May 24, 2018
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Analysis: 2017 ACC/AHA hypertension guideline increases use of antihypertensive treatment

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More patients were recommended antihypertensive treatment with the 2017 hypertension guidelines compared with the 2014 guidelines, which led to a reduction in all-cause mortality and major CVD events, although it may increase adverse events, according to an analysis published in JAMA Cardiology.

NHANES data

Joshua D. Bundy, PhD, MPH, fellow in the department of preventive medicine at Northwestern University Feinberg School of Medicine, and colleagues analyzed data from 9,746 patients from the National Health and Nutrition Examination Survey 2013 to 2016, including BP measurements, diabetes status, estimated glomerular filtration rate, chronic kidney disease status and CVD risk.

The 2017 American College of Cardiology/American Heart Association guideline and the 2014 guideline written by the panel convened for the Eighth Joint National Committee but not endorsed by the ACC and AHA were used to assess hypertension status and whether a patient was eligible for pharmacologic treatment.

Data from 9,329 patients from the NHANES 2011 to 2016 were also used to estimate systolic BP in adults in the U.S. Four community-based U.S. cohort studies were analyzed to calculate the incidence of all-cause mortality and major CVD. HRs for mortality and CVD were estimated using data from 42 antihypertensive clinical trials.

Based on the 2017 hypertension guideline, 45.4% of patients had hypertension (95% CI, 43.9-46.9). This represented 105.3 million U.S. adults (95% CI, 101.9-108.8). The newer guideline identified more patients with hypertension compared with the 2014 guidelines (32%; 95% CI, 30.3-33.6). The number of patients with hypertension using the 2014 guidelines represented 74.1 million adults (95% CI, 70.3-77.9).

More patients were recommended antihypertensive treatment using the 2017 guidelines (35.9%; 95% CI, 34.2-37.5) vs. the 2014 guidelines (31.1%; 95% CI, 29.6-32.7), according to the researchers.

Systolic BP treatment goals based on the 2017 guidelines may reduce an estimated 334,000 total deaths (95% CI, 245,000-434,000) and 610,000 CVD events (95% CI, 496,000-734,000) in patients from the U.S. older than 40 years, whereas using treatment goals from the 2014 guidelines, 177,000 total deaths (95% CI, 123,000-241,000) and 270,000 CVD events (95% CI, 202,000-349,000) may be prevented, Bundy and colleagues wrote.

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Lawrence Fine, MD
Lawrence J. Fine

Increase in adverse events

Implementation of the 2017 guidelines was estimated to increase hypotension in 62,000 patients and acute kidney injury or failure events in 79,000 patients.

“If [systolic] BP treatment goals were achieved, the 2017 ACC/AHA hypertension guideline recommendations are estimated to reduce major CVD events by an additional 340,000 and total deaths by an additional 156,000 compared with the 2014 evidence-based hypertension guideline but may increase the number of adverse events,” Bundy and colleagues wrote.

Clyde W.Yancy, MD, MSc
Clyde W. Yancy

“Preventing childhood obesity, reducing adult weight gain and healthier diets, such as the Dietary Approaches to Stop Hypertension (DASH)/low-sodium dietary pattern, may all be important in an effective strategy for reducing hypertension prevalence, thereby reducing the number of individuals who require medications and reducing the intensity of antihypertension therapy when it is necessary,” Lawrence J. Fine, MD, DrPH, of the division of cardiovascular sciences at NHLBI, and colleagues wrote in a related editorial. “The article by Bundy et al helps us understand the possible benefits of more effective treatment and prevention of hypertension.”

Based on these benefits, the responsibility to implement hypertension therapy now falls on physicians, according to an editor’s note written by Clyde W. Yancy, MD, MSC, vice dean of diversity and inclusion, Magerstadt Professor of Medicine, professor of medical social sciences and chief of the division of cardiology at Northwestern University Feinberg School of Medicine, associate director of Bluhm Cardiovascular Institute and past president of the American Heart Association, and Gregg C. Fonarow, MD, director of Ahmanson-UCLA Cardiomyopathy Center, co-director of UCLA preventive cardiology program, co-chief of the division of cardiology at UCLA and the Eliot Corday Chair in Cardiovascular Medicine and Science.

Gregg C. Fonarow, MD
Gregg C. Fonarow

“These estimates are in keeping with comparable number needed to treat data for statin therapy as primary prevention,” Yancy and Fonarow wrote. “Thus, the benefit of hypertension therapy per the 2017 hypertension guidelines meets the bar to qualify as a robust prevention strategy. Given that benefits, especially fewer CVD events and fewer deaths in those at higher CVD risk, now clearly exceed potential harms, barriers to implementation should fall. It is our opinion that the time is on us to implement.” – by Darlene Dobkowski

Disclosures: The authors, Fine, Fonarow and Yancy report no relevant financial disclosures.