Meeting NewsPerspective

New guidelines broaden definition of hypertension

Paul K. Whelton

ANAHEIM, Calif. — Hypertension is now defined as systolic BP 130 mm Hg/diastolic BP 80 mm Hg, which will lead to a new diagnosis in approximately 14% more Americans, according to newly released, long-awaited guidelines published by the American Heart Association, the American College of Cardiology and nine other societies.

The guidelines lower the threshold for hypertension from systolic BP 140 mm Hg/diastolic BP 80 mm Hg, and eliminate the category of prehypertension.

“We’re excited about these guidelines. We think they will empower clinicians as well as adults with high blood pressure, and perhaps those with normal blood pressure who want to prevent going into the elevated [BP] sphere,” writing committee chair Paul K. Whelton, MB, MD, MSc, Show Chwan Chair of Global Public Health, Tulane University School of Public Health and Tropical Medicine, Tulane University School of Medicine, said during a press conference. “We are confident in what we represent in the guideline, and we are confident that if the guideline is implemented, it will improve the cardiovascular health of our adult community in the United States.”

Notable updates

According to the authors, the percentage of U.S. adults considered to have hypertension will rise from 31.9% (72.2 million adults) to 45.6% (103.3 million adults), but the increase should not result in a major increase of people who will be placed on antihypertensive medications. The guidelines state that in patients with stage 1 hypertension, which includes many not previously considered to have hypertension, antihypertensive medication should not be prescribed unless the patient has a previous CV event, diabetes or chronic kidney disease, or is at high 10-year risk for atherosclerotic CVD according to the ACC/AHA Pooled Cohort Equation.

Other notable updates:

  • The guidelines define systolic BP < 120 mm Hg/diastolic BP < 80 mm Hg as normal BP, just like in the Seventh Joint National Committee guideline (JNC 7).
  • Systolic BP 120 to 129 mm Hg/diastolic BP < 80 mm Hg, previously defined as prehypertension, is now defined as elevated BP.
  • Systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg, previously defined as prehypertension, is now defined as stage 1 hypertension.
  • Systolic BP 140 to 159 mm Hg/diastolic BP 90 to 99 mm Hg, previously defined as stage 1 hypertension, is now defined as stage 2 hypertension.
  • Systolic BP of 160 mm Hg or higher/diastolic BP of 100 mm Hg or higher remains defined as stage 2 hypertension.

Lifestyle modification encouraged

For patients with systolic BP 120 to 129 mm Hg/diastolic BP < 80 mm Hg, lifestyle modifications should be encouraged, writing committee vice chair Robert M. Carey, MD, MACP, FAHA, professor of medicine and dean emeritus at the University of Virginia Health System School of Medicine, said at the press conference. Carey noted that this is also the case for systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg who are not at high risk. BP-lowering medication should be used in patients with systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg who are at high risk, and in all patients with systolic BP of 140 mm Hg or more or diastolic BP of 90 mm Hg or more, he said.

Recommended lifestyle modifications include weight loss; healthy diet, especially the Dietary Approaches to Stop Hypertension (DASH) diet; reduced sodium intake, ideally < 1,500 mg per day but at least a reduction of at least 1,000 mg per day; increased potassium intake to 3,500 mg per day; physical activity of at least 90 to 150 minutes per week; and moderate alcohol intake, no more than two drinks per day for men and one drink per day for women, Carey said.

“Lifestyle should be the cornerstone” of any treatment plan, Carey said.

BP target recommendations

The writing committee gave a Class I recommendation to a BP target of < 130 mm Hg systolic/80 mm Hg diastolic in patients with confirmed hypertension and known CVD or a 10-year risk for atherosclerotic CVD of 10% or higher, and a Class IIb recommendation to that target in adults with confirmed hypertension but no additional markers for CVD risk.

The decision to make the BP target < 130 mm Hg systolic/80 mm Hg diastolic was influenced by the results of the SPRINT trial, in which, as Cardiology Today previously reported, patients treated to a systolic BP target of < 120 mm Hg had fewer CV events than those treated to a target of < 140 mm Hg, but “there were a number of factors which led us to select the intermediate level of 130 over 80 rather than going all the way to less than 120 over 80 as a target,” Carey said. “Some of those factors included the method of blood pressure measurement in SPRINT as compared to what’s available in practice at this time [and] the caution about introducing untoward side effects in patients if we had a lower universal target. We are applying this to a general population, so we feel that [a target of < 130 mm Hg systolic/80 mm Hg diastolic] would be more prudent at this time, until we have more clinical trial evidence.”

The BP target of < 130 mm Hg systolic/80 mm Hg diastolic is recommended in community-dwelling adults aged 65 years and older, but it is reasonable to consider different targets for older adults with extensive comorbidities and a limited life expectancy, Whelton said, noting an analysis from SPRINT showed an intensive BP target benefited patients age 75 years and older.

New analysis

According to an analysis simultaneously published in Circulation and JACC by Paul Muntner, PhD, from the department of epidemiology of School of Public Health at the University of Alabama at Birmingham, and colleagues, antihypertensive medication was recommended for 34.3% of U.S. adults (95% CI, 32.5-36.2) under JNC 7 and is recommended for 36.2% of U.S. adults (95% CI, 34.2-38.2) under the new guidelines. Those recommended for treatment by the new guidelines but not JNC 7 had elevated CVD risk, Muntner and colleagues wrote.

Among those taking antihypertensive medication, 53.4% (95% CI, 49.9-56.8) had BP above treatment goal according to the new guidelines, and 39% (95% CI, 36.4-41.6) had BP above the treatment goal according to the JNC 7 guidelines, according to the analysis.

The guidelines also endorse taking multiple medications in a single pill to increase adherence, and taking the patient’s socioeconomic standard and any psychosocial distress into consideration when developing a treatment plan. – by Erik Swain

References:

Whelton PK, et al. 2017 Hypertension Clinical Practice Guidelines. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, California.

Muntner P, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032582.

Muntner P, et al. J Am Coll Cardiol. 2017;doi: 10.1016/j.jacc.2017.10.073.

Whelton PK, et al. Hypertension. 2017;doi:10.1161/HYP.0000000000000065.

Whelton PK, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.11.006.

Disclosure: Whelton reports no relevant financial disclosures.

Paul K. Whelton

ANAHEIM, Calif. — Hypertension is now defined as systolic BP 130 mm Hg/diastolic BP 80 mm Hg, which will lead to a new diagnosis in approximately 14% more Americans, according to newly released, long-awaited guidelines published by the American Heart Association, the American College of Cardiology and nine other societies.

The guidelines lower the threshold for hypertension from systolic BP 140 mm Hg/diastolic BP 80 mm Hg, and eliminate the category of prehypertension.

“We’re excited about these guidelines. We think they will empower clinicians as well as adults with high blood pressure, and perhaps those with normal blood pressure who want to prevent going into the elevated [BP] sphere,” writing committee chair Paul K. Whelton, MB, MD, MSc, Show Chwan Chair of Global Public Health, Tulane University School of Public Health and Tropical Medicine, Tulane University School of Medicine, said during a press conference. “We are confident in what we represent in the guideline, and we are confident that if the guideline is implemented, it will improve the cardiovascular health of our adult community in the United States.”

Notable updates

According to the authors, the percentage of U.S. adults considered to have hypertension will rise from 31.9% (72.2 million adults) to 45.6% (103.3 million adults), but the increase should not result in a major increase of people who will be placed on antihypertensive medications. The guidelines state that in patients with stage 1 hypertension, which includes many not previously considered to have hypertension, antihypertensive medication should not be prescribed unless the patient has a previous CV event, diabetes or chronic kidney disease, or is at high 10-year risk for atherosclerotic CVD according to the ACC/AHA Pooled Cohort Equation.

Other notable updates:

  • The guidelines define systolic BP < 120 mm Hg/diastolic BP < 80 mm Hg as normal BP, just like in the Seventh Joint National Committee guideline (JNC 7).
  • Systolic BP 120 to 129 mm Hg/diastolic BP < 80 mm Hg, previously defined as prehypertension, is now defined as elevated BP.
  • Systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg, previously defined as prehypertension, is now defined as stage 1 hypertension.
  • Systolic BP 140 to 159 mm Hg/diastolic BP 90 to 99 mm Hg, previously defined as stage 1 hypertension, is now defined as stage 2 hypertension.
  • Systolic BP of 160 mm Hg or higher/diastolic BP of 100 mm Hg or higher remains defined as stage 2 hypertension.
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Lifestyle modification encouraged

For patients with systolic BP 120 to 129 mm Hg/diastolic BP < 80 mm Hg, lifestyle modifications should be encouraged, writing committee vice chair Robert M. Carey, MD, MACP, FAHA, professor of medicine and dean emeritus at the University of Virginia Health System School of Medicine, said at the press conference. Carey noted that this is also the case for systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg who are not at high risk. BP-lowering medication should be used in patients with systolic BP 130 to 139 mm Hg/diastolic BP 80 to 89 mm Hg who are at high risk, and in all patients with systolic BP of 140 mm Hg or more or diastolic BP of 90 mm Hg or more, he said.

Recommended lifestyle modifications include weight loss; healthy diet, especially the Dietary Approaches to Stop Hypertension (DASH) diet; reduced sodium intake, ideally < 1,500 mg per day but at least a reduction of at least 1,000 mg per day; increased potassium intake to 3,500 mg per day; physical activity of at least 90 to 150 minutes per week; and moderate alcohol intake, no more than two drinks per day for men and one drink per day for women, Carey said.

“Lifestyle should be the cornerstone” of any treatment plan, Carey said.

BP target recommendations

The writing committee gave a Class I recommendation to a BP target of < 130 mm Hg systolic/80 mm Hg diastolic in patients with confirmed hypertension and known CVD or a 10-year risk for atherosclerotic CVD of 10% or higher, and a Class IIb recommendation to that target in adults with confirmed hypertension but no additional markers for CVD risk.

The decision to make the BP target < 130 mm Hg systolic/80 mm Hg diastolic was influenced by the results of the SPRINT trial, in which, as Cardiology Today previously reported, patients treated to a systolic BP target of < 120 mm Hg had fewer CV events than those treated to a target of < 140 mm Hg, but “there were a number of factors which led us to select the intermediate level of 130 over 80 rather than going all the way to less than 120 over 80 as a target,” Carey said. “Some of those factors included the method of blood pressure measurement in SPRINT as compared to what’s available in practice at this time [and] the caution about introducing untoward side effects in patients if we had a lower universal target. We are applying this to a general population, so we feel that [a target of < 130 mm Hg systolic/80 mm Hg diastolic] would be more prudent at this time, until we have more clinical trial evidence.”

PAGE BREAK

The BP target of < 130 mm Hg systolic/80 mm Hg diastolic is recommended in community-dwelling adults aged 65 years and older, but it is reasonable to consider different targets for older adults with extensive comorbidities and a limited life expectancy, Whelton said, noting an analysis from SPRINT showed an intensive BP target benefited patients age 75 years and older.

New analysis

According to an analysis simultaneously published in Circulation and JACC by Paul Muntner, PhD, from the department of epidemiology of School of Public Health at the University of Alabama at Birmingham, and colleagues, antihypertensive medication was recommended for 34.3% of U.S. adults (95% CI, 32.5-36.2) under JNC 7 and is recommended for 36.2% of U.S. adults (95% CI, 34.2-38.2) under the new guidelines. Those recommended for treatment by the new guidelines but not JNC 7 had elevated CVD risk, Muntner and colleagues wrote.

Among those taking antihypertensive medication, 53.4% (95% CI, 49.9-56.8) had BP above treatment goal according to the new guidelines, and 39% (95% CI, 36.4-41.6) had BP above the treatment goal according to the JNC 7 guidelines, according to the analysis.

The guidelines also endorse taking multiple medications in a single pill to increase adherence, and taking the patient’s socioeconomic standard and any psychosocial distress into consideration when developing a treatment plan. – by Erik Swain

References:

Whelton PK, et al. 2017 Hypertension Clinical Practice Guidelines. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, California.

Muntner P, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032582.

Muntner P, et al. J Am Coll Cardiol. 2017;doi: 10.1016/j.jacc.2017.10.073.

Whelton PK, et al. Hypertension. 2017;doi:10.1161/HYP.0000000000000065.

Whelton PK, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.11.006.

Disclosure: Whelton reports no relevant financial disclosures.

    Perspective

    The most important development of these guidelines is the recognition that when your systolic BP increases from 120 mm Hg to 130 mm Hg, you double your risk for having complications. It is important to think about intervening in that group of patients, especially if they have comorbidities, which so many of the patients that I see do. To ignore that is to do a disservice to your patients.

    There will certainly be difficulties in getting the new recommendations to catch on. There is already a level of frustration by clinicians with getting patients to the currently recommended goal of systolic BP < 140 mm Hg/diastolic BP < 90 mm Hg. The new goals will be even more challenging. But you cannot put your head in the sand and ignore the fact that you are not doing all you can to aggressively control your patients’ BP. A positive aspect of the new guidelines is that they come with solid recommendations about how to initiate care using a team approach.

    We know an awful lot about hypertension and have a number of very good medications. We understand the importance of lifestyle. What’s frustrating is that while about 75% of patients with hypertension are on at least one medication, our control rate is only about 54% overall, and even worse in certain populations. We have learned a lot, but there is still much more to do.

    It’s important that we recognize that controlling hypertension is crucial; it is not a silent killer, especially given its connection to stroke. These recommendations reflect where the science has taken us. We have to act on them.

    • Willie Lawrence Jr., MD, FAHA, FACC
    • Chief of Cardiology
      Research Medical Center
      HCA Midwest Health, Kansas City, Missouri

    Disclosures: Lawrence reports no relevant financial disclosures.

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