January 13th, 2014
Minority Report: Five Guideline Authors Reject Change in Systolic Blood Pressure Goal
Larry Husten, PHD
It didn’t seem possible, but the guideline situation just got even more confusing. Last December, after years of delay and other twists and turns, the Eighth Joint National Committee (JNC 8) hypertension guideline was published in JAMA. The previous guideline recommended that all adults have a target systolic blood pressure below 140 mm Hg. In the new guideline, the target remained the same for adults under 60 years of age but for people over the age of 60 the new guideline set a more conservative, easier-to-achieve target of 150 mm Hg or lower.
Now, however, five of the seventeen JNC 8 authors have written a commentary, published in Annals of Internal Medicine, disagreeing with this change. They say they are in agreement with the other major recommendations of JNC 8 but that they reject the new target, arguing that the evidence does not support the change, and predict that the change may well lead to harmful consequences.
The JAMA article was “was not the place to discuss a dissenting view” of the recommendation, said the first author of the Annals dissent, Jackson T. Wright, Jr, in an interview. The Annals article provides a forum for the minority position and outlines the key areas of disagreement.
The Annals authors write that the evidence to support changing the target “was insufficient and inconsistent with the evidence supporting the panel’s recommendations.” They argue that the new target could reverse gains in blood pressure treatment achieved in recent decades. Currently 82% of people with hypertension are receiving treatment, and the median systolic blood pressure of people being treated is 136 mm Hg. “If we go to the higher blood pressure target that would mean potentially backing off on therapy in over half of the patients who are already below 140,” Wright said.
Furthermore, the median blood pressure for the population not currently being treated is 152 mm Hg. According to Wright, this means that about half of this group would not receive treatment with the new target.
A central argument is that the revised goal could reverse the gains in public health of recent years. Both coronary heart disease and stroke mortality “have been decreasing as the blood pressure has been declining and has been decreasing at twice the rate in those over the age 60 as those under age 60,” said Wright.
They note that other guideline groups have stayed with the 140 mm Hg goal. In addition, since people over age 60 are much more likely to die of cardiovascular disease, “this means we would be backing off on patients at highest risk,” said Wright.
Finally, the authors write that although there are two trials that support the lower target in patients over 60, “We failed to identify any evidence of the risk benefit of treating to a systolic blood pressure of less than 140 in those under age 60, and yet we still we recommended a target of less than 140 in that population,” said Wright. He said the Annals authors were particularly concerned about reducing treatment in the high-risk subpopulations of people over 60, including African Americans, patients with established cardiovascular disease, and patients with multiple cardiovascular risk factors.
Response to Confusion
In their rejection of the lower target, the Annals authors appear to have gathered some key support. The American College of Cardiology and the American Heart Association, which have assumed responsibility for developing and publishing cardiovascular guidelines, said in a statement that they continue to “recognize the most recent hypertension guidelines, published in 2004 by the Joint National Committee (JNC 7), as the national standard.” In other words, they are ignoring the JAMA JNC 8 publication and tacitly endorsing the old targets. The ACC and the AHA said they had “begun the process of developing” a new hypertension guideline and anticipate that they will publish it in 2015 “for clinicians to follow as the national standard for hypertension prevention and treatment.”
It appears unlikely that any consensus will emerge before then. Some observers think that the confusion may turn out to be beneficial. Harlan Krumholz made the following comment:
This turn of events is quite surprising and adds to the uncertainty around treatment. It may be that we are seeing the beginning of the end of monolithic treatment goal recommendations as the uncertainty should highlight the importance of personalizing treatment according to patient preferences.”
Sanjay Kaul thinks the difference in opinion “reflects the uncertainty in the evidence”:
When the same evidence is viewed differently by different individuals, it only reflects the uncertainty in the evidence. In my opinion JAMA should have published this minority report. Nonetheless, I am glad that the dissenting opinion is getting the proper attention it deserves. I tend to agree with the authors of this minority report that the quality and the quantity of evidence is not persuasive enough to formally change BP treatment thresholds, even if one can arguably disagree with them. Recommending different treatment thresholds is only going to end up confusing practicing clinicians, making them more skeptical of guideline recommendations and ultimately detracting from the Institute of Medicine’s stated goal of developing trustworthy guidelines.”
5 Responses to “Minority Report: Five Guideline Authors Reject Change in Systolic Blood Pressure Goal”
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The elephant in the room with the American JNC 8 guidelines is the omission of any consideration of OUT-of-clinic blood pressure (24 hour ambulatory blood pressure and home blood pressure monitoring). IN-clinic blood pressure is an excellent screening tool but has diagnostic limitations that can lead to incorrect assessment of the true underlying blood pressure.
Potential problems with reliance on in-clinic blood pressure include:
1. Failure to identify different forms of hypertension that may require a different treatment approach (e.g. white coat hypertension, nocturnal hypertension)
2. Under recognition of increased risk related to blood pressure in the case of masked hypertension.(1, 2)
3. Potential for overtreatment and increased falls risk in the elderly who have a high prevalence of white coat hypertension.
Several expert and guideline committees in Australia, Europe, the UK and Japan appreciate the relevance of using out-of-clinic blood pressure for diagnostic and treatment purposes.(3-8) Out-of-clinic blood pressure is also more cost effective. In the context of the current economic conditions and the fact that around $70 billion spent on hypertension-related drugs each year in the US,(9) this could be pertinent.
The rest of the world appears to have noticed the elephant – perhaps it may get a mention in the American JNC 9 guidelines?
Jim Sharman and Tom Marwick
Menzies Research Institute Tasmania
References
1. Ohkubo T, et al. Prognosis of “masked” hypertension and “white-coat” hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the ohasama study. J Am Coll Cardiol. 2005;46:508-515.
2. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: An updated meta analysis. Am J Hypertens. 2011;24:52-58.
3. Hypertension: The clinical management of primary hypertension in adults: Update of clinical guidelines 18 and 34 [internet]. National institute for clinical excellence. 2011
4. Head GA, et al. Ambulatory blood pressure monitoring in australia: 2011 consensus position statement. J Hypertens. 2012;30:253-266.
5. Imai Y, et al. The japanese society of hypertension guidelines for self-monitoring of blood pressure at home (second edition). Hypertens Res. 2012;35:777-795.
6. Mancia G, et al. 2013 esh/esc guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). Journal of Hypertension. 2013;31:1281-1357.
7. O’Brien E, et al. European society of hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;11:11.
8. Parati G, et alEuropean society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens. 2010;24:779-785.
9. Wang G, et al. Hypertension-associated expenditures for medication among us adults. American Journal of Hypertension. 2013;26:1295-1302.
I agree 100% about the “elephant”. The dependence of clinicians on in-office BP determinations is antiquated and dangerous. In my experience, office blood pressures are significantly higher than “real-life” pressure determinations obtained at home with a reliable blood pressure cuff.
Our office protocol is to identify patients with high blood pressure, recommend the purchase of a home cuff, compare the accuracy of the cuff with our standard office devices and then have the patient monitor their pressures on a schedule at home.
I believe that there are several advantages to this methodology. First, it actively engages the patient in his/her problem. The patient can see that they have a problem and work with the clinician to adequately treat the problem. The corollary is that the clinician is not “giving” them a condition.
Finally, and most importantly, the dangers of over-treatment are avoided. Compliance is improved and patient satisfaction is increased.
Agree with Dr. Kempf. I have similar protocol, plus if patient has significant orthostatic drop of BP in the office or I add diuretic or alpha blocker I ask them to take standing BPs as well with parameters to call, as well as for symptoms. I do see a lot of dizziness and falls/fractures/injuries eliminated by this approach, especially in the (very) elderly.
Agree with Dr. Sharman too – we are probably overtreating a lot of patients by relying on office BP. Patient with office notmotension are quite rare in my experience.
Problem with treating patients on the basis of home BP numbers is that there is really zero outcome data on improvement in hard CV endpoints/total mortality. Not that there is much evidence for treatment of mild to moderate office HTN without end organ damage/comorbidities either.
BP is just a cheap and convenient vital sign and a surrogate marker (albeit lousy one) for CV risk… Treat the patient, not the number… I think JNC8 kind of gives us soft permission to start doing it. Which is a plus.
I feel more confortable with wider definition of Hypertension where there is a rol for the target organ damage.
For me the best definition for hypertension comes from the American Hypertension Working Group, and was stated in 2005.
“Hypertension is a progresive cardiovascular síndrome…. heart structural damage, vascular damage, kidney damage….”
So for me, and I thing is the way is gonna be in the future, a patient is hypertensive if there is a hight blood pressure from 135 mmHg and up and a the finding of organ damage: ventricular hypertrophia, carotid ateroma plaques, vascular crossing at the eye exploration…. and so on.
That is the key to prevent vascular damage. If not you are just doing secondary prevention. Believe it or not.
Best regards,
I agree with Dr Sharman and In some cases I also follow the protocol of Dr. Kempf but in a significant number of patients taking the blood pressure at home has the same high results as taking it in the office, the trigger for the this response is not the place is the act of taking the blood pressure so in prone reactive patients you still have higher determinations. In this situations the best result is ABPM, with aleatory determinations and blocking the read out.