Experts: Hypertension guideline sound, but implementation challenges ahead
ANAHEIM, Calif. — Hypertension experts interviewed by Cardiology Today praised the new American Heart Association/American College of Cardiology hypertension guideline as accurately reflecting current science, but expressed concern about ease of implementation.
The guideline changed the definition of hypertension to systolic BP 130 mm Hg or higher or diastolic BP 80 mm Hg or higher, which will lead to a new diagnosis in more than 30 million U.S. adults, and recommended those thresholds be treatment targets for most adults. It also emphasizes lifestyle modification and suggests treatment decisions be based in part on the AHA/ACC’s Pooled Cohort Equation of CVD risk.
“While the news media says that now half the country is hypertensive, that’s not arbitrary at all. It’s based on very good data that look at risk,” George L. Bakris, MD, professor of medicine and director of the American Society for Hypertension Comprehensive Hypertension Center, University of Chicago Medicine, a Cardiology Today Editorial Board Member and a reviewer of the new guidelines, said in an interview. “It specifically has as a goal that if [a patient has] greater than 10% 10-year cardiovascular risk, you should be more aggressive with treatment. That may sound obvious, but previous guidelines assumed that, never really defined it and never put it into context. This guideline does that, and it’s a very important step forward.”
Keith C. Ferdinand, MD, FACC, FAHA, professor of medicine at Tulane University School of Medicine and Cardiology Today Editorial Board Member, agreed.
“The science- and evidence-based approach to this new guideline is a leap forward for clinical medicine,” he told Cardiology Today. “Blood pressure elevation is probably the most powerful predictor of atherosclerotic cardiovascular disease, including heart attacks, strokes, heart failure and renal disease, along with other comorbid risk factors. The utilization of [atherosclerotic] CVD risk calculation to guide the initiation of pharmacotherapy is appropriate since it will focus attention on those patients who need medication to lower their risk.”
Wanpen Vongpatanasin, MD, FACC, FAHA, professor of medicine, director of the Hypertension Section, and holder of the Norman and Audrey Kaplan Chair in Hypertension at UT Southwestern Medical Center, said the guidelines reflect the relationship between BP level and CVD risk shown in the SPRINT trial and now allow doctors to “incorporate risk into day-to-day management of hypertension.”
However, she said, “the challenge is to get blood pressure measured accurately in clinical practice. The way SPRINT was conducted, blood pressure was measured using a standardized protocol that we can’t often afford in practice: resting for 5 minutes, no talking, no looking at your iPhone. Each practice needs to think about these protocols carefully and try to incorporate them into practice. If they ignore that, it could potentially increase the risks of the treatment, because you could potentially have more side effects from overtreatment if you don’t measure blood pressure carefully.”
Although the guideline rightly emphasizes achieving BP goals of less than 130 mm Hg systolic/80 mg diastolic and identifies lifestyle changes and drugs proven to get BP under control, it is “unfortunately incredibly dense,” Steven E. Nissen, MD, MACC, chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at the Cleveland Clinic’s Sydell and Arnold Miller Family Heart and Vascular Institute and Cardiology Today Editorial Board Member, told Cardiology Today. “The primary people who treat hypertension are the primary care doctors, internists and family practitioners. And they’re not going to read a 200-page guideline. Making it simpler is an important goal for the medical community so that it gets implemented.”
Bakris said doctors should read the guideline’s executive summary and a management algorithm near the front of the main document, which have almost everything needed for use in clinical practice.
He also said success of implementation may well depend on reimbursement issues.
Those who decide on reimbursement “need to allow time for the physician to educate the patient about low-sodium diets, about getting a good sleep history, etc. But because [doctors] are limited in time for what they’re getting paid for, it’s not happening. What really drives clinical practice is: Are there policy decisions that link payment to outcomes? If the answer is yes, doctors will follow the guideline. If the answer is no, it’s not going to happen.”
Expanding the definition of hypertension could have some “unintended consequences,” Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, associate professor of medicine, director of research of the cardiac catheterization laboratory and director of the Cardiovascular Outcomes Group in the Cardiovascular Clinical Research Center at NYU Langone Health, and a Cardiology Today Editorial Board Member, said in an interview.
“The positive aspects are that starting early might be beneficial to reduce the risk of events, but let’s not forget that branding somebody with a disease condition may actually worsen it,” he said. “At the end of the day, you have to individualize treatment.”
Bakris said there remain a few areas where the evidence is insufficient.
“While the guideline is useful in managing early risk, the guidance given for more advanced disease like isolated systolic hypertension is deficient and provides little to no guidance in this area,” he said. “Also, there is an extrapolation from the < 130 mm Hg systolic BP/80 mm Hg diastolic BP goal assuming all will measure it per guidelines to the ambulatory BP monitoring numbers, which really do not have a good evidence base to defend > 125 mm Hg/75 mm Hg as hypertension. So, there is good news and not so good news with the recent guidelines.”
Nissen questioned whether using the Pooled Cohort Equation is the best way to assess CVD risk.
“The risk calculator has been shown to be relatively inaccurate in multiple other studies,” he said. “I would have preferred if they had done something else. In addition, it hasn’t been extensively tested for blood pressure. It was designed for determining lipid-lowering therapy, so it’s being morphed to use for this purpose.”
Several experts said they were encouraged that the guideline’s recommendations on how to treat patients with diabetes and hypertension are consistent with the American Diabetes Association’s guideline on the topic, and that patients with comorbidities that put them at very high risk are addressed extensively.
“There are some clear sections on patients with comorbid conditions, including heart failure, which suggest that newer goals should be obtained in patients with left ventricular dysfunction and cardiac risk,” Ferdinand said. “There are also some easy-to-read-and-comprehend suggestions on appropriate approaches to patients with secondary hypertension and resistant hypertension. These conditions often become areas of concern for internists, hypertension specialists and cardiologists who may see patients that have had months or even years of poorly controlled hypertension but have not been evaluated appropriately for secondary causes.”
He said the guideline comes at a particularly important time, when it has been documented that gains in CHD and stroke mortality are being lost because of increases in diabetes, obesity and uncontrolled hypertension, among other factors.
“It is indeed the control of risk factors, including hyperlipidemia and hypertension, which have been the primary reasons for the decline in CVD mortality that has been seen in the United States,” Ferdinand said. “If we don’t control hypertension, then we may actually see a reversal of these gains in heart disease and stroke.” – by Erik Swain
Whelton PK, et al. 2017 Hypertension Clinical Practice Guidelines. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, Calif.
Disclosures: Ferdinand reports he is a consultant for Amgen, Boehringer Ingelheim, Novartis, Quantum Genomics and Sanofi. Bakris, Bangalore, Nissen and Vongpatanasin report no relevant financial disclosures.