A new guideline for the management of high blood pressure, developed by an expert panel and including nine recommendations and a treatment algorithm (flow chart) to help doctors treat patients with hypertension, was published online on December 18, 2013 by JAMA. Department of Veterans Affairs (VA) Barnwell Award Laureate, William C. Cushman, M.D., chief of Preventive Medicine, Memphis Veterans Affairs Medical Center and VA lead consultant on hypertension; professor of Preventive Medicine, Medicine, and Physiology, University of Tennessee Health Sciences Center (UTHSC), is a member of this panel and coauthor of the report.
Hypertension is the most common condition seen in primary care and leads to heart attack, stroke, kidney failure, and death if not detected early and treated appropriately. “Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults,” according to information in the article.
The report, the “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,” is from panel members appointed to the Eighth Joint National Committee.
The guideline addresses three questions related to high BP management:
- At what BP should medication be started in patients with hypertension?
- What BP goal should patients achieve to know they are enjoying proven health benefits from their medication?
- What are the best choices for medications to begin treatment for high blood pressure?
The nine recommendations in the guideline answer those three questions. In summary, “There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years.
“There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes.”
The authors emphasize important differences from the past versions of the guideline. For development of these recommendations, “evidence was drawn from randomized controlled trials (RCTs), which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important health outcomes,” the authors write. These guidelines also sought to establish “similar treatment goals for all hypertensive populations except when evidence … supports different goals for a particular subpopulation.”
Also, rather than defining hypertension, the panel addressed threshold blood pressure for starting treatment. The report recommends beginning treatment for people aged 60 and older at a blood pressure of 150/90, and treating to below that level based on trial evidence, but the authors emphasize that “this evidence-based guideline has not redefined high BP and the panel believes that the 140/90 mm Hg definition from Joint National Committee 7 remains reasonable.” Lifestyle interventions should be used for everyone with blood pressures in this range.
They add that with each strategy, clinicians should regularly assess BP, encourage evidence-based lifestyle and adherence interventions, and adjust treatment until goal BP is attained and maintained. “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. These lifestyle treatments have the potential to improve BP control and even reduce medication needs.”
“The recommendations from this evidence-based guideline from panel members appointed to the Eighth Joint National Committee offer clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies to achieve those goals based on evidence from RCTs. However, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. We hope that the algorithm will facilitate implementation and be useful to busy clinicians. The strong evidence base of this report should inform quality measures for the treatment of patients with hypertension,” the authors conclude.