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The 2013 Eighth Joint National Committee (JNC 8) guidelines on hypertension management, which raised the blood pressure (BP) target in older patients to <150/90 mm Hg, could lead to 8,000 additional cardiovascular events over 10 years compared with the older target of <140/90 mm Hg, according to recent studies.
Both studies, led by William Borden, MD, and Thomas Maddox, MD, were published in the Journal of the American College of Cardiology and evaluated the the clinical impact of the controversial new treatment guidelines for the prevention of heart attack and stroke.
We reached out to experts on hypertension, as well as a diverse group of healthcare professionals, and asked:
What is your opinion of the higher target and, in general when it comes to hypertension management, how do you judge overtreatment versus undertreatment?
The participants were:
- Randall Mark Zusman, MD, director, division of hypertension at Massachusetts General Hospital in Boston
- Wanpen Vongpatanasin, MD, program director, hypertension fellowship program at the University of Texas Southwestern Medical Center in Dallas
- John William McEvoy, MB BCh, chief fellow, division of cardiology at Johns Hopkins School of Medicine in Baltimore
- Payal Bhandari, MD, primary care physician at Advanced Health in San Francisco
- Merle Myerson, MD, assistant professor, medicine in cardiology at Mount Sinai Hospital in New York City
Effect on High-Risk Patients
Merle Myerson, MD: "I feel that the JNC 8 document, while helpful in many aspects, should have considered the lower targets for blood pressure for older persons. There is ample evidence that higher blood pressure is the leading risk factor for stroke and also contributes to risk for heart disease, kidney disease, and other arterial disease. Research done after these guidelines were issued suggests that there was a significant decrease in the number of patients who would either be labeled as 'hypertension' or 'treatment eligible' and that certain 'at-risk' populations, in particular blacks, women, and elderly may not receive optimal treatment."
Payal Bhandari, MD: "Setting lower 'normal' blood pressure targets will increase the detection of cardiovascular disease. Increased detection leads to increased prevention of disease progression. If the primary approach to treating elevated blood pressure readings is through pharmaceuticals, cardiovascular events are not adequately being prevented because the underlying culprit is not addressed. Pharmaceuticals are often plagued with side effects. Their effectiveness is also more futile in the setting of advanced cardiovascular disease."
John William McEvoy, MB BCh: "The study by Borden, et al. should be a cause for concern. It is increasingly apparent that following the more lenient systolic target of 150 mmHg, endorsed in the JNC 8 panel's document, for [people over age 60] could lead to adverse consequences. This is particularly true for those individuals in this age category who are higher risk, based on either prior events (over 60% of subjects in this age range with a BP of between 140 and 150 mmHg had prior coronary artery disease) or based on their overall cardiovascular risk profile."
Flaws in the Process
Wanpen Vongpatanasin, MD: "The recommendation by the JNC 8 to use a less stringent goal was based on two clinical trials conducted in Japan, which failed to show that lowering systolic BP below 140 mmHg improved cardiovascular outcomes compared with a higher target goal in elderly hypertensive patients. However, the follow-up duration is relatively short, and the studies were underpowered to detect differences in cardiovascular outcomes. By contrast, observational analysis of patients with coronary artery disease in the U.S. and many Western countries indicates that less stringent control of BP to levels between 140 to 150 mmHg is associated with higher cardiovascular mortality and stroke compared with the goal of <140 mmHg."
Myerson: "It is acknowledged that there was a lack of randomized clinical trials with which to determine the optimal blood pressure. However, the increased target in older patients was criticized with a call to return to previous targets. Although randomized clinical trials provide very strong evidence, they are not without fault. Many are sponsored by industry and therefore designed to increase chances of a favorable outcome."
Randall Mark Zusman, MD: "The assessment of the JNC 8 guidelines [has generated] a renewed discussion and debate about cholesterol targets. Not to be unduly critical, but guidelines are out-of-date the moment they're published because, generally, they were written months before; they've been reviewed, approved, spindled, and mutilated along the way, and by the time they get into press, other scientific observations have been made that may impact them in an important way."
Overtreatment Versus Undertreatment
Zusman: "One has to consider the quality of life of the patient. You certainly wouldn't want to take someone who's independent and self-sufficient and make them fatigued, depressed, and light-headed. That being said, I will perhaps compromise on my targets if I find that it's not possible to bring their blood pressure down to the level I'm seeking without producing side effects. But, generally, by carefully selecting drugs that work well together and by thinking about the timing of their administration, you can usually control a patient's blood pressure values without producing unacceptable side effects. No individual patient fits all the criteria of the guideline, so we would always want to individualize the treatment to meet the needs of that person -- their tolerance of the treatment, their comorbidities, and the type of lifestyle activities that are important to them."
Vongpatanasin: "Given the uncertainty about the impact of less stringent control of BP, clinicians should apply the new guidelines with caution. Patients with increased risk of stroke may benefit from tight control of BP. As a matter of fact, hypertension guidelines in many countries, including Canada, the U.K., and the rest of the European countries, do not advocate higher BP goal until after the age of 80, which was the age group studied in the HYVET trial."
McEvoy: "While it is worth noting that the data from this study are derived from a registry that may enrich the sample with higher-risk patients (and is, thus, not nationally representative), these results remind us that BP management should be individualized to the patients' risk and that physicians should apply the JNC 8 panel's higher systolic threshold with caution while awaiting formal guidelines endorsed by the AHA/ACC due out next year."
Bhandari: "By determining the underlying culprit of the blood pressure elevation, treatment can be directed towards addressing the root causes and thereby lessening the body's chronic stress and development of disease. If higher 'normal' blood pressure targets are set, earlier detection of cardiovascular, renal, and other essential organ disease will be missed. If lower 'normal' blood pressure targets are set, earlier detection of end organ damage may occur."