The problem with blood pressure guidelines

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Commentary

The problem with blood pressure guidelines

J Fam Pract. 2018 July;67(7):402,404

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References

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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248.

2. Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166:430-437.

3. Phend C. Europe stands pat on hypertension thresholds. ESC doesn’t follow ACC/AHA diagnotic cutoff, focuses on control rates. Medpage Today. Available at: https://www.medpagetoday.com/cardiology/hypertension/73384?xid=NL_breakingnews_2018-06-09&eun=g1206318d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=BreakingNews_060918&utm_term=Breaking%20News%20Targeted. Accessed June 19, 2018.

4. Institute of Medicine (US). Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; eds, Graham R, Mancher M, Miller Wolman D, et al. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.

5. 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. 2014;311:507-520.

6. Wright JT Jr., Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. 2014;160:499-503.

7. Graham R, James P, Cowan T. Are clinical practice guidelines valid for primary care? J Clin Epidemiol. 2000;53:949-954.

8. Welch HG, Schwartz LM, Woloshin S. Overdiagnosed: Making People Sick in the Pursuit of Health. Boston, Mass: Beacon Press; 2011.

9. Clancy CM, Kamerow DB. Evidence-based medicine meets cost-effectiveness analysis. JAMA. 1996;276:329-330.

10. Frame PS. A critical review of adult health maintenance. Part 1: Prevention of atherosclerotic diseases. J Fam Pract. 1986;22:341-346.

11. Starfield B, Hyde Jervas J, Heath I. Glossary: the concept of prevention: a good idea gone astray? J Epidemiol Community Health. 2008;62:580-583.

12. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967;202:1028-1034.

13. Wright JT Jr., Whelton PK, Reboussin DM. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2016;374:2294.

14. Ortiz E, James PA. Let’s not SPRINT to judgment about new blood pressure goals. Ann Intern Med. 2016;164:692-693.

Let’s examine what this means

In 1967, a study of 143 hypertensive patients showed that treating high BP (average diastolic BP between 115 and 129 mm Hg) dramatically improved important health outcomes.¹² The number needed to treat (NNT) after about 1.5 years showed that for every 1.4 people treated, 1 benefited.⁸ This is strong and effective medicine.

We must all advocate for better guideline processes.

Successive randomized controlled trials of lower BP goals showed consistent RR reductions; however, AR reductions were much lower, reflecting a higher NNT.⁸ To prove BP-lowering benefits were not a random effect, higher numbers of participants were needed (SPRINT required over 9300 participants).¹³ The AR reduction in SPRINT was 1.6% (meaning no benefit was seen in 98.4% receiving the intensive intervention). One participant with high cardiovascular disease risk benefited for every 63 subjects given the intensive therapy compared with usual care (BP goal of 120 mm Hg vs 140 mm Hg).^13,14 The researchers noted serious harms in 1 of 22 subjects treated. Treating younger patients to lower BP goals labels healthy people with risk factors as “sick” and commits them to lifelong medications. It exposes them to more frequent harms than benefits. For healthy patients who are unlikely to benefit from taking more antihypertensive medication, these harms matter.

Interpreting the benefits of BP Tx when the benefit to individuals appears small

If only there were a biomarker that could tell us who is most likely to benefit from antihypertensive medication treatment, FPs could ensure that the correct patients are treated. The ACP/AAFP guideline points the way. There is a biomarker, and it is called BP. Systolic BP above 150 mm Hg signals urgency to treat with medications.

A call to advocate. We must all advocate for better guideline processes. The status quo in guideline development and its reliance on special interest funding requires ongoing vigilance to advocate on behalf of our patients. High-value medical care is expensive and hard work. When it is applied to the wrong people at the wrong time, we don’t deliver on our promises.