Health Industry Reactions to the New AHA/ACC Blood Pressure Guidelines

This past November, the American Heart Association (AHA) and the American College of Cardiology (ACC) issued new hypertension guidelines in an effort to clarify which patients should be diagnosed with hypertension and to recommend subsequent treatment strategies. The guidelines were written by a panel of 21 scientists and health experts and involved 11 health professional organizations. Despite the invested expertise, not all medical organizations and physicians are in agreement with the new measures.

Review of the recommended changes

The recently released guidelines provide the first official comprehensive update to recommendations on hypertension since the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines were issued in 2003. The primary recommended changes include:

• Hypertension is now defined as readings of 130 mmHg and higher for systolic blood pressure (SBP) and 80 mmHg and higher for diastolic blood pressure (DBP) measurements. This change updates the previous definition of hypertension as 140/90 mmHg and above.
• The category of prehypertension, which was 120 to 139 mmHg SBP or 80 to 89 mmHg DBP, has been eliminated. Individuals in this group will now be diagnosed with elevated blood pressure (120 to 129 SBP and <80 DBP) or stage 1 hypertension (130 to 139 SBP and 80 to 89 DBP). Meanwhile, stage 2 hypertension is now defined as SBP of at least 140 mmHg or DBP of at least 90 mmHg.
• Greater emphasis has been placed on the importance of home or ambulatory blood pressure monitoring with proper technique and validated devices to avoid white coat hypertension and masked hypertension. The guidelines also stress that blood pressure measurements should be based on an average of two to three readings on at least two different occasions.
• Emphasis has also been placed on tailoring treatment to both a combination of blood pressure measurements and an estimated 10-year risk of cardiovascular disease.
• Recommendations have also changed for patients with chronic kidney disease (CKD). While previous guidelines issued by JNC8 in 2014 (which were not endorsed by several medical organizations, including the AHA) set a blood pressure goal of less than 140/90 mmHg for CKD patients, the new goal for CKD patients is less than 130/80 mmHg.

The changes will result in nearly half of the U.S. adult population (46 percent) having hypertension versus 32 percent under the old guidelines, tripling the number of men and doubling the number of women under age 45 with the diagnosis, according to the AHA. The majority of adults in the elevated blood pressure category (120 to 129 SBP and <80 DBP) will be encouraged to adopt diet and lifestyle changes versus being treated with drugs.

Reactions to the new guidelines

While some organizations, such as the American Medical Association, have supported the new guidelines, others have expressed concerns, including the American Academy of Family Physicians (AAFP).  This organization supports the 2014 JNC8 recommendations and stated the new AHA/ACC guidelines:

• Were not based on a systematic evidence review,
• Did not assess background resources and
• Placed significant weight on the Systolic Blood Pressure Intervention Trial (SPRINT) while minimizing other studies.

The AAFP also stated that several of the new guideline panel members had conflicts of interest. While the AAFP praised the new guidelines for encouraging accurate blood pressure monitoring as well as healthy lifestyles, the organization also noted that the harms of treating a patient to obtain a lower blood pressure were not assessed.

Nephrologists across the industry have expressed the following thoughts on the guidelines.

• More-intensive blood pressure treatment in patients could increase rates of kidney disease, noted Raymond Townsend, MD, director of the hypertension program at the Hospital of the University of Pennsylvania, in a New York Times article. In the SPRINT Trial, for example, the incidence of acute kidney injury was twice as high in patients receiving drugs to reduce their systolic pressure to 120 mmHg than those not receiving the drugs.
• George Thomas, MD, director of the Center for Blood Pressure Disorders at Cleveland Clinic, told Renal & Urology News the new target is reasonable, with the understanding that patients should be closely monitored because some may not tolerate blood pressure-lowering medications. Patient preferences, renal function and electrolyte imbalances should also be taken into account.
• Csaba P. Kovesdy, MD, nephrology section chief of the Memphis VA Medical Center, said their recent re-analysis of SPRINT suggests that current data do not support a blanket recommendation for lower blood pressure treatment targets in all CKD patients. In the re-analysis, investigators found that the estimated glomerular filtration rate (eGFR) significantly changes the risk-benefit ratio of intensive blood pressure control. The new guidelines’ stricter target may provide little or no benefit and may be harmful to patients with an eGFR below 45.
• In an editorial in the New England Journal of Medicine, George Bakris, MD, director of the comprehensive hypertension center at the University of Chicago Medical Center, pointed out that while the new guidelines expand on the JNC7 recommendations in a useful way, “a one-size-fits-all blood-pressure goal is problematic.” He and others argue that this type of approach could lead to pharmacologic treatments that may not benefit patients who are newly defined as hypertensive and could lead to unnecessary side effects. He stressed that while the new target of 130/80 mmHg makes sense for high-risk patients, it’s reasonable to continue to recognize 140/90 mmHg and above as the acceptable definition of hypertension in other adults.

Although organizations and physicians have differing thoughts on the new AHA/ACC guidelines, many appear to agree on one thing: because blood pressure management is complex, patients should be treated with a personalized approach that takes into account their unique risks and preferences.