COMMENTARY

An Enthusiastic Embrace of the New Hypertension Guidelines

Clyde W. Yancy, MD, MSc; Patrick T. O'Gara, MD

Disclosures

December 04, 2017

Clyde W. Yancy, MD, MSc: Hi. This is Clyde Yancy here at the 2017 American Heart Association (AHA) Annual Scientific Sessions. I am chief of cardiology and professor of medicine at Northwestern University in Chicago. I am joined today by my very good friend and colleague, Pat O'Gara, from the Brigham and Women's Hospital in Boston. Pat and I are going to share with you our perspectives, our takeaways, about what we think may be the most important topic that's been discussed here at the AHA annual meeting. That's the new hypertension guidelines,[1,2] Pat. Wow, we finally got them.

Patrick T. O'Gara, MD: It's been terrific in terms of the release around this particular meeting and the emphasis that the AHA has played with respect to this very important public health problem.

Dr Yancy: I totally agree. To put it in context, it has been over a decade since we had a clear directive from any governing organization of substantial size, at least, to say: This is how we believe you should approach hypertension. You and I know that there's been a ton of new information that has come forward in the last decade. Yet, we didn't provide guidance, and now we have that guidance.

Dr O'Gara: Absolutely. I think there's been some confusion and a bit of consternation in the community about targets and how it is we should think about blood pressure in the context of overall cardiovascular risk. I know you're excited about that.

Dr Yancy: I'm very excited about that. You and I are contemporaries. You will remember that when we were first introduced to the concept of treating hypertension, the hypertensive patient was at 160 mm Hg over 100 mm Hg. We were trying to treat them to perhaps less than 140/90 mm Hg or right at 140/90 mm Hg. We didn't understand much about risk. We didn't understand a lot about comorbidities. We didn't have drugs with as much finesse as we have now.

We've seen the needle move. Let's talk about some of the things that they're doing differently. The first is making the diagnosis. How is hypertension defined in these new guidelines?

Dr O'Gara: The new guidelines are helpful with respect to reminding us how to measure blood pressure and how to make an initial diagnosis of hypertension. You should not rely on a single number but rather a sampling of numbers, preferably outside of an office situation and preferably never assessed by a physician because, as you know, physician blood pressure measurements are typically higher than those taken by nurses or pharmacists or other advanced practice providers.

The guidelines are very clear with respect to the benefit of both home blood pressure assessment as well as ambulatory blood pressure monitoring, especially among that very large population of patients we treat with white coat effect or when you are suspicious of masked hypertension. I think that our community hasn't really appreciated masked hypertension for at least the period of time that you and I have been practicing.

Dr Yancy: I agree. To be very clear, the guidelines are explicit: greater than two separate measurements on greater than two separate occasions. Let's take the ambiguity out of this. Take the guessing game out. Make certain that hypertension is present. I think that's the first thing that was terrific.

Risk Assessment

The next thing that's terrific is that they've come forward with the risk base concept, which we've never really appreciated before in hypertension. It's wonderful because it aligns so nicely with our approach to dyslipidemia now. What we are doing is getting away from "see a number, treat a number" to "see a number and have a conversation and discuss risk." I have to think that you agree with me.

What we are doing is getting away from 'see a number, treat a number.'

Dr O'Gara: Absolutely. I applaud the chairs as well as the writing committee members for framing the issue of hypertension within the context of a broader assessment of risk: secondary prevention, primary prevention, low risk, high risk, the sorts of things that we are now applying to the treatment of hyperlipidemia.

Dr Yancy: As you outline, it's almost a certain amount of elegance in the way that this is done. For primary prevention purposes, if your risk for an event is greater than 10% over 10 years, now at a blood pressure threshold of 130/80 mm Hg or greater, we believe that we start with lifestyle changes and institute medical therapy, if we can't get to goal over a short number of months. But if you already have established cardiovascular disease, we're talking secondary prevention, and we suggest that you start therapy right away.

The other big part of this that is really going to be a challenge, frankly, is the lifestyle modification. There is such a big emphasis on it for obvious reasons. What do you think about the success we'll have with the lifestyle modifications?

Dr O'Gara: It remains to be seen, but it is our number one priority at this point. I am very appreciative of the way the guidelines were not necessarily focused exclusively on drug therapy for hypertension, and they remind us about the basics of lifestyle intervention and provide an evidence base on top of which we can actually take home some solid messages.

As a practitioner, I find it very easy to remember the major principles that are provided in this guideline ranging from a conversation with patients about their weight, their level of physical activity, whether they're actually doing other things that are counterproductive with respect to blood pressure control, whether it's alcohol related, for example, or whether it's taking too much in the way of ibuprofen for aches and pains. An emphasis on lifestyle measures as a foundation for treatment cannot be overemphasized.

Dr Yancy: I agree, and I particularly like what was done with diet. Once again, we emphasize that low sodium is the way to go. I know there is a lot of dialogue about sodium, but the tenets of a low-sodium diet as a factor on health remain. I also thought that it was novel that the higher potassium intake was brought into the discussion. That seemed to be very reasonable. Now, there are some things that I think we should emphasize as highlights.

One is now that we've made the diagnosis and have had the conversation and have determined that either it's for secondary prevention or the risk assessment puts you in a mode of primary prevention, we now have a new target of therapy, and I think that merits some conversation.

Lower Is Better but Use Clinical Judgement

Dr O'Gara: It seems to me that the take-home message from the guideline is that lower is better. Obviously, this is predicated to a fairly substantial degree on the results of the SPRINT trial[3] that were more impressive, I think, than most of us had anticipated. Not only would lower necessarily be better, but I do think that there is some discussion about the potential risk of overly treating hypertension in vulnerable populations. I think we have to be careful to individualize the approach based on patient age, frailty, comorbidities, and the other kinds of things that we deal with when managing patients with hypertension—so many of whom have other cardiovascular, renal, or central nervous system comorbidities.

Dr Yancy: I think that really will be the challenge—allowing all of us as practitioners to feel comfortable with the new targets but to not retreat away from good clinical judgment. There will be those patients for whom going to 130 mm Hg [systolic] is going to be problematic, but there will also be those patients for whom going to 130 mm Hg will prevent cardiovascular disease and stroke. We shouldn't overlook that opportunity. I'm thrilled that the new guideline is here. What kind of closing sentiments do you want to express to our viewers?

We have to be careful to individualize the approach based on patient age, frailty, comorbidities...

Dr O'Gara: We have to be very appreciative of the work that this committee did in bringing forward something that the National Heart, Lung, and Blood Institute asked the AHA and the American College of Cardiology to do back in 2013. The committee took their time and sifted through the information. I think they have adopted a new approach to formatting guidelines that should make it a bit more user-friendly, but I come away from this with a much broader appreciation for hypertension and the context of overall risk.

The lifestyle measures that would be important, drug therapies, lower is better, and I think we've flattened the target for blood pressure achievement, around 130/80 mm Hg except in very unusual circumstances. That's much easier for clinicians to remember. There's no longer this gradation or bifurcation dependent on age, with which I think our community struggled over the last few years.

Dr Yancy: You bring up another good point that merits emphasis. You and I have been involved in generating guidelines for many years, and part of our vulnerability has been in implementation. I'm very pleased to know that there are partnerships that have been created with the American Medical Association; for example, that there will be a public health campaign, that there will be consumer-facing messaging, and that there is a really good faith opportunity for these guidelines to become inculcated in the way that we as a practice community think but also a way that we as a population understand what it is we need to do to have better health going forward.

The information is incontrovertible; the clarity of the statement cannot be debated; the implementation plan is present—something that has been missing many, many times before; and the potential benefit is there. I'm delighted that we both have enthusiasm about these guidelines.

I hope that those of you who are listening will take a look at the guidelines and will appreciate why Dr O'Gara and I are so thrilled to see this statement come forward. This may be one of the most important cardiovascular news stories of 2017 because of its potential to save lives and allow people to be healthier and be free of the burden of heart disease and stroke. Might I add: Treating hypertension reduces the burden of heart failure, which particularly makes me a happy man.

Thanks, Pat. Great talking to you.

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