New Blood Pressure Guideline Sets Lower 130/80 Threshold

[Michael Scally MD]

New Blood Pressure Guideline Sets Lower 130/80 Threshold
New Blood Pressure Guideline Sets Lower 130/80 Threshold

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg. This means that more than 100 million adults will now have high blood pressure, though many will be unaware of the diagnosis.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure was released today at the American Heart Association meeting in Anaheim and published simultaneously in Hypertension and the Journal of the American College of Cardiology. 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 / 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

The new guideline eliminates the category of prehypertension. The new blood pressure categories are:
• Normal:<120/80 mm Hg;
• Elevated:Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic >180 and/or diastolic >120.

 

[Michael Scally MD]

New Blood Pressure Guideline Sets Lower 130/80 Threshold
New Blood Pressure Guideline Sets Lower 130/80 Threshold

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg. This means that more than 100 million adults will now have high blood pressure, though many will be unaware of the diagnosis.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure was released today at the American Heart Association meeting in Anaheim and published simultaneously in Hypertension and the Journal of the American College of Cardiology. 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 / 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

The new guideline eliminates the category of prehypertension. The new blood pressure categories are:
• Normal:<120/80 mm Hg;
• Elevated:Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic >180 and/or diastolic >120.

 

[TheOldFart]

So what is the most important, the average reading or the highest reading? My diastolic is always below 80 and averages about 70. However, my systolic is all over the place. Some of my latest systolic readings are 134, 117, 133, 137, 121, 122, 134, 126, 148. The last time I averaged 20 or more systolic readings it was 132. Both my previous and my current PCPs say that I'm fine and that I shouldn't increase my BP med dosage. I've never been comfortable with these readings and was more comfortable when systolic averaged 122 a few years ago. I'm 72 YO now.

 

[Dale338]

So what is the most important, the average reading or the highest reading? My diastolic is always below 80 and averages about 70. However, my systolic is all over the place. Some of my latest systolic readings are 134, 117, 133, 137, 121, 122, 134, 126, 148. The last time I averaged 20 or more systolic readings it was 132. Both my previous and my current PCPs say that I'm fine and that I shouldn't increase my BP med dosage. I've never been comfortable with these readings and was more comfortable when systolic averaged 122 a few years ago. I'm 72 YO now.

You BP is fine!! In fact I would say pretty good. Remember, taking your BP reading at the doctor etc is a joke. They over diagnose so many people. Mine is often like 135/88 at the doctor etc, but ALWAYS like 110/65 or so in the comfort of my own home when I'm relaxed. Check you BP regular when at home and relaxed and average it out over time.

 

[Michael Scally MD]

New Blood Pressure Guideline Sets Lower 130/80 Threshold
New Blood Pressure Guideline Sets Lower 130/80 Threshold

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg. This means that more than 100 million adults will now have high blood pressure, though many will be unaware of the diagnosis.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure was released today at the American Heart Association meeting in Anaheim and published simultaneously in Hypertension and the Journal of the American College of Cardiology. 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 / 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

The new guideline eliminates the category of prehypertension. The new blood pressure categories are:
• Normal:<120/80 mm Hg;
• Elevated:Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic >180 and/or diastolic >120.

[LMAO]

For persons ≥75 years of age, 100% have an ASCVD risk score ≥10% or a history of CVD. Therefore, the BP target of ≤130/80 mm Hg would be appropriate (see Section 8.1.2). [Recommendation-Specific Supportive Text. P. 131]

 

[Michael Scally MD]

Conclusions

In his widely cited paper Ioannidis6 states “There is increasing concern that in modern (medical) research, false findings may be the majority or even the vast majority of published research claims.” What are the reasons for such an extraordinary statement that renders medical research practically useless, as it makes impossible to separate the false from the true findings? We believe that the reasons have a lot to do with the epistemological, methodological and statistical concerns reported in this paper. Popper's theory advocates ‘falsifiability’ as the criterion distinguishing science from non-science. According to Popper even one single study whose results are contrary to the accepted theory is enough to falsify it. Given the extent of falsification in HTN studies findings would need to be applied with extreme care.

Medicine can be extremely useful when treating major CHD, strokes or traumas from car accidents. The same is true with the use of antibiotics to cure infectious diseases and most of vaccinations. But in many other cases, the harm from treatment can exceed the benefits, producing iatrogenics as with Galen's ‘medicine’, bloodletting and tonsillectomy and all the way to the widespread utilisation of preventive breast and prostate cancer tests. According to Taleb63 iatrogenics, concerned with costs and benefits, is linked to small and visible benefits coupled with large, delayed and hidden non-linear costs and this may well be the case with the treatment of HTN. Are the benefits from such treatment greater than the monetary costs and especially the negative side effects, including a life-long dependence on medical drugs? This is a critical question that must be answered by objective, scientific evidence.

Key messages
· There are significant conflicts in the conclusions of hypertension studies that cannot be explained statistically as these studies are based on large sample sizes. The reasons for the conflicts are due to the methodological, epistemological and statistical deficiencies of the hypertension studies. These reasons must be accepted and remedied in order to improve the scientific standing of medicine.
· It is uncertain if treating otherwise healthy mild hypertensive patients with antihypertensive therapy will reduce morbidity and mortality.
· The current evidence in the literature does not support the blood pressure goals set by the JNC-8 guidelines.

Makridakis S, DiNicolantonio JJ. Hypertension: empirical evidence and implications in 2014. Open Heart 2014;1(1). http://openheart.bmj.com/content/1/1/e000048

High blood pressure (HBP) or hypertension (HTN) is one of the leading causes of cardiovascular (CV) morbidity and mortality throughout the world. Despite this fact, there is widespread agreement that the treatment of HBP, over the last half century, has been a great achievement.

However, after the release of the new Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-8 (JNC-8) guidelines, there have been heated debates with regard to what are the most evidence-based blood pressure goals.

While JNC-8 claims that the goal blood pressure for otherwise healthy patients with mild hypertension (systolic blood pressure ≥140–159 mm Hg and diastolic blood pressure ≥90–99 mm Hg) should be <140/90 mm Hg; a recent Cochrane meta-analysis is in direct conflict with these recommendations.

Indeed, a 2012 Cochrane meta-analysis indicated that there is no evidence that treating otherwise healthy mild hypertension patients with antihypertensive therapy will reduce CV events or mortality. Additionally, the Cochrane meta-analysis showed that antihypertensive therapy was associated with a significant increase in withdrawal due to adverse events. Thus, the current evidence in the literature does not support the goals set by the JNC-8 guidelines.

In this review we discussed the strengths and limitations of both lines of evidence and why it takes an evidence-based medication to reduce CV events/mortality (eg, how a goal blood pressure is achieved is more important than getting to the goal). As medications inherently cause side effects and come at a cost to the patient, the practice of evidence-based medicine becomes exceedingly important.

Although the majority of HTN studies claim great advantages by lowering HBP, this review finds severe conflicts in the findings among the various HTN studies, as well as serious epistemological, methodological and statistical problems that cast doubt to such claims.

 

[Michael Scally MD]

New Blood Pressure Guideline Sets Lower 130/80 Threshold
New Blood Pressure Guideline Sets Lower 130/80 Threshold

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg. This means that more than 100 million adults will now have high blood pressure, though many will be unaware of the diagnosis.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure was released today at the American Heart Association meeting in Anaheim and published simultaneously in Hypertension and the Journal of the American College of Cardiology. 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 / 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

The new guideline eliminates the category of prehypertension. The new blood pressure categories are:
• Normal:<120/80 mm Hg;
• Elevated:Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic >180 and/or diastolic >120.

[98] Does SPRINT change our approach to blood pressure targets?
http://www.ti.ubc.ca/2016/04/07/98-sprint-change-approach-blood-pressure-targets/

Therapeutics Letter #821 summarized evidence from the Cochrane systematic review, Treatment blood pressure targets for hypertension.2 The Cochrane review was based on the 7 randomized controlled trials (RCTs) designed to test treatment targets that were available as of October 2008. The conclusion was that “Treating patients to lower than standard blood pressure (BP) targets (≤ 140-160/90-100 mmHg) does not reduce mortality or morbidity.”

SPRINT

In September 2015, Systolic blood PRessure INtervention Trial (SPRINT) added a new trial that studied BP targets. It was stopped early for benefit. Results were published in November 2015.3 SPRINT randomly assigned 9361 persons with a systolic BP of 130 mmHg or higher and an increased cardiovascular risk (but without diabetes or prior stroke) to a low systolic BP target of < 120 mmHg or a standard target of < 140 mmHg. SPRINT was an open label trial conducted at 102 sites. The average achieved BP at one year in the low BP target group was 121/69 versus 136/76 mmHg in the standard BP target group. The average number of antihypertensive drugs in the low BP target group was 2.8, vs. 1.8 in the standard BP target group.

Benefits

After an average duration of 3.3 years, the primary outcome (a composite of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes) was decreased in the low BP target group at 5.2%, vs. 6.8% in the standard BP target group, RR 0.76 [0.65, 0.90], ARR 1.6%, NNT 63 for 3.3 years.

Harms

Specific serious adverse events classified as possibly or definitely related to the intervention were increased in the low BP target group, 4.7%, vs. 2.5% in the standard BP target group, RR 1.87 [1.50, 2.33] ARI 2.2%, NNTH 46 for 3.3 years. This was due mainly to a 1.2% absolute increase in acute kidney injury or acute renal failure in the low BP target group.

Overall effect

Total serious adverse events were appropriately defined as fatal or life-threatening events resulting in clinically significant or persistent disability, or events that required or prolonged a hospitalization. The number of people with one or more serious adverse events was numerically greater in the low BP target group at 38.3% vs. 37.1% in the standard BP target group, RR 1.03 [0.98, 1.09]. However, deaths were significantly lower in the low BP target group at 3.3%, vs. 4.5% in the standard BP target group, RR 0.74 [0.60, 0.91], ARR 1.2%. These two findings are hard to reconcile, insofar as this means the number of people with non-fatal serious adverse events was significantly greater in the low BP target group, at 35.0% vs. 32.6% in the standard BP target group, RR 1.07 [1.02, 1.14], ARI 2.4%.

Risk of bias

Because of the BP target design, investigators could not be blinded to treatment group. This results in a high risk of performance and detection bias. Performance bias means the people caring for the patients treat the lower BP target group preferentially. Detection bias means investigators ascertain the outcomes in favour of the lower target group. Evidence of such bias in SPRINT is that the observed mean BP difference between the two groups of 15/7 mmHg is much greater than expected from a mean difference of one antihypertensive drug (2.8 vs. 1.8) between the target groups. The average BP reduction produced by a single antihypertensive drug has been studied extensively and estimated at about 8/5 mmHg.4-7

Stopping the trial early for benefit also adds additional risk of bias in favour of the lower BP target.8 This action would tend to exaggerate the benefits and underestimate the harms outlined above. We judge that the outcome least susceptible to bias is the total serious adverse events (SAE), because investigators presently do not recognize this outcome as an important way to assess the benefits and harms of an intervention.

Clinical implications of SPRINT

Most of the editorials and commentaries about the SPRINT trial have given it a positive spin and recommended that target BPs should be lower as a result of this trial. These commentaries have ignored the finding that individuals experiencing at least one serious adverse event were numerically increased in the low BP target group. None of these commentaries have situated SPRINT into the totality of available evidence on BP lowering targets.

Systematic review

The relevant Cochrane review has the objective: To determine if there is a reduction in total mortality and morbidity associated with treatment of blood pressure to “lower targets” (≤ 135/85 mmHg) as compared with “standard targets” (≤ 140-160/90-100 mmHg) in the management of patients with elevated arterial blood pressure. First published in 2009, it is now being updated. In addition to SPRINT, two large trials, ACCORD and SPS3 have been added to the review.9,10 In the updated review, mortality data from 11 RCTs (N = 38,584) indicate that lower targets do not reduce total mortality, RR 0.95 [0.86, 1.05]. Furthermore this analysis demonstrates that the mortality data from SPRINT are discordant with the rest of the trials. In a sensitivity analysis with SPRINT removed, the RR for total mortality in the remaining 10 RCTs (N = 29,223) increased to RR 1.03 [0. 92, 1.05]. Unfortunately, total serious adverse events were reported in only 3 of the 11 RCTs. In these 3 RCTs (N = 14,432), total serious adverse events were not decreased in the low BP target group, RR 1.03 [0.99, 1.08].

Other non-Cochrane systematic reviews

Systematic reviews that combine all RCTs comparing more intensive with less intensive BP therapy11,12 are misleading and should not be used as evidence in favour of lower targets. These reviews include trials with markedly different targets, for example, a trial comparing a BP target of < 150/85 with < 180/105 mmHg.13

Conclusions
· At the present time, lower BP targets (≤ 135/85 mmHg) have not been demonstrated to reduce mortality or total serious adverse events as compared with standard BP targets (≤ 140-160/90-100 mmHg).
· Careful analysis of the SPRINT trial reveals that benefits of a lower blood pressure target in high-risk nondiabetic people do not outweigh harms.
· Critical appraisal of systematic reviews and clinical trial reports often leads to interpretation and conclusions different from initial impressions.

 

[Michael Scally MD]

Rakotz MK, Townsend RR, Yang J, et al. Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge. J Clin Hypertens (Greenwich) 2014;19(6):614-9. http://onlinelibrary.wiley.com/doi/10.1111/jch.13018/full

Blood pressure (BP) measurement is the most common procedure performed in clinical practice. Accurate BP measurement is critical if patient care is to be delivered with the highest quality, as stressed in published guidelines. Physician training in BP measurement is often limited to a brief demonstration during medical school without retraining in residency, fellowship, or clinical practice to maintain skills. One hundred fifty-nine students from medical schools in 37 states attending the American Medical Association's House of Delegates Meeting in June 2015 were assessed on an 11-element skillset on BP measurement. Only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1. The findings suggest that changes in medical school curriculum emphasizing BP measurement are needed for medical students to become, and remain, proficient in BP measurement. Measuring BP correctly should be taught and reinforced throughout medical school, residency, and the entire career of clinicians.


Abbasi J. Medical Students Fall Short on Blood Pressure Check Challenge. JAMA. 2017;318(11):991–992. Medical Students Fail Blood Pressure Check

A third of US adults have hypertension, a major risk factor for heart disease, which is the leading cause of death in the country. Additionally, more than a quarter of the population has higher than normal blood pressure (BP), or prehypertension. With stats like that, one might assume checking BP would be at the top of the list of medical student proficiencies. Yet a recent report suggests otherwise. Only 1 out of 159 medical students correctly performed all 11 elements in a BP check challenge with simulated patients, and the average number of steps performed properly was an abysmal 4.1.

 

[Michael Scally MD]

Key Points

Question - What is the association between treatment to lower blood pressure and death and cardiovascular disease at different blood pressure levels?

Findings - In this systematic review and meta-analysis, including 74 trials and more than 300 000 patients, treatment to lower blood pressure was associated with a reduced risk for death and cardiovascular disease if baseline systolic blood pressure was 140 mm Hg or above. Below 140 mm Hg, the treatment effect was neutral in primary preventive trials, but with possible benefit on nonfatal cardiovascular events in trials of patients with coronary heart disease.

Meaning - Systolic blood pressure of 140 mm Hg or higher should be treated to prevent death and cardiovascular disease, whereas treatment may be considered in patients with coronary heart disease and systolic blood pressure below 140 mm Hg, but not for primary prevention.


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. Published online November 13, 2017. Association of Blood Pressure Lowering With Mortality and CVD

Importance High blood pressure (BP) is the most important risk factor for death and cardiovascular disease (CVD) worldwide. The optimal cutoff for treatment of high BP is debated.

Objective To assess the association between BP lowering treatment and death and CVD at different BP levels.

Data Sources Previous systematic reviews were identified from PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effect. Reference lists of these reviews were searched for randomized clinical trials. Randomized clinical trials published after November 1, 2015, were also searched for in PubMed and the Cochrane Central Register for Controlled Trials during February 2017.

Study Selection Randomized clinical trials with at least 1000 patient-years of follow-up, comparing BP-lowering drugs vs placebo or different BP goals were included.

Data Extraction and Synthesis Data were extracted from original publications. Risk of bias was assessed using the Cochrane Collaborations assessment tool. Relative risks (RRs) were pooled in random-effects meta-analyses with Knapp-Hartung modification. Results are reported according to PRISMA guidelines.

Main Outcomes and Measures Prespecified outcomes of interest were all-cause mortality, cardiovascular mortality, major cardiovascular events, coronary heart disease (CHD), stroke, heart failure, and end-stage renal disease.

Results Seventy-four unique trials, representing 306 273 unique participants (39.9% women and 60.1% men; mean age, 63.6 years) and 1.2 million person-years, were included in the meta-analyses. In primary prevention, the association of BP-lowering treatment with major cardiovascular events was dependent on baseline systolic BP (SBP). In trials with baseline SBP 160 mm Hg or above, treatment was associated with reduced risk for death (RR, 0.93; 95% CI, 0.87-1.00) and a substantial reduction of major cardiovascular events (RR, 0.78; 95% CI, 0.70-0.87). If baseline SBP ranged from 140 to 159 mm Hg, the association of treatment with mortality was similar (RR, 0.87; 95% CI, 0.75-1.00), but the association with major cardiovascular events was less pronounced (RR, 0.88; 95% CI, 0.80-0.96). In trials with baseline SBP below 140 mm Hg, treatment was not associated with mortality (RR, 0.98; 95% CI, 0.90-1.06) and major cardiovascular events (RR, 0.97; 95% CI, 0.90-1.04). In trials including people with previous CHD and mean baseline SBP of 138 mm Hg, treatment was associated with reduced risk for major cardiovascular events (RR, 0.90; 95% CI, 0.84-0.97), but was not associated with survival (RR, 0.98; 95% CI, 0.89-1.07).

Conclusions and Relevance Primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.