COMMENTARY

Pharmacologic Management of Hypertension: A New Guideline From ACP and AAFP

Kenneth W. Lin, MD, MPH

Disclosures

January 24, 2017

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

It's been 3 years since the expert panel formerly known as JNC 8 published a guideline[1] that raised the systolic blood pressure goal for adults aged 60 years or older from 140 to 150 mm Hg, citing a lack of randomized trial evidence that treating to the lower goal produced additional health benefits. This recommendation proved to be controversial, as later that year, five dissenting panel members published a "minority report"[2] that argued for keeping the lower goal. As a member of the American Academy of Family Physicians (AAFP) Commission on the Health of the Public and Science, I voted with my colleagues to endorse the full JNC 8 guideline on behalf of our members.[3]

Then in 2015, the Systolic Blood Pressure Intervention Trial (SPRINT)[4] found additional benefits and harms from treating a high-risk population of adults aged 50 years or older to a systolic blood pressure of 120 mm Hg. In a previous Medscape commentary, I explained why this study's findings should not necessarily be generalized to all older adults with hypertension in primary care. Other experts also urged caution[5] about lowering the blood pressure goals for older adults that were established by JNC 8.

Now, the American College of Physicians and the AAFP have published a joint guideline[6] on pharmacologic treatment of hypertension in adults aged 60 years or older. This guideline was based on an independent systematic review,[7] performed by researchers at the Veterans Affairs Portland Health Care System, that incorporated the latest data from SPRINT and other relevant randomized trials and cohort studies. I participated in the guideline discussion and approval process for AAFP but did not serve on the panel.

The new primary care guideline makes three major recommendations. First, based on high-quality evidence, clinicians should treat older adults with sustained systolic blood pressures of 150 mm Hg or greater to a goal of less than 150 mm Hg. Second, moderate-quality evidence supports treating to a lower goal of 140 mm Hg in older adults with a history of stroke or transient ischemic attack (TIA). Finally, low-quality evidence suggests that other older adults at high cardiovascular risk may also benefit from treating to the lower goal on a case-by-case basis.

Trials of hypertension treatment generally excluded participants with multiple chronic conditions, several medications, or frailty, making it difficult to determine whether these persons would benefit from lower blood pressure goals, or if benefits would outweigh the increased adverse events associated with intensive treatment in SPRINT and other studies. Although diabetes increases cardiovascular risk, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial[8] found that a systolic blood pressure goal of 120 mm Hg did not reduce cardiovascular events.

The take-home points for practice are that for most adults aged 60 or older, the ACP/AAFP guideline reaffirms the JNC 8 systolic blood pressure goal of 150 mm Hg. For patients with a history of stroke or TIA, and patients without diabetes who have several risk factors or a calculated 10-year cardiovascular event risk of 15% or higher, clinicians may discuss the pros and cons of lower goals and intensify drug therapy in patients willing to accept the risks.

Finally, it's worth noting that this guideline addresses pharmacologic therapy only, and that regular aerobic exercise, healthy eating patterns such as the Dietary Approaches to Stop Hypertension (DASH) diet, and intentional weight loss can all lower blood pressure significantly without the adverse effects of drugs.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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