New Hypertension Guidelines: Do They Add Clarity?

New hypertension guidelines jointly issued by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) recommend treating persistent systolic blood pressure at or above 150 mm Hg with a goal of less than 150 mm Hg—a change from guidance issued from the American Heart Association (AHA), American College of Cardiology (ACC), and the Centers for Disease Control and Prevention (CDC).

Issued in March 2017, the new ACP and AAFP guidelines recommended treatment in patients aged 60 years or older with hypertension and urge reducing blood pressure to a target of less than 150 mm Hg to lower the risks of stroke, cardiac events, and death. The organizations rated the recommendation as strong, with high-quality evidence.

Conflicting guidelines are common among expert panels, says Michael A. Blazing, MD, a Duke cardiologist who monitors the recommendations. A specialist in cardiovascular disease prevention and rehabilitation, Blazing urges consensus with more precise targeting with electronic medical records (EHRs).

Each recommendation is “an evolution of the risk–benefit equation,” Blazing says, describing the data as “somewhat rudimentary” regarding the risks and benefits for specific populations.

“The research to date has come to a general consensus that 150 mm Hg is the upper limit to begin treatment and 130 to 140 mm Hg is a valid lower limit to start treatment,” Blazing says. “The question is: How do we design future interventions that are appropriate to treat populations to get to a safe number?”

The earlier recommendations from the AHA, ACC, and CDC identified high blood pressure as being at or above 140/90 mm Hg and advised lifestyle improvements—diet, exercise, and weight management—before adding medication to maintain blood pressure below 140/90 mm Hg.

A third significant recommendation was released in 2017 from the Eighth Joint National Committee, which aligns more closely with the advice from the ACP and AAFP, also released this year. Both the American Society of Hypertension and the American Diabetes Association have issued separate guidelines.

Guidance is more precise for patients who have experienced stroke or have diabetes mellitus because clinicians have access to specific trial data.

“We need to design the next set of studies seeking specific populations that can be identified by EMR and look at how we can apply a treatment algorithm in that situation,” Blazing says. “A more intuitive-based decision process can be developed for the ‘gray-area’ patients that will be evidence based with analytic techniques mining EMR data.”