New Hypertension Guidelines and Clinical Decision Making
Decisions regarding pharmacotherapy choices in older adults are often challenging. Multimorbidity (e.g., fancy term for many chronic medical conditions), time to benefit, and risk are often part of the clinical decision-making milieu.
To illustrate this point, consider the new guidelines for hypertension that were published in 2017 by the American Heart Association and the American College of Cardiology. By modest projections, the guidelines, which reduce the target blood pressure range from 140 mmHg systolic and 90 mmHg diastolic, to 130 and 80, respectively, will increase the number of adults in the U.S. who qualify for treatment for hypertension from 32 to 46 percent.2 In addition to the newly diagnosed, individuals who are currently receiving treatment may need additional drugs or dosage adjustment to meet the new goals. This is not an insignificant finding, as adding more drugs to an over-medicated population, particularly older adults, is not without consequence.
These new guidelines were heavily influenced by a clinical trial published in 2015 called SPRINT. SPRINT had a large population of individuals 75 years of age and older (28%). Those over 75 years had more benefit from reduced blood pressure than younger individuals. There are some limitations as the enrolled population had to have pre-existing cardiovascular disease (excluding stroke) or an elevated 10-year risk of cardiovascular disease, chronic kidney disease, or be 75 years or older.
Previous guidelines for adults relaxed the blood pressure target to 150 mm Hg systolic and 90 mm Hg diastolic in people over 60 years, primarily to reduce the risk for adverse events associated with lower blood pressure, and limited compelling information on improved cardiovascular outcomes.
Interestingly, the American Academy of Family Physicians reported that they will not endorse the ACC/AHA guidelines, as they believe that the guidelines placed too much emphasis on the SPRINT results and did not embrace the whole body of evidence on this issue.
It will be interesting to follow how these new guidelines influence care over the next decade, particularly in older adults.
1. Whelton PK, Carey RM, Aronow WS et al. 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. J Am Coll Cardiol 2017;S0735-1097.
2. Muntner P, Carey RM, Gidding S, et al. Potential U.S. population impact of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline. J Am Coll Cardiol 2018;71;109-18.
3. The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.
4. James PA, Oparil S, Carter BL et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 311:507-20.
5. AAFP decides to not endorse AHA/ACC hypertension guideline. https://www.aafp.org/news/health-of-the-public/20171212notendorseaha-accgdlne.html. Accessed January 8, 2018.