AHA/ACC/CDC Issue 'Science Advisory' on Treating BP

November 15, 2013

SAN FRANCISCO, CA – It's not the long-awaited eighth version of Managing Blood Pressure in Adults: Report from the Joint National Committee (JNC 8), but physicians treating patients with hypertension now have some help and direction from the American Heart Association (AHA), American College of Cardiology (ACC), and the Centers from Disease Control and Prevention (CDC)[1].

The three organizations collaborated to write a "science advisory" on effective approaches for managing high blood pressure. In it, Dr Alan Go (University of California, San Francisco), the first author on the new report, and colleagues recommend the development of evidence-based algorithms in the treatment of high blood pressure as well lifestyle changes needed to control hypertension in adults.

"This advisory is intended to complement and support clinical guidelines, providing clinicians and health systems tools to improve treatment and control of hypertension," state Go and colleagues in their report, published online November 15, 2013 in Hypertension. "The prevention of heart disease and stroke mandates a greater emphasis on the populationwide improvement of blood-pressure awareness, treatment, and control together with other cardiovascular health factors."

Earlier this week, the AHA and ACC, in conjunction with the National Heart, Lung, and Blood Institute (NHLBI), released four new guidelines, including new recommendations for the management of cholesterol and obesity. What wasn't released just yet, however, was JNC 8, a document so long delayed it's been dubbed "JNC-Late."

The Recommendations From the AHA/ACC/CDC

The new AHA/ACC/CDC report emphasizes "broad-based efforts to improve hypertension awareness, treatment, and the proportion of patients treated and controlled." With an evidence-based algorithm and the standardization of treatment, the AHA hopes the team-based focus on blood pressure will help it achieve its ambitious goal of reducing the US death rate from cardiovascular disease and stroke by 20% in 2020. The Million Hearts campaign, led by the CDC and Centers for Medicare & Medicaid Services (CMS), aims to prevent a million heart attacks and strokes by 2017.

In the advisory, the organizations recommend a blood-pressure goal of <139/89 mm Hg. To achieve the goal, they highlight a treatment algorithm that is based on the clinical guidelines and is associated with improved blood-pressure control on a large scale.

They recommend lifestyle modification and the consideration of a thiazide diuretic in individuals with stage 1 hypertension (systolic 140–159 mm Hg or diastolic 90–99 mm Hg). For those with stage 2 hypertension (systolic >160 mm Hg or diastolic >100 mm Hg), they recommend combination therapy with a thiazide diuretic and ACE inhibitor, angiotensin receptor blocker (ARB), or calcium-channel blocker (CCB).

If the patient is not at goal, the ACC/AHA/CDC recommends that physicians increase the dose of the medications and/or add a drug from a different class. Should the patient still not be at goal, physicians should question patient adherence, request readings from home, or consider secondary causes of hypertension. A hypertension specialist should be considered if the patient still fails to get to goal.

However, they state that just about any evidence-based treatment protocol can work and encourage healthcare centers to develop one based on the best available science. They point out that several existing algorithms have been developed in large healthcare settings, such as the Veterans Affairs medical system, and are available online.

The AHA/ACC/CDC also highlight several principles for creating an effective algorithm, including that it be updatable and feasible; that it consider the costs of diagnosis, monitoring, and treatment; and that it can be formatted easily within a team approach to healthcare. Importantly, they state that no algorithm should be used to counter the treating physician's best clinical judgment.

Algorithms and Protocols Are Not Magic Bullets

In an editorial[2], published in the Journal of the American Medical Association, Drs Thomas Frieden, Sallyann Coleman, and Janet Wright (Centers for Disease Control and Prevention, Atlanta, GA) state that hypertension is quite possibly the single most neglected area of medicine. In the US, approximately one in three adults has high blood pressure. Of these, 36 million adults have uncontrolled hypertension and about 40% of those people are unaware of their high blood pressure. At least 16 million in the US are taking medication for their high blood pressure, but it is not yet under control, write the editorialists.

"But the most compelling statistic—and the one that makes the case for more focused clinical attention—is that nearly three out of four people with uncontrolled hypertension—26 million people—visited a healthcare professional at least twice in the prior year," write Frieden and colleagues. "We're missing opportunities to initiate and improve care of our patients with hypertension, and as a result they are experiencing preventable heart attacks, strokes, and kidney and heart failure."

In a question-and-answer session with Medscape, Frieden said that healthcare systems have a role to play in getting patients to goal.

"In fact, the best-performing healthcare systems get to 80% or 90% blood-pressure control," said Frieden. "It's essential to use health [information technology] to find patients who need more attention, to create systemwide targets, and update staff monthly on progress. We have found that systems that give monthly feedback can improve quality within a year, whereas if you are giving annual feedback, you might or might not get improvement in a decade."

The secret, says Frieden, is to "pick an evidence-based hypertension treatment protocol, just about any protocol, as long as it's evidence-based, and use it."

In the editorial, Frieden and colleagues offer praise for evidence-based treatment protocols but add they aren't a "magic bullet." In addition, lifestyle changes and drug therapy aren't an either-or proposition. Communitywide interventions to reduce sodium intake, prevent obesity, and increase physical activity can help to modestly lower blood pressure, but better access to primary care and increased awareness about the risks of hypertension are also needed.

Go reports no conflicts of interest. Disclosures for the coauthors are listed in the paper. Frieden, Coleman, and Wright report no conflicts of interest.


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