<0.001 for the Cornell product and P=0.005 for the Sokolow-Lyon voltage).
Women were 32% (P<0.001) and 15% (P=0.003) less likely to have above-average regression by Cornell product and Sokolow-Lyon voltage criteria, respectively.
The disparity in regression grew larger as the study progressed (P<0.001 for both criteria).
Also over time, women had less reduction in left ventricular mass in relation to height than men (P=0.01).
The prevalence of left ventricular hypertrophy decreased by a greater percentage in men than in women using both Cornell product (-19% versus 14.7%) and Sokolow-Lyon voltage (-14.9% versus -6.1%) criteria (P<0.001 for both).
The authors acknowledged some limitations, including the fact that the patients were at particularly high risk with moderate-to-severe hypertension.
Also, they said, the patients were selected for elevated measures of hypertrophy and some of the regression may have been a return to the mean.
Furthermore, ambulatory blood pressure readings may have given a more exact measure of the effect of treatment.
Finally, they said, the relative severity of hypertrophy in women varied depending on which of the two criteria were used.
In an accompanying editorial, Enrico Agabiti-Rosei, M.D., and Massimo Salvetti, M.D., of the University of Brescia in Italy, said that the study findings might partially explain why the risk of cardiovascular events increases more in women than in men as they age.
However, they said, they advised a careful interpretation of the results, "which are the result of a post hoc analysis."
They noted that the prevalence of electrocardiographic left ventricular hypertrophy is low in primary care.
"Therefore, caution is advisable in extrapolating the results observed in this highly selected, high-risk population to hypertensive patients who are encountered in everyday clinical practice."
The study was supported in part by grants from Merck, maker of losartan.
Dr. Okin received grant support from Merck. His co-authors have potential conflicts of interest with Merck, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Leo, Nycomed, Novartis, Pfizer, sanofi-aventis, and Sankyo.
The editorialists made no disclosures.
Primary source: Hypertension: Journal of the American Heart AssociationSource reference:Okin P, et al "Gender differences in regression of electrocardiographic left ventricular hypertrophy during antihypertensive therapy" Hypertension 2008; 52: 100-106. Additional source: Hypertension: Journal of the American Heart AssociationSource reference: Agabiti-Rosei E, Salvetti M "Gender differences in the regression of electrocardiographic left ventricular hypertrophy during antihypertensive therapy" Hypertension 2008; DOI: 10.31161/HYPERTENSIONAHA.108.111948.