How the New Blood Pressure Management Guidelines May Lead to More Headaches for Physicians

By: David J. Nagel, MD

February 16, 2018

Controversy over blood pressure treatment recommendations has been brewing for more than 5 years. The Eighth Joint National Committee (JNC-8) departed from historical norms by recommending that systolic blood pressures up to 150 mm Hg be tolerated in certain patients. In 2017, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released guidelines that largely agreed with JNC-8 recommendations.

Later that year the new American Heart Association/American College of Cardiology (AHA/ACC) hypertension guidelines lowered the threshold of a tolerable blood pressure (greater than 130/80 rather than the traditional >140/90). It is estimated that this new concept of hypertension would increase the prevalence of hypertension in the United States from 32% to 46%, and at least 4.2 million of people with newly defined high blood pressure would require treatment with one or more antihypertensive agents. Among those under the age of 45, this new definition of hypertension will triple the prevalence among men and double it among women.

However, many of the large clinical trials on hypertension have not included people under the age of 50. Since most of these young individuals will have yet to develop overt cardiovascular disease, the decision to treat them will be based on estimating the 10-year CVD risk. However, this risk estimator has been highly criticized for overestimating cardiovascular risk in younger people. Finally, approximately 53% of patients currently being treated for hypertension will need to take more medications to reach the newly proposed blood pressure goals.

The SPRINT trial largely influenced the AHA/ACC guideline recommendations. The Systolic Blood Pressure Intervention Trial (SPRINT) was a well-done study that demonstrated a 25% relative risk reduction of heart attack, stroke, cardiovascular death, or decompensated heart failure with more aggressive blood pressure management (BP goal < 120/90 versus <140/90). However, the primary endpoint occurred in less than 8% of study participants and thus the benefit of tighter blood pressure control may be lower in terms of absolute risk reduction.

To their credit, both the SPRINT and AHA/ACC guidelines tout the benefits of lifestyle modifications (weight loss, consuming a healthy diet, decreasing alcohol intake, and increasing physical activity) as first-line treatment of hypertension. Blood pressure was measured in the SPRINT trial under ideal conditions after the patient had rested for 5 minutes, an uncommon occurrence in a routine office visit. The new guidelines also note the importance of obtaining ambulatory blood pressure measurements to allow a more comprehensive view of patient’s hypertension.

While the scientific rigor employed for the development of the AHA/ACC guidelines is commendable, substantial concerns about the “real world” applicability of the recommendations remains. Although overall rates were low, the aggressive treatment arm suffered nearly three and a half times the number of adverse events in SPRINT.

Implementing preventive medicine strategies will be extremely difficult in the current health-care reimbursement environment without substantial increases in infrastructure support. These guidelines add to the conversation about managing the “silent killer” in our society, but it remains to be seen whether aggressive blood pressure management is worth the potential risks and to what extent ideal blood pressure measurement can be applied in community practices.

Dr. David Nagel earned his medical and graduate degrees from the University of Rochester School of Medicine and Dentistry. He plans to pursue a physician-scientist career exploring the cell signaling mechanisms involved in the development of idiopathic pulmonary fibrosis. Dr. Nagel serves on the Cardiovascular Medicine and Surgery NetWork Steering Committee. Dr. Nagel would like to recognize Steven Hollenberg, MD, FCCP; Olivier Axler, MD, PhD, FCCP; and Richard Dart, MD, FCCP, for their professional insight in preparing this publication.