You need an expert to write high blood pressure guidelines. A medical expert is he (or she) who does not agree with anybody. Sometimes the expert does not agree even with himself. Agreeing with other so-called experts might be construed as a sign of weakness!
Cake, anybody?
What about the lowly practitioners out there in the trenches, seeing real-life patients, giving real-life advice, and facing real-life consequences? Well, as the French lady said: “Qu’ils mangent de la brioche.” Let them eat cake.
Let us control blood pressure!
Hurray! Full steam ahead! Up and at them! But what should we aim for?
Um, well, let us look at the guidelines, which are, as we said, devised by experts.
But wait a second. Which guidelines should we look at?
I have principles!
A great man once said, “Look, I have principles. And if you don’t like them, I have others.”
Guidelines are the same. If you don’t like one set, well, we have others.
Let us start with JNC 8.
JNC 8
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure had been in the business of dishing out advice about how to treat high blood pressure since 1976. Its eighth avatar issued its set of recommendations in December 2013, after having been originally commissioned to perform its task in 2008 by the National Heart, Lung, and Blood Institute (NHLBI).
Along the way, something interesting happened. In 2013, before the JNC 8 report was published, the NHLBI announced that in the future, the American College of Cardiology and the American Heart Association (ACC/AHA) would be in charge of writing guidelines about how to treat high blood pressure.
So the JNC 8 report, as the members acknowledge themselves, is not sanctioned by the NHLBI, and does not reflect the views of the NHLBI!
Debate
There has been significant controversy and debate about the recommendations of JNC 8.
Around the time of release of the JNC 8 report, the president-elect of the American Heart association said that the AHA had some reservations about the JNC 8 recommendations.
In January 2014, an article appeared in the prestigious journal, the Annals of Internal Medicine, written by five of the seventeen authors of the JNC 8 report. In this, they stated that they did not agree with the guidelines of JNC 8, and explained their reasons.
What is the problem?
The biggest controversy was triggered by the JNC 8 recommendations regarding patients 60 years or older.
JNC 8 guidelines recommend starting drug treatment for high blood pressure in this group of patients if their systolic BP (the top number) is 150 mm Hg or higher, or if their diastolic BP (the bottom number) is 90 mm Hg or higher.
Furthermore, the experts state that the goal of BP treatment in this age group should be to bring the BP below the levels mentioned above.
Why the debate?
JNC 8 panelists felt that there were not enough good trials of patients over the age of 60 to recommend treating them to a goal systolic BP of less than 140 mm Hg, as opposed to below 150 mm Hg.
Other expert bodies disagree. Some of them point to the ALLHAT, ACCOMPLISH, and VALUE trials.
And the debate goes on.
ASH/ISH guidelines
The good folks at the American Society of Hypertension and the International Society of Hypertension, not to be outdone, issued their own set of guidelines jointly in the latter part of 2013.
They recommended an age cut-off for treating non-black patients with high BP. Below the age of 60 years, they advised using an ARB (angiotensin receptor blocker) or ACE (angiotensin converting enzyme) inhibitor, while above that age, their advice was to use a thiazide-type fluid pill, or a calcium channel blocker.
These bodies also disagreed with the advice of JNC 8 to start treating high BP in patients 60 years or older only if their BP was 150/90 mm Hg or higher, and to use less strict criteria for BP control in this older age group. They recommended a goal BP of less than 140/90 mm Hg with treatment. They also stated that a target BP of less than 150 mm Hg systolic (upper number) should be used only in people older than 80.
ACC/AHA/CDC
The experts at these bodies, the American College of Cardiology, the American Heart Association, and the Centers for Disease Control and Prevention, put their heads together, and issued a “Science Advisory” in November, 2013. Their recommendation is for a target BP of less than 140/90 mm Hg. They recommend using different medications for Stage I hypertension (BP 140–159/90–99 mm Hg). There are also guidelines for testing for secondary causes of hypertension, as well as considering referral to a hypertension specialist if good control is still not established.
The Europeans weigh in
The European Society of Hypertension (ESH) and the European Society of cardiology (ESC) also issued their own set of guidelines for BP control in 2013. They had previously recommended a target of 130/80 mm Hg for high-risk patients and 140/90 for those at low or moderate risk. However, in 2013, they advised that nearly all patients should be treated to a goal systolic (top number) BP of less than 140 mm Hg.
For patients with diabetes, the Europeans advised the same systolic BP, but a lower diastolic BP (lower number) target of less than 85 mm Hg.
In people over the age of 80 years, these guidelines recommend a systolic BP of less than 140 mm Hg, if the patient is physically and mentally fit. Otherwise, the goal should be 140–150 mm Hg.
Let us SPRINT to some answers!
If you are getting confused, you are not alone!
Doctors have been treating high BP for quite some time now, and we are still looking for good answers. At times, it feels like perhaps we are not even asking the right questions!
So the good folks at the National Heart, Lung, and Blood Institute sprang into action. Or, should we say, SPRINTED into action with the… of course, SPRINT study.
This study was supposed to last for 5-6 years, but the monitoring committee halted the study early, in August 2015, because of potentially life-saving results.
Saving lives?
Yes, if we believe the SPRINT trial results. They studied more than 9000 patients, with the goal of evaluating the differences between the outcomes of people whose target systolic BP with treatment was less than 140 versus those with a target of less than 120 mm Hg.
The patients assigned to the lower BP target had their risk of heart attacks, heart failure, and stroke reduced by a third. Their risk of death was reduced by nearly 25%.
So shall we all SPRINT?
Not so fast!
The results in this study were obtained in a highly selected population, using rather strict inclusion and exclusion criteria, and do not apply to the entire population of patients with high BP.
The American College of Cardiology is in the process of writing a new set of guidelines for the treatment of hypertension, and the expert panel will obviously look carefully at the data from the SPRINT study, and recommend what should be incorporated into general practice. Obviously, that will also generate some debate.
In the meantime …
Medical care is best provided one-on-one, with discussion between the patients and their personal physician, who knows their unique situation best.
We will provide details of the SPRINT trial in a subsequent post.
In the meantime … talk to your doctor!
More about high blood pressure
You can read more about this devastating condition and its treatment in my ebook “High Blood Pressure: 10 Reasons Your Blood Pressure Is NOT Under Control,” which is available here … http://www.amazon.com/dp/B015P919CI.
We need better guidelines to evaluate all these guidelines!
So true!