Disclosures: D’Anci reports receiving grants from the U.S. Department of Veterans Affairs during the conduct of the study. Tschanz reports no relevant financial disclosures. Please see the review and the guideline for all other authors’ relevant financial disclosures.
August 31, 2020
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VA, DOD guideline recommends intensive BP lowering for patients with hypertension

Disclosures: D’Anci reports receiving grants from the U.S. Department of Veterans Affairs during the conduct of the study. Tschanz reports no relevant financial disclosures. Please see the review and the guideline for all other authors’ relevant financial disclosures.
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A guideline from the Veterans Affairs and Department of Defense strongly recommended intensive BP lowering in patients with hypertension, and a literature review published at the same time found that the evidence supports this approach.

Cmdr. Mark P. Tschanz, DO, MACM, and colleagues made 28 recommendations on behalf of the VA and DOD, evaluating them based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Some of the recommendations included the following:

Strong recommendations in the VA/DOD hypertension guideline: Intensive BP lowering and Pharmacist-led medication management program.
Reference: Tschanz MP, et al. Ann Intern Med. 2020;doi:10.7326/M20-3798.
  • All individuals should have their BP measured by a fully automated office device that is designed to wait 5 minutes and register the average of three measurements separated by at least 30 seconds (weak recommendation).
  • These same individuals, when a fully automated device is not available, should use the standard BP collection technique via properly calibrated and validated sphygmomanometer (weak recommendation).
  • Patients with hypertension should be offered home BP self-monitoring with co-interventions for lowering systolic BP and diastolic BP (weak recommendation).
  • All individuals should use out-of-office BP monitoring methods such as ambulatory 24-hour monitoring or home BP measurements to help advise the diagnosis and management of hypertension (weak recommendation).
  • These same individuals should be treated to a systolic BP goal of < 130 mm/Hg (weak recommendation).
  • Patients with hypertension should be offered a pharmacist-led medication management program (strong recommendation).
  • Patients with hypertension also should be offered nurse-led interventions as treatment options (weak recommendation).
  • These same patients, whether or not they take medications, should be presented with registered dietitian-led nutrition interventions (weak recommendation).
  • Patients with hypertension should also use technology-based interventions (eg., e-counseling, electronic transmission of data, mobile applications and/or telehealth) to improve their hypertension (weak recommendation).
  • These same patients should be offered a thiazide-type diuretic, calcium-channel blocker, or either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker as primary pharmacologic therapy to treat their hypertension and reduce composite cardiovascular outcomes (strong recommendation).
  • Patients with hypertension who are overweight or obese should be presented with a weight-reduction diet (weak recommendation).
  • Patients with hypertension who are older than age 65 years should be offered a thiazide-type diuretic to lower the number of cardiovascular outcomes (weak recommendation).
  • Patients with resistant hypertension — those whose BP is not adequately controlled with maximally tolerated dose of triple therapy — should receive spironolactone if the patients do not have contraindications (weak recommendation).

The experts acknowledged that some of their recommendations, particularly regarding the definition of hypertension and systolic BP and diastolic BP targets, are inconsistent with those from the American Academy of Family Physicians and other medical organizations.

“Most important, all guidelines have found strong and consistent evidence to support the benefit of lowering blood pressure in hypertensive patients,” they wrote.

Kristen E. D’Anci, PhD, of the ECRI Center for Clinical Evidence and Guidelines in Pennsylvania, and colleagues analyzed eight systematic reviews of randomized controlled trials that assessed either a standardized systolic BP target of –10 mm Hg or BP lowering below a target threshold.

“Overall, current clinical literature supports intensive BP lowering in patients with hypertension for improving cardiovascular outcomes,” they wrote. “In most subpopulations, intensive lowering was favored over less-intensive lowering, but the data were less clear for patients with diabetes mellitus or cardiovascular disease.”

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