Hypertension Journal

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Impact of American College of Cardiology/AmericanHeart Association Guidelines 2017
  JOHTN
COMMENTARY ON HYPERTENSION GUIDELINES
Impact of American College of Cardiology/American
Heart Association Guidelines 2017
1Mahim Saran, 2Sudhanshu K Dwivedi
1Fellow Interventional Cardiology, 2Professor
1,2Department of Cardiology, King George's Medical UniversityLucknow, Uttar Pradesh, India
Corresponding Author: Sudhanshu K Dwivedi, ProfessorDepartment of Cardiology, King George's Medical UniversityLucknow, Uttar Pradesh, India
e-mail: dr_skdwivedi@rediffmail.
 
ABSTRACT
Reduction in the level of blood pressure (BP) from 140/90 to130/80 mm Hg for defining hypertension is one of the majorpractice changing modifications of the 2017 American Collegeof Cardiology/American Heart Association guidelines whichare bound to have a huge societal impact. The number ofhypertension patients will increase 1.5 times after this definitionchange. Although the BP levels for defining hypertension havechanged, the levels at which pharmacological therapy should bestarted have remained the same, i.e., ≥140/90 mm Hg (Stage 2hypertension according to newer guidelines) except in specialsituations (clinical atherosclerotic cardiovascular disease orestimated 10-year cardiovascular disease risk of ≥10%). All inall, definitely these guidelines are more comprehensive, givea much more clarity to the treating physician, and are aimedat better long-term prevention of target-organ damage. But atthe same time, they leave us in the same dilemma which arisesafter every major guideline change: how to deal with patientswho are being treated as per the old guidelines?
Keywords: Guidelines, Hypertension, Noncommunicabledisease.
How to cite this article: Saran M, Dwivedi SK. Impact ofAmerican College of Cardiology/American Heart AssociationGuidelines 2017. Hypertens J 2017;3(4):193-195.
Source of support: Nil
Conflict of interest: None
 
 

INTRODUCTION

The definitions and practice guidelines of hypertensionhave been continuously changing over a period of time.The new hypertension guidelines published on November14, 2017 is another effort toward a more systematic andcomprehensive evaluation and treatment of hypertension.The newer guidelines provide a more systematic approachtoward when to make a diagnosis of hypertension, whento start lifestyle modifications, and when to start pharmacotherapy.Reduction in the level of BP from 140/90to 130/80 mm Hg for defining hypertension is one of the major practice changing modifications which are boundto have a huge societal impact.

 
DEFINITION CHANGE: IS IT JUST NUMBERS?

Although the BP levels for defining hypertension havechanged, the levels at which pharmacological therapyshould be started have remained the same, i.e., ≥ 140/90mm Hg (Stage 2 hypertension according to newer guidelines)except in special situations (clinical atheroscleroticcardiovascular disease or estimated 10-year cardiovasculardisease risk of ≥10%).

Lowering the BP levels for defining hypertensionmeans that a large group of population which was earlierconsidered as normotensive will be now considered ashypertensive. For example, according to Joint NationalCommittee (JNC 7) definition, 32% of the adult populationof the United States was hypertensive which hasincreased to 46% after the definition change.1 A similarincrease in the prevalence of hypertension by 1.5 timesmay be seen in Indian scenario also. At the same time,the number of hypertensives on pharmacological therapywill remain more or less the same in general populationwithout high-risk features.

So, can we say that the newer guidelines will justchange the current statistics? Probably not:
  • By labeling patients with BP more than 130/80 mmHg as hypertensives, lifestyle modifications (nonpharmacologicalinterventions) can be initiated early andlikely to be more acceptable
  • This gives a lot of time for patient education andbringing disease awareness
  • Closer follow-up of hypertensive patients who are notyet requiring pharmacotherapy (stage 1 hypertension)ensures earlier initiation of pharmacotherapy
  • This might go a long way in preventing target organdamage.

Is it really as good as it sounds? Again, probably not:An almost 50% increase in prevalence is not just anumber. As far as psychosocial impact of the disease isconcerned, numbers do matter!!!

SO WHY WERE THE TARGETS LOWERED?

A large meta-analysis has shown that with every 20 mm Hgsystolic and 10 mm Hg diastolic rise in BP (starting from115/75 to 180/110 mm Hg), the cardiovascular mortality doubles.2 If this is true, then the BP target should havebeen 120/80 mm Hg. However, if we analyze the metaanalysispublished in Lancet in 2014, although the relativerisk reduction remains the same for all subgroups withevery 20/10 mm Hg fall, absolute risk reduction is dependentupon the baseline risk of individuals, i.e., the numberneeded to treat for prevention of one event will be muchless in high-risk group as compared with the low-riskgroup.3 The same was shown in Systolic Blood PressureIntervention (SPRINT) trial where high-risk hypertensivepatients had 27% relative risk reduction in mortality and25% relative risk reduction in cardiac events from bringingdown BP from 140/90 to 120/80 mm Hg.4 In addition,the Medical Research Council (MRC) trial showed thatthe number needed to treat for preventing one strokewas 791 for 1 year and no benefit in preventing coronaryevents in low-risk prehypertensive patients.5 Similarly,the Heart Outcomes Prevention Evaluation 3 (HOPE 3)trial showed that there was no benefit in reducing BPbelow 140/90 mm Hg in intermediate-risk patients.6

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Mahim Saran, Sudhanshu K Dwivedi

Furthermore, the SPRINT trial used oscillometricmethod for measuring BP where 120/80 mm Hg isequivalent to 130/80 mm Hg by manual method. Hence,the target for high-risk group was set at 130/80 mm Hg.

CHANGING TREATMENT TARGETS: A CLINICAL
CHALLENGE, A SOCIOECONOMIC BURDEN OR
NEED OF THE HOUR?


Another important change that these new guidelineshave brought about is the revision of treatment target to< 130/80 mm Hg.

If we look at the data from the Prospective Urban andRural Epidemiological (PURE) study, only 40% of thehypertensives receiving treatment had BP < 140/90 mm Hg.Numbers are still less (12.7%) if we include those unawareof the disease and those not receiving treatment.7 Bytaking the BP target further down, the number of peoplewith adequate BP control will decrease further.

Achieving new targets will be a clinical challenge andthe reasons are manifold:
  • A lot of patients in the BP range of 130/80 to 140/90mm Hg who were being assured that their hypertensionis being adequately controlled will now have tobe conveyed that they need to maintain lower targets.
  • Even for elderly patients, the systolic BP targets havebeen revised to < 130 mm Hg except in situationswhere clinical judgment precludes intensive control.
  • With the ever-increasing prevalence of noncommunicablediseases, balancing the drug-drug interactionsand drug side effects with clinical benefit is not aneasy task.
  • Further lowering the targets will not only add to thepill burden but also increase in cost therapy-an addition to the economic burden, especially in thelow-income households.

 
Another important change is the recommendation tostart with two antihypertensives in stage 2 hypertension(BP ≥ 140/90 mm Hg). When to start with two drugs hasalways been a confusion, as there was never a clear-cutrecommendation. This will come as a relief, especially togeneral physicians.

Newer guidelines have also clarified the concept ofmasked and white-coat hypertension further, with clearcutsuggestions on how to deal with these situations. Theimportance of home BP monitoring and ambulatory BPmonitoring could not have been stressed in a better way.Even the nonpharmacological therapy has been givenits due importance and has been very distinctly andprecisely mentioned.

PSYCHOSOCIAL AND ECONOMIC IMPACT

After pondering upon the fact that strict control isrequired for clinical benefit, now it is necessary totalk about the problems associated. Hypertension isa chronic disease and once labeled, it is for a lifetime.Studies have shown that patients being labeled as hypertensivemay adopt a sick role and in turn affect theirquality of life.8 The association of psychological distresswith hypertension may be directly due to BP, side effectsof medications, or the consequence of being labeled ashypertensive. Like other chronic illnesses, hypertensionalso has immense emotional impact leading to anxietyand depression.9,10

India is a developing country and comes under lowincomecountries. Expenditure on health is of utmostimportance and should be properly looked after. Strictcontrol of BP results in multidrug prescriptions whichin turn leads to higher economic burden and poorercompliance. Not only this, multidrug therapy leadsto higher incidence of side effects. In 2004, the annualincome loss due to noncommunicable diseases was 251billion rupees and that due to hypertension alone was43 billion rupees.11 The benefit of treating high-riskgroup is acceptable but for patients in low-risk category,aggressive treatment is only going to add to theeconomic burden (as emphasized in these guidelines).

The impact of these guidelines is manifold. Theemphasis should be on high-risk population and strictcontrol of BP has the maximum benefit in this subgroup.

All in all, definitely these guidelines are more comprehensive,give much more clarity to the treating physician,and are aimed at better long-term prevention of targetorgandamage. But at the same time, they leave us in thesame dilemma which arises after every major guidelinechange-how to deal with patients who are being treatedas per the old guidelines.

 
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Impact of American College of Cardiology/American Heart Association Guidelines 2017

In the present scenario, where the noncommunicablediseases are toward a rising trend, the newer guidelinesare very much welcome, but then all good things comewith a pinch of salt.

REFERENCES
  1. Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT,Whelton PK. Potential U.S. Population Impact of the 2017American College of Cardiology/American Heart AssociationHigh Blood Pressure Guideline. Circulation 2018Jan;137(2):109-118.
  2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R;Prospective Studies Collaboration. Age-specific relevance ofusual blood pressure to vascular mortality: a meta-analysisof individual data for one million adults in 61 prospectivestudies. Lancet 2002 Dec;360(9349):1903-1913.
  3. Blood Pressure Lowering Treatment Trialists' Collaboration.Blood pressure-lowering treatment based on cardiovascularrisk: a meta-analysis of individual patient data. Lancet 2014Aug;384(9943):591-598.
  4. SPRINT Research Group; Wright JT Jr, Williamson JD,Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM,Rahman M, Oparil S, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015Nov;373(22):2103-2116.

 
  1. Medical Research Council Working Party on Mild Hypertension.MRC trial of treatment of mild hypertension: principalresults. Medical Research Council Working Party. Br MedJ (Clin Res Ed) 1985 Jul;291:97.
  2. Lonn EM, Bosch J, Lopez-Jaramillo P, Zhu J, Liu L, Pais P, Diaz R,Xavier D, Sliwa K, Dans A, et al. Blood-pressure lowering inintermediate-risk persons without cardiovascular disease.N Engl J Med 2016 Apr;374(21):2009-2020.
  3. Rao D. Epidemiology of hypertension in India: insights fromPURE. J Indian Coll Cardiol 2015 Mar;5(Suppl 1):S28-S32.
  4. Pickering TG. Now we are sick: labeling and hypertension.J Clin Hypertens (Greenwich) 2006 Jan;8(1):57-60.
  5. DeJean D, Giacomini M, Vanstone M, Brundisini F. Patientexperiences of depression and anxiety with chronic disease: asystematic review and qualitative meta-synthesis. Ont HealthTechnol Assess Ser 2013 Sep;13(16):1-33.
  6. Vetere G, Ripaldi L, Ais E, Korob G, Kes M, Villamil A.Prevalence of anxiety disorders in patients with essentialhypertension. Vertex 2007 Jan-Feb;18(71):20-25.
  7. Mahal, A.; Karan, A.; Engelgau, M. Health Nutrition andPopulation (HNP) discussion paper. The economic implicationsof non-communicable disease for India. Washington(DC): The World Bank; 2010.

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