A nationally recognized expert panel on which a University of Iowa physician and researcher serves as co-chairman is releasing new guidelines for the management of high blood pressure that would raise the threshold for what is considered dangerous levels for people age 60 and older and could reduce the number of drugs some patients may have to take.
The guidelines, presented in the report, the “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,” was prepared by panel members appointed to the Eighth Joint National Committee and released online Wednesday, Dec. 18, 2013, by JAMA.
Paul James, professor and head of family medicine who holds the Donald J. and Anna M. Ottilie Chair in Family Medicine at University of Iowa Hospitals and Clinics, was co-chair of the panel.
Hypertension is the most common condition seen in primary care and leads to heart attacks, kidney failure, and death if not detected early and treated appropriately. Study authors say patients “want to be assured that blood pressure treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence.”
“This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults,” the study says.
It’s that evidence-based approach that serves as the basis of the new guidelines, James says, and the foundation of the panel’s support of them.
“The other guidelines, from the last several decades, have been based on consensus by experts,” James says. “These were based on scientific evidence from randomized controlled trials. Expert opinion was used only in the absence of scientific evidence.”
Panelists reviewed evidence from relevant studies conducted over a 43-year span, from Jan. 1, 1966 through Dec. 31, 2009, as well as major, eligible studies that took place between December 2009 and August 2013. The evidence review focused on adults age 18 and older with hypertension and included studies involving diabetes, coronary artery disease, peripheral artery disease, heart failure, previous stroke, chronic kidney disease, proteinuria, older adults, men and women, racial and ethnic groups, and smokers. Studies were included in evidence review based on health outcomes in each group.
The guideline addresses three questions related to high BP management:
- At what BP should medication be started in patients with hypertension?
- What BP goal should patients achieve to know they are enjoying proven health benefits from their medication?
- What are the best medication choices to reach the goal BP?
The nine recommendations in the guideline answer those three questions. In summary, “There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years.”
“There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes.”
The authors emphasize important differences from earlier versions of the guideline. For development of these recommendations, “evidence was drawn from randomized controlled trials (RCTs), which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes,” the authors write. These guidelines also sought to establish “similar treatment goals for all hypertensive populations except when evidence … supports different goals for a particular subpopulation.”
“The recommendations from this evidence-based guideline from panel members appointed to the Eighth Joint National Committee offer clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies to achieve those goals based on evidence from RCTs. However, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. We hope that the algorithm will facilitate implementation and be useful to busy clinicians. The strong evidence base of this report should inform quality measures for the treatment of patients with hypertension,” the authors conclude.
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