Reviews

Hypertension guidelines: Treat patients, not numbers

Cleveland Clinic Journal of Medicine. 2019 January;86(1):47-56

Author(s):

Wesam Aleyadeh, MD

Erika Hutt-Centeno, MD

Haitham M. Ahmed, MD, MPH

Nishant P. Shah, MD

Release date: January 1, 2019
Expiration date: December 31, 2019
Estimated time of completion: 1 hour

Click here to start this CME/MOC activity.

ABSTRACT

The updated 2017 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for managing hypertension advocate tighter blood pressure control than previous guidelines. This review summarizes the evidence behind the guidelines, discusses the risks and benefits of stricter blood pressure control, and provides our insights on blood pressure management in clinical practice.

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KEY POINTS

The 2017 ACC/AHA guidelines lowered the definition of hypertension to 130/80 mm Hg or higher, thereby in-creasing the number of US adults with hypertension from 31.9% to 45.6%.
For patients with known cardiovascular disease or a 10-year risk of an atherosclerotic cardiovascular disease event of 10% or higher, drug treatment “is recommended” if the average blood pressure is 130/80 mm Hg or higher. For those without cardiovascular disease and at lower risk, drug treatment is recommended if the aver-age blood pressure is 140/90 mm Hg or higher.
A treatment goal of less than 130/80 mm Hg “is recommended” for patients with hypertension and known car-diovascular disease or a 10-year risk of an atherosclerotic cardiovascular disease event of 10% or higher, and “may be reasonable” for those without additional markers of increased cardiovascular risk.
Intensive blood pressure control has the potential to significantly reduce rates of morbidity and death associated with cardiovascular disease, at the price of causing more adverse effects.

References

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71(19):e127–e248. doi:10.1016/j.jacc.2017.11.006
Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289(19):2560–2572. doi:10.1001/jama.289.19.2560
Go AS, Bauman MA, King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension 2014; 63(4):878–885. doi:10.1161/HYP.0000000000000003
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311(5):507–520. doi:10.1001/jama.2013.284427
Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med 2014; 160(7):499–503. doi:10.7326/M13-2981
Weber MA, Schiffrin EL, White WB, et al. Notice of duplicate publication [duplicate publication of Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens 2014; 16(1):14–26. doi:10.1111/jch.12237] J Hypertens 2014; 32(1):3–15. doi:10.1097/HJH.0000000000000065
Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens 2015; 9(6):453–498. doi:10.1016/j.jash.2015.03.002
de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care 2017; 40(9):1273–1284. doi:10.2337/dci17-0026
Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166(6):430–437. doi:10.7326/M16-1785
The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in over-weight people with high normal blood pressure: the Trials of Hypertension Prevention, phase II. Arch Intern Med 1997; 157(6):657–667. pmid:9080920
He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000; 35(2):544–549. pmid:10679495
Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001; 344(1):3–10. doi:10.1056/NEJM200101043440101
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for US adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10; 2014(260):1–161. pmid:24819891
Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71(2):109–118. doi:10.1016/j.jacc.2017.10.073
SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373(22):2103–2116. doi:10.1056/NEJMoa1511939
Bress AP, Kramer H, Khatib R, et al. Potential deaths averted and serious adverse events incurred from adoption of the SPRINT (Systolic Blood Pressure Intervention Trial) intensive blood pressure regimen in the United States: Projections from NHANES (National Health and Nutrition Examination Survey). Circulation 2017; 135(17):1617–1628. doi:10.1161/CIRCULATIONAHA.116.025322
Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: a randomized clinical trial. JAMA 2016; 315(24):2673–2682. doi:10.1001/jama.2016.7050
Beddhu S, Rocco MV, Toto R, et al. Effects of intensive systolic blood pressure control on kidney and cardiovascular outcomes in persons without kidney disease: a secondary analysis of a randomized trial. Ann Intern Med 2017; 167(6):375–383. doi:10.7326/M16-2966
Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med 2018; 178(1):28–36. doi:10.1001/jamainternmed.2017.6015
Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991; 265(24):3255–3264. pmid:2046107
Bulpitt CJ, Beckett NS, Cooke J, et al. Results of the pilot study for the Hypertension in the Very Elderly Trial. J Hypertens 2003; 21(12):2409–2417. doi:10.1097/01.hjh.0000084782.15238.a2
Liu L, Zhang Y, Liu G, et al. The Felodipine Event Reduction (FEVER) study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 2005; 23(12):2157–2172. pmid:16269957
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res 2008; 31(12):2115–2127. doi:10.1291/hypres.31.2115
Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension 2010; 56(2):196–202. doi:10.1161/HYPERTENSIONAHA.109.146035
Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016; 387(10022):957–967. doi:10.1016/S0140-6736(15)01225-8
Sleight P. The HOPE study (Heart Outcomes Prevention Evaluation). J Renin Angiotensin Aldosterone Syst 2000; 1(1):18–20. doi:10.3317/jraas.2000.002
Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000; 355(9200):253–259. pmid:10675071
Yusuf S, Bosch J, Dagenais G, et al. Cholesterol lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374(21):2021–2031. doi:10.1056/NEJMoa1600176
Yusuf S, Lonn E, Pais P, et al. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med 2016; 374(21):2032–2043. doi:10.1056/NEJMoa1600177
Lonn EM, Bosch J, López-Jaramillo P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374(21):2009–2020. doi:10.1056/NEJMoa1600175
Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol 2017; 2(7):775–781. doi:10.1001/jamacardio.2017.1421
Emdin CA, Rahimi K, Neal B, Callender T, Perkovic V, Patel A. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA 2015; 313(6):603–615. doi:10.1001/jama.2014.18574
ACCORD Study Group; Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362(17):1575–1585. doi:10.1056/NEJMoa1001286
SPS3 Study Group; Benavente OR, Coffey CS, Conwit R, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 2013; 382(9891):507–515. doi:10.1016/S0140-6736(13)60852-1

When treating high blood pressure, how low should we try to go? Debate continues about optimal blood pressure goals after publication of guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) in 2017 that set or permitted a treatment goal of less than 130 mm Hg, depending on the population.¹

In this article, we summarize the evolution of hypertension guidelines and the evidence behind them.

HOW THE GOALS EVOLVED

JNC 7, 2003: 140/90 or 130/80

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),² published in 2003, specified treatment goals of:

< 140/90 mm Hg for most patients
< 130/80 mm Hg for those with diabetes or chronic kidney disease.

JNC 7 defined hypertension as 140/90 mm Hg or higher, and introduced the classification of prehypertension for patients with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg. It advocated managing systolic hypertension in patients over age 50. It also recommended lifestyle changes such as the Dietary Approaches to Stop Hypertension (DASH) diet, moderate alcohol consumption, weight loss, and a physical activity plan.

JNC 7 provided much-needed clarity and uniformity to managing hypertension. Since then, various scientific groups have published their own guidelines (Table 1).^1–9

ACC/AHA/CDC 2014: 140/90

In 2014, the ACC, AHA, and US Centers for Disease Control and Prevention (CDC) published an evidence-based algorithm for hypertension management.³ As in JNC 7, they suggested a blood pressure goal of less than 140/90 mm Hg, lifestyle modification, and polytherapy, eg, a thiazide diuretic for stage 1 hypertension (< 160/100 mm Hg) and combination therapy with a thiazide diuretic and an angiotensin-converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or calcium channel blocker for stage 2 hypertension (≥ 160/100 mm Hg).

JNC 8 2014: 140/90 or 150/90

Soon after, the much-anticipated report of the panel members appointed to the eighth JNC (JNC 8) was published.⁴ Previous JNC reports were written and published under the auspices of the National Heart, Lung, and Blood Institute, but while the JNC 8 report was being prepared, this government body announced it would no longer publish guidelines.

In contrast to JNC 7, the JNC 8 panel based its recommendations on a systematic review of randomized clinical trials. However, the process and methodology were controversial, especially as the panel excluded some important clinical trials from the analysis.

JNC 8 relaxed the targets in several subgroups, such as patients over age 60 and those with diabetes and chronic kidney disease, due to a lack of definitive evidence on the impact of blood pressure targets lower than 140/90 mm Hg in these groups. Thus, their goals were:

< 140/90 mm Hg for patients under age 60
< 150/90 mm Hg for patients age 60 and older.

Table 2 shows the differences in recommendations between JNC 7 and JNC 8.

Of note, a minority of the JNC 8 panel disagreed with the new targets and provided evidence for keeping the systolic blood pressure target below 140 mm Hg for patients 60 and older.⁵ Further, the JNC 8 report was not endorsed by several important societies, ie, the AHA, ACC, National Heart, Lung, and Blood Institute, and American Society of Hypertension (ASH). These issues compromised the acceptance and applicability of the guidelines.

ASH/ISH 2014: 140/90 or 150/90

Also in 2014, the ASH and the International Society of Hypertension released their own report.⁶ Their goals:

< 140/90 mm Hg for most patients
< 150/90 mm Hg for patients age 80 and older.

AHA/ACC/ASH 2015: Goals in subgroups

In 2015, the AHA, ACC, and ASH released a joint scientific statement outlining hypertension goals for specific patient populations⁷:

< 150/90 mm Hg for those age 80 and older
< 140/90 mm Hg for those with coronary artery disease
< 130/80 mm Hg for those with comorbidities such as diabetes and cardiovascular disease.

ADA 2016: Goals for patients with diabetes

In 2016, the American Diabetes Association (ADA) set the following blood pressure goals for patients with diabetes⁸:

< 140/90 mm Hg for adults with diabetes
< 130/80 mm Hg for younger adults with diabetes and adults with a high risk of cardiovascular disease
120–160/80–105 mm Hg for pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy.

References

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71(19):e127–e248. doi:10.1016/j.jacc.2017.11.006
Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289(19):2560–2572. doi:10.1001/jama.289.19.2560
Go AS, Bauman MA, King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension 2014; 63(4):878–885. doi:10.1161/HYP.0000000000000003
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311(5):507–520. doi:10.1001/jama.2013.284427
Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med 2014; 160(7):499–503. doi:10.7326/M13-2981
Weber MA, Schiffrin EL, White WB, et al. Notice of duplicate publication [duplicate publication of Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens 2014; 16(1):14–26. doi:10.1111/jch.12237] J Hypertens 2014; 32(1):3–15. doi:10.1097/HJH.0000000000000065
Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens 2015; 9(6):453–498. doi:10.1016/j.jash.2015.03.002
de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care 2017; 40(9):1273–1284. doi:10.2337/dci17-0026
Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166(6):430–437. doi:10.7326/M16-1785
The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in over-weight people with high normal blood pressure: the Trials of Hypertension Prevention, phase II. Arch Intern Med 1997; 157(6):657–667. pmid:9080920
He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000; 35(2):544–549. pmid:10679495
Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001; 344(1):3–10. doi:10.1056/NEJM200101043440101
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for US adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10; 2014(260):1–161. pmid:24819891
Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71(2):109–118. doi:10.1016/j.jacc.2017.10.073
SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373(22):2103–2116. doi:10.1056/NEJMoa1511939
Bress AP, Kramer H, Khatib R, et al. Potential deaths averted and serious adverse events incurred from adoption of the SPRINT (Systolic Blood Pressure Intervention Trial) intensive blood pressure regimen in the United States: Projections from NHANES (National Health and Nutrition Examination Survey). Circulation 2017; 135(17):1617–1628. doi:10.1161/CIRCULATIONAHA.116.025322
Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: a randomized clinical trial. JAMA 2016; 315(24):2673–2682. doi:10.1001/jama.2016.7050
Beddhu S, Rocco MV, Toto R, et al. Effects of intensive systolic blood pressure control on kidney and cardiovascular outcomes in persons without kidney disease: a secondary analysis of a randomized trial. Ann Intern Med 2017; 167(6):375–383. doi:10.7326/M16-2966
Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med 2018; 178(1):28–36. doi:10.1001/jamainternmed.2017.6015
Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991; 265(24):3255–3264. pmid:2046107
Bulpitt CJ, Beckett NS, Cooke J, et al. Results of the pilot study for the Hypertension in the Very Elderly Trial. J Hypertens 2003; 21(12):2409–2417. doi:10.1097/01.hjh.0000084782.15238.a2
Liu L, Zhang Y, Liu G, et al. The Felodipine Event Reduction (FEVER) study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 2005; 23(12):2157–2172. pmid:16269957
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res 2008; 31(12):2115–2127. doi:10.1291/hypres.31.2115
Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension 2010; 56(2):196–202. doi:10.1161/HYPERTENSIONAHA.109.146035
Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016; 387(10022):957–967. doi:10.1016/S0140-6736(15)01225-8
Sleight P. The HOPE study (Heart Outcomes Prevention Evaluation). J Renin Angiotensin Aldosterone Syst 2000; 1(1):18–20. doi:10.3317/jraas.2000.002
Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000; 355(9200):253–259. pmid:10675071
Yusuf S, Bosch J, Dagenais G, et al. Cholesterol lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374(21):2021–2031. doi:10.1056/NEJMoa1600176
Yusuf S, Lonn E, Pais P, et al. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med 2016; 374(21):2032–2043. doi:10.1056/NEJMoa1600177
Lonn EM, Bosch J, López-Jaramillo P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374(21):2009–2020. doi:10.1056/NEJMoa1600175
Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol 2017; 2(7):775–781. doi:10.1001/jamacardio.2017.1421
Emdin CA, Rahimi K, Neal B, Callender T, Perkovic V, Patel A. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA 2015; 313(6):603–615. doi:10.1001/jama.2014.18574
ACCORD Study Group; Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362(17):1575–1585. doi:10.1056/NEJMoa1001286
SPS3 Study Group; Benavente OR, Coffey CS, Conwit R, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 2013; 382(9891):507–515. doi:10.1016/S0140-6736(13)60852-1

MGUS: It’s about the protein, not just the marrow

Hypertension guidelines: Treat patients, not numbers

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ABSTRACT

KEY POINTS

References

HOW THE GOALS EVOLVED

JNC 7, 2003: 140/90 or 130/80

ACC/AHA/CDC 2014: 140/90

JNC 8 2014: 140/90 or 150/90

ASH/ISH 2014: 140/90 or 150/90

AHA/ACC/ASH 2015: Goals in subgroups

ADA 2016: Goals for patients with diabetes

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