At Issue

New hypertension guidelines generate discussion among medical community

The latter weeks of 2013 saw the release of the long-awaited guideline for the management of high BP in adults developed by members appointed to the Eighth Joint National Committee, or JNC 8, and the subsequent publication of a joint guideline on the same topic by the American Society of Hypertension and International Society of Hypertension.

In the wake of the new flurry of guidelines, which offer different recommendations on target BP targets, for example, discussion among the medical community has brought this important topic of BP management to the forefront in 2014. Read comments from three experts whom Cardiology Today asked for their opinion. We welcome you to share your impressions of the guidelines by commenting below.


Philip B. Gorelick, MD, MPH

Professor of translational science and molecular medicine at Michigan State University College of Human Medicine and medical director at Mercy Health Hauenstein Neurosciences in Grand Rapids, Mich.

Randall Zusman, MD

Director of hypertension at Massachusetts General Hospital, associate professor of medicine at Harvard Medical School and consultant in cardiology at Massachusetts Institute of Technology.

Franz H. Messerli, MD

Director of the hypertension program at St. Luke’s and Roosevelt Hospitals, N.Y., and a member of the Cardiology Today Editorial Board.


Gorelick: The long-awaited guidelines devised by the JNC 8 working group for the management of high BP utilized a rigorous evidence-based approach to review randomized controlled trials of BP management to answer three critical questions in adults with hypertension: (1) Does initiation of antihypertensive pharmacologic therapy at specified BP thresholds lead to improvements in health outcomes? (2) Does such therapy to a specified BP target goal improve health outcomes? (3) Do various antihypertensive drugs or classes differ in comparative benefits and harms on specific health outcomes?

Philip B. Gorelick

Philip B. Gorelick

Following at the heels of JNC 8, ASH and ISH released clinical practice guidelines for management of hypertension in the community with the purpose of providing a straightforward approach to managing BP.  Whereas the JNC 8 document addresses three critical questions and provides nine evidence-based recommendations that are built around the three key questions, the ASH/ISH document provides a brief but diverse curriculum, including but not limited to hypertension-related topics such as epidemiology, definition and classification, special issues in black patients, causes and diagnosis, evaluation, physical exam and tests, goals, and treatment including that for resistant hypertension. Thus, compared with the JNC 8 report, the ASH/ISH document provides a more practical or “how-to” approach arrived at by expert opinion. 

As it turns out, there is quite a bit of overlap between the BP management algorithms in the two documents, although the target systolic BP goal for those aged 60 years and older is <150 mm Hg/90 mm Hg in JNC 8 and <140 mm Hg/90 mm Hg in the ASH/ISH review — unless one is aged 80 years or older, in which the target BP goal is <150 mm Hg/90 mm Hg.

The two documents should be used in a complementary fashion. The JNC 8 report is a rigorous evidence-based review with algorithmic recommendations for BP management according to randomized controlled trial results, whereas the ASH/ISH review provides a brief but diverse curriculum of pertinent topics related to BP and BP management. Authors of each document are likely to agree that the guidance statements provide important knowledge bases, but are not a substitute for pragmatic clinical reasoning when making patient-level decisions.

Finally, although BP control has been considered by some as the “crown jewel” of stroke prevention, neither document specifically addresses the issue of BP target goals for first or recurrent stroke prevention. Yet, it has been suggested that a J-shaped hypertension curve may not exist for stroke, and in epidemiologic studies, stroke risk may be down to BP levels of at least 115 mm Hg/75 mm Hg. Thus, we are faced with a complicated but pertinent hypertension–stroke question to be addressed in the future.

Zusman: The biggest take-away from the JNC 8 guideline is that patient care can be individualized to meet the goals of reducing stroke, MI, HF and renal disease in a hypertensive patient population. It’s hard to disagree with the overall recommendations in terms of the importance of BP control. Personally, I am more aggressive in terms of treatment and would use the lower target of 140 mm Hg/90 mm Hg rather than 150 mm Hg/90 mm Hg in elderly patients. But, I think that the focus on the need to identify patients to initiate therapies that are effective when used alone or in combination and to follow patients in a focused fashion to achieve BP control is something we can all agree upon and support.

Randall Zusman

Randall Zusman

The only thing that I found surprising was the failure to support the use of ACE inhibition and/or angiotensin receptor blockade in African-American patients with diabetes. The authors recommend starting with a thiazide diuretic or calcium channel blocker. That reflects a longstanding, but perhaps not convincing, feeling that African-American patients do not respond to ACE inhibition. I think it’s a matter of dosage and titration. The evidence for the nephroprotective effect of ACE inhibitors and angiotensin receptor blockers in diabetic patients is well established, and I would afford the African-American population that same benefit, even if it may not be associated with as great a BP-lowering effect as in the white patient population.

I would have emphasized more the potential for lifestyle modification and, perhaps, at least included peripherally non-drug therapies that are potentially beneficial in resistant patient populations. The guideline also doesn’t focus much on resistant hypertension. This is an ever-expanding group of people that’s worth mentioning and might have warranted a discussion of multidrug regimens, how to improve compliance, the importance of diet, and the use of non-drug therapies such as relaxation response. The authors also didn’t discuss emerging [therapies], including renal denervation, and what role that might play in the next decade.

Many of us were disappointed that it took so long to develop this document. Because these guidelines come out so infrequently, I might have taken the opportunity to broaden the scope of the commentary. Given that the number of people who have hypertension is increasing, this would have been an opportunity to provide a more forward-looking thought about where we might end up in another decade.

Messerli: This report takes a rigorous, evidence-based approach to recommend treatment thresholds and medications. The guidelines were supposed to be evidence-based, but when you scrutinize them they are not. In looking at the recommendations, six are based on consensus of opinion and only two receive a grade of ‘A’ for the strongest evidence. Unfortunately, meta-analyses were completely neglected from the evidence base. Those analyses have their drawbacks and are not as convincing as powerful randomized trials, but nevertheless can be helpful.

Franz H. Messerli

Franz H. Messerli

By and large, the recommendations are very thorough, but I have a few points of contention. One, 24-hour ambulatory BP monitoring is nowhere to be found. That’s of concern because it is a very useful tool to assess need for treatment, white-coat hypertension, secondary hypertension, etc.

Two, the authors use the term “thiazides.” There is no morbidity and mortality evidence for hydrochlorothiazide in its usual dose of 12.5 mg to 25 mg; there is only evidence for chlorthalidone and indapamide. To lump them together is, in my opinion, not acceptable.

Three, thiazides are still recommended as initial therapy. This may be acceptable in the elderly patient, but given the obesity epidemic in the United States and the high risk for developing new-onset diabetes, a thiazide should not be initial therapy in any at-risk patient. Calcium channel blockers, angiotensin receptor blockers and ACE inhibitors are all metabolically much more patient-friendly than thiazides. It is good to see that beta-blockers have been relegated to add-on, fourth-line therapy. But again, this is based on pure consensus; there is no good evidence that they should be fourth-line at all.

Disclosure: Gorelick reports consulting for Novartis. Messerli is an ad hoc consultant for Abbott, Daiichi Sankyo, Ipca Laboratories, Medtronic, Pfizer, Servier and Takeda. Zusman reports no relevant financial disclosures.

The latter weeks of 2013 saw the release of the long-awaited guideline for the management of high BP in adults developed by members appointed to the Eighth Joint National Committee, or JNC 8, and the subsequent publication of a joint guideline on the same topic by the American Society of Hypertension and International Society of Hypertension.

In the wake of the new flurry of guidelines, which offer different recommendations on target BP targets, for example, discussion among the medical community has brought this important topic of BP management to the forefront in 2014. Read comments from three experts whom Cardiology Today asked for their opinion. We welcome you to share your impressions of the guidelines by commenting below.


Philip B. Gorelick, MD, MPH

Professor of translational science and molecular medicine at Michigan State University College of Human Medicine and medical director at Mercy Health Hauenstein Neurosciences in Grand Rapids, Mich.

Randall Zusman, MD

Director of hypertension at Massachusetts General Hospital, associate professor of medicine at Harvard Medical School and consultant in cardiology at Massachusetts Institute of Technology.

Franz H. Messerli, MD

Director of the hypertension program at St. Luke’s and Roosevelt Hospitals, N.Y., and a member of the Cardiology Today Editorial Board.


Gorelick: The long-awaited guidelines devised by the JNC 8 working group for the management of high BP utilized a rigorous evidence-based approach to review randomized controlled trials of BP management to answer three critical questions in adults with hypertension: (1) Does initiation of antihypertensive pharmacologic therapy at specified BP thresholds lead to improvements in health outcomes? (2) Does such therapy to a specified BP target goal improve health outcomes? (3) Do various antihypertensive drugs or classes differ in comparative benefits and harms on specific health outcomes?

Philip B. Gorelick

Philip B. Gorelick

Following at the heels of JNC 8, ASH and ISH released clinical practice guidelines for management of hypertension in the community with the purpose of providing a straightforward approach to managing BP.  Whereas the JNC 8 document addresses three critical questions and provides nine evidence-based recommendations that are built around the three key questions, the ASH/ISH document provides a brief but diverse curriculum, including but not limited to hypertension-related topics such as epidemiology, definition and classification, special issues in black patients, causes and diagnosis, evaluation, physical exam and tests, goals, and treatment including that for resistant hypertension. Thus, compared with the JNC 8 report, the ASH/ISH document provides a more practical or “how-to” approach arrived at by expert opinion. 

As it turns out, there is quite a bit of overlap between the BP management algorithms in the two documents, although the target systolic BP goal for those aged 60 years and older is <150 mm Hg/90 mm Hg in JNC 8 and <140 mm Hg/90 mm Hg in the ASH/ISH review — unless one is aged 80 years or older, in which the target BP goal is <150 mm Hg/90 mm Hg.

The two documents should be used in a complementary fashion. The JNC 8 report is a rigorous evidence-based review with algorithmic recommendations for BP management according to randomized controlled trial results, whereas the ASH/ISH review provides a brief but diverse curriculum of pertinent topics related to BP and BP management. Authors of each document are likely to agree that the guidance statements provide important knowledge bases, but are not a substitute for pragmatic clinical reasoning when making patient-level decisions.

Finally, although BP control has been considered by some as the “crown jewel” of stroke prevention, neither document specifically addresses the issue of BP target goals for first or recurrent stroke prevention. Yet, it has been suggested that a J-shaped hypertension curve may not exist for stroke, and in epidemiologic studies, stroke risk may be down to BP levels of at least 115 mm Hg/75 mm Hg. Thus, we are faced with a complicated but pertinent hypertension–stroke question to be addressed in the future.

PAGE BREAK

Zusman: The biggest take-away from the JNC 8 guideline is that patient care can be individualized to meet the goals of reducing stroke, MI, HF and renal disease in a hypertensive patient population. It’s hard to disagree with the overall recommendations in terms of the importance of BP control. Personally, I am more aggressive in terms of treatment and would use the lower target of 140 mm Hg/90 mm Hg rather than 150 mm Hg/90 mm Hg in elderly patients. But, I think that the focus on the need to identify patients to initiate therapies that are effective when used alone or in combination and to follow patients in a focused fashion to achieve BP control is something we can all agree upon and support.

Randall Zusman

Randall Zusman

The only thing that I found surprising was the failure to support the use of ACE inhibition and/or angiotensin receptor blockade in African-American patients with diabetes. The authors recommend starting with a thiazide diuretic or calcium channel blocker. That reflects a longstanding, but perhaps not convincing, feeling that African-American patients do not respond to ACE inhibition. I think it’s a matter of dosage and titration. The evidence for the nephroprotective effect of ACE inhibitors and angiotensin receptor blockers in diabetic patients is well established, and I would afford the African-American population that same benefit, even if it may not be associated with as great a BP-lowering effect as in the white patient population.

I would have emphasized more the potential for lifestyle modification and, perhaps, at least included peripherally non-drug therapies that are potentially beneficial in resistant patient populations. The guideline also doesn’t focus much on resistant hypertension. This is an ever-expanding group of people that’s worth mentioning and might have warranted a discussion of multidrug regimens, how to improve compliance, the importance of diet, and the use of non-drug therapies such as relaxation response. The authors also didn’t discuss emerging [therapies], including renal denervation, and what role that might play in the next decade.

Many of us were disappointed that it took so long to develop this document. Because these guidelines come out so infrequently, I might have taken the opportunity to broaden the scope of the commentary. Given that the number of people who have hypertension is increasing, this would have been an opportunity to provide a more forward-looking thought about where we might end up in another decade.

PAGE BREAK

Messerli: This report takes a rigorous, evidence-based approach to recommend treatment thresholds and medications. The guidelines were supposed to be evidence-based, but when you scrutinize them they are not. In looking at the recommendations, six are based on consensus of opinion and only two receive a grade of ‘A’ for the strongest evidence. Unfortunately, meta-analyses were completely neglected from the evidence base. Those analyses have their drawbacks and are not as convincing as powerful randomized trials, but nevertheless can be helpful.

Franz H. Messerli

Franz H. Messerli

By and large, the recommendations are very thorough, but I have a few points of contention. One, 24-hour ambulatory BP monitoring is nowhere to be found. That’s of concern because it is a very useful tool to assess need for treatment, white-coat hypertension, secondary hypertension, etc.

Two, the authors use the term “thiazides.” There is no morbidity and mortality evidence for hydrochlorothiazide in its usual dose of 12.5 mg to 25 mg; there is only evidence for chlorthalidone and indapamide. To lump them together is, in my opinion, not acceptable.

Three, thiazides are still recommended as initial therapy. This may be acceptable in the elderly patient, but given the obesity epidemic in the United States and the high risk for developing new-onset diabetes, a thiazide should not be initial therapy in any at-risk patient. Calcium channel blockers, angiotensin receptor blockers and ACE inhibitors are all metabolically much more patient-friendly than thiazides. It is good to see that beta-blockers have been relegated to add-on, fourth-line therapy. But again, this is based on pure consensus; there is no good evidence that they should be fourth-line at all.

Disclosure: Gorelick reports consulting for Novartis. Messerli is an ad hoc consultant for Abbott, Daiichi Sankyo, Ipca Laboratories, Medtronic, Pfizer, Servier and Takeda. Zusman reports no relevant financial disclosures.