January 22, 2018
3 min read

Hypertension guideline explained, criticized

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Robert M. Carey

In columns published in the Annals of Internal Medicine, the 2017 American College of Cardiology/American Heart Association hypertension guideline was defended for its evidence-based approach and emphasis on lifestyle modification, but criticized for expanding the definition of hypertension without adequate proof of benefit.

As Cardiology Today previously reported, the new guideline lowers the threshold for hypertension from systolic BP 140 mm Hg/diastolic BP 90 mm Hg to 130/80 mm Hg, and it eliminates the category of prehypertension.

Robert M. Carey, MD, MACP, FAHA, professor of medicine and dean emeritus at the University of Virginia Health System School of Medicine and vice chair of the guideline’s writing committee, and 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 and chair of the writing committee, published a summary of the guideline and an opinion piece explaining how it can be a resource for practicing clinicians.

“We hope that the 2017 ACC/AHA guideline will stimulate renewed efforts to engage adults in lifestyle modification,” they wrote.

Timothy Wilt, MD, MPH, from the Minneapolis VA Health Care System, and colleagues wrote an editorial charging that the ACC/AHA guideline does not adequately assess potential harms of intensive BP reduction and recommending more individualized BP targets.

“The expanded definition of hypertension would label millions of persons as unwell and lowers the BP threshold for diagnosis and treatment, with no supporting evidence that it optimally balances benefits, harms and patient preferences,” Wilt and colleagues wrote.

Lifestyle improvements

According to Carey and Whelton, the guideline “emphasizes lifestyle modification as the cornerstone of therapy, regardless of whether antihypertensive drug therapy is used” and “increases the proportion of adults with hypertension for whom antihypertensive drug therapy is recommended by only about 1.7%” compared with the 2003 guideline written by the Seventh Joint National Committee.

They wrote that the following lifestyle changes are recommended:

  • weight loss (expected BP reduction, approximately 1 mm Hg per kg of weight lost);
  • heart-healthy diet such as Dietary Approaches to Stop Hypertension (DASH; expected BP reduction, 11 mm Hg);
  • dietary sodium reduction (expected BP reduction, approximately 5 mm Hg per 1-g reduction in sodium intake);
  • dietary potassium supplementation (expected BP reduction, approximately 5 mm Hg with intake of 3.5 g to 5 g per day);
  • increased physical activity (expected BP reduction, approximately 5 mm Hg for 90 to 120 minutes per week of aerobic exercise); and
  • moderate to no alcohol intake, defined as no more than one drink per day for women and no more than two drinks per day for men.


Risks may be underestimated

Wilt and colleagues wrote that the lifestyle recommendations are important, but “initiation of pharmacologic therapy at or above a BP of 130/80 mm Hg and treatment to targets less than 130/80 mm Hg in a broad population of older adults are not supported by evidence and may result in low-value care for several reasons.”

Despite the results of the SPRINT trial, which found that an intensive BP-lowering regimen reduced CV events compared with a standard regimen, “clinical trials do not provide consistent evidence of benefit with [systolic BP] targets less than 130 mm Hg in older adults, including those with diabetes or kidney disease,” they wrote.

In addition, “benefits are often overestimated and harms are often underestimated when trial findings are applied to broad primary care populations” and “there is no evidence from randomized controlled trials to support a [diastolic] BP target less than 80 mm Hg,” according to Wilt and colleagues.

They also wrote that the guideline “inadequately recognizes and assesses potential harms,” noting that “more intensive treatment increases symptomatic hypotension and syncope risk, and antihypertensive medications have common, bothersome and sometimes serious harms,” especially in older patients taking many medications for a variety of conditions.

“Clinical policy focused on lower [systolic] BP targets should permit a choice based on a patient’s risk profile, susceptibility to harms and treatment preferences,” Wilt and colleagues wrote. – by Erik Swain


Carey RM, et al. Ann Intern Med. 2018;doi:10.7326/M17-3203.

Carey RM, et al. Ann Intern Med. 2018;doi:10.7326/M18-0025.

Wilt T, et al. Ann Intern Med. 2018;doi:10.7326/M17-3293.

Disclosures: Carey, Whelton, Wilt and the other editorial authors report no relevant financial disclosures.