New blood pressure guidelines from primary care professional organizations recommend a looser diagnostic and treatment threshold of below 150 mm Hg systolic for average and lower-risk adults age 60 and older.
For those in the same age range with prior stroke or transient ischemic attack or otherwise high cardiovascular risk, the American College of Physicians (ACP) and American College of Family Physicians (ACFP) recommended a systolic goal of less than 140 mm Hg, albeit graded as a weak recommendation based on the lack of high-quality evidence.
The recommendations, published online in , drew comparisons to those released in 2013 by some panel members of what was to have been the Eighth Joint National Committee (JNC8) guidelines but was halted when the National Heart, Lung, and Blood Institute handed over guidelines responsibilities jointly to the American College of Cardiology (ACC) and American Heart Association (AHA).
The 150 mm Hg recommendation has remained contentious, as the ACC/AHA has stuck with the JNC7 recommendation of 140 mm Hg as a diagnostic threshold and treatment target.
Points of Contention
The ACP/AAFP guideline isn't a "game-changer," since "it was the 2013 guideline that first threw down the gauntlet and recommended a <150 mm Hg systolic blood pressure treatment for older adults," internist , told MedPage Today.
"This recommendation has been controversial and will likely remain so for some time as we await more evidence on the balance of benefits and harms of treating raised blood pressure more aggressively in older adults," noted Moran, of New York-Presbyterian/Columbia Medical Center in New York City.
While the ACP/AAFP guidelines wouldn't change things for most patients seen by cardiologists -- typically a higher-risk group for which both guidelines agree on a lower target, "I expect they will have a major influence on primary care practice," , director of cardiovascular medicine at the Ohio State University in Columbus, told MedPage Today.
, vice chair of family and community medicine at the University of Missouri in Columbia and a member of the panel that was to have released the JNC8 guidelines, agreed.
"This guideline does a good job of independently reinforcing the central conclusion of JNC8, while emphasizing flexibility for more intense treatment of high-risk patients based largely on the recent SPRINT trial," he said in an email to MedPage Today.
SPRINT subanalyses showed as well as in frail individuals, but with more treatment-related serious adverse events among frail individuals in either treatment arm, making it "wise to treat frail older adults more carefully," Moran said.
"The multiple guideline recommendations and new evidence from SPRINT and other trials has made clinical practice more challenging. But the recommendations are in the end more similar than they are different."
The Way Forward
Abraham agreed that multiple, sometimes discordant, guidelines would be a barrier to adoption and could cause confusion for clinicians -- "the goal of developing a single harmonized hypertension guideline should be pursued in the future," he said.
The next set of ACC/AHA blood pressure guidelines are due out later this year, noted , director of the Clinical Hypertension Program of UH Cleveland Medical Center, who was a dissenting voice from the JNC8 panel, a key investigator on SPRINT, and is now on the ACC/AHA guideline panel.
However, American Society of Hypertension President , noted that unification may not be feasible: "In the past, we were always looking for a 'magic number' that we could apply widely to the population, but more and more clinical trials have been done on specific groups of patients -- diabetics, non-diabetics, older, middle age, with cardiovascular disease, without, etc. -- and we are learning that perhaps 'one-size fits all' is not the way to approach patients with hypertension."
As to how things will actually play out in practice, LeFevre said: "Don't underestimate the impact of quality measurement and reporting on care, particularly when physician payment is linked to those quality measures. NCQA [the National Committee for Quality Assurance] specifically has maintained a 140/90 stance, and current Medicare quality measures echo that goal."
"A central conclusion from this guideline is that one size does not fit all, but unfortunately as currently designed, quality measurement does not support individualization of blood pressure goals."
Moreover, Bisognano pointed out that as many as 40% of patients are not reaching even the loosest blood pressure goals.
"So, it is not singularly important to focus on the small differences between goals when a large number of patients aren't adequately treated anyway," he said in an email. "In some ways, the argument over the precision of the goals is just a side show compared to the real public health issue, that a large number of people need FAR better control of their blood pressure and are way above any goal."
Disclosures
The guidelines were supported by the American College of Physicians.
The guideline writing committee disclosed no relevant relationships with industry. Four members with indirect conflicts of interest were recused from voting on the recommendations.
Primary Source
Annals of Internal Medicine
Source Reference: Qaseem A, et al "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; doi: 10.7326/M16-1785.
Secondary Source
Annals of Internal Medicine
Source Reference: Pignone M, Viera AJ "Blood pressure treatment targets in adults over age 60" Ann Intern Med 2017; doi: 10.7326/M17-0034