Guidelines for Blood Pressure Targets

Reading the new blood pressure guidelines

Guidelines for Blood Pressure Targets
Harvard Men's Health Watch

If you didn't have high blood pressure before, there's a good chance you do now.

In 2017, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organizations lowered the numbers for the diagnosis of hypertension (high blood pressure) to 130/80 millimeters of mercury (mm Hg) and higher for all adults. The previous guidelines set the threshold at 140/90 mm Hg for people younger than age 65 and 150/80 mm Hg for those ages 65 and older.

This means 70% to 79% of men ages 55 and older are now classified as having hypertension. That includes many men whose blood pressure had previously been considered healthy. Why the change?

Behind the numbers

“Blood pressure guidelines are not updated at regular intervals. Instead, they are changed when sufficient new evidence suggests the old ones weren't accurate or relevant anymore,” says Dr.

Paul Conlin, an endocrinologist with Harvard-affiliated VA Boston Healthcare System and Brigham and Women's Hospital.

“The goal now with the new guidelines is to help people address high blood pressure — and the problems that may accompany it heart attack and stroke — much earlier.”

The new guidelines stem from the 2017 results of the Systolic Blood Pressure Intervention Trial (SPRINT), which studied more than 9,000 adults ages 50 and older who had systolic blood pressure (the top number in a reading) of 130 mm Hg or higher and at least one risk factor for cardiovascular disease.

The study's aim was to find out whether treating blood pressure to lower the systolic number to 120 mm Hg or less was superior to the standard target of 140 mm Hg or less.

The results found that targeting a systolic pressure of no more than 120 mm Hg reduced the chance of heart attacks, heart failure, or stroke over a three-year period.

More than blood pressure

The new guidelines have other changes, too. First, they don't offer different recommendations for people younger or older than age 65. “This is because the SPRINT study looked at all patients regardless of age and didn't break down groups above or below a certain age,” says Dr. Conlin.

The guidelines also redefined the various categories of hypertension.

It eliminated the category of prehypertension, which had been defined as systolic blood pressure of 120 to 139 mm Hg or diastolic pressure (the lower number in a reading) of 80 to 89 mm Hg.

Instead, people with those readings are now categorized as having either elevated pressure (120 to 129 systolic and less than 80 diastolic) or Stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic).

A reading of 140/90 mm Hg or higher is considered Stage 2 hypertension, and anything higher than 180/120 mm Hg is hypertensive crisis.

The new guidelines note that blood pressure should be measured on a regular basis and encourage people to use home blood pressure monitors. Monitors can range from $40 to $100 on average, but your insurance may cover part or all of the cost. Measure your blood pressure a few times a week and see your doctor if you notice any significant changes. Here are some tips on how to choose and use a monitor.Choosing
  • Select a monitor that goes around your upper arm. Wrist and finger monitors are not as precise.
  • Select an automated monitor, which has a cuff that inflates itself.
  • Look for a digital readout that is large and bright enough to see clearly.
  • Consider a monitor that also plugs into your smartphone to transfer the readings to an app, which then creates a graph of your progress. Some devices can send readings wirelessly to your phone.

Using

  • Avoid caffeinated or alcoholic beverages 30 minutes beforehand.
  • Sit quietly for five minutes with your back supported and your legs uncrossed.
  • Support your arm so your elbow is at or near heart level.
  • Wrap the cuff over bare skin.
  • Don't talk during the measurement.
  • Leave the deflated cuff in place, wait a minute, then take a second reading. If the readings are close, average them. If not, repeat again and average the three readings.
  • Keep a record of your blood pressure readings, including the time of day.

What should you do?

If you had previously been diagnosed with high blood pressure, the new guidelines don't affect you too much, says Dr. Conlin, as you still need to continue your efforts to lower it through medication, diet, exercise, and weight loss. “However, new information in the guidelines, your doctor may propose treating your blood pressure to a lower level,” he says.

The larger issue is that many men ages 65 and older suddenly find themselves diagnosed with elevated or high blood pressure, since the new normal is a whopping 20 points lower than before. Does this mean an automatic prescription for blood pressure drugs? Not necessarily.

“They should consult with their doctor about first adjusting lifestyle habits, such as getting more exercise, losing weight, and following a heart-healthy diet the DASH or Mediterranean diet,” says Dr. Conlin.

Medications are recommended to lower blood pressure in Stage 1 hypertension if you've already had a heart attack or stroke or if your 10-year risk of a heart attack is higher than 10%. (You can find your 10-year estimation at www.cvriskcalculator.com.) For others with Stage 1 hypertension, lifestyle changes alone are recommended.

“Overall, the new guidelines may help people get more involved with monitoring their blood pressure, which can hopefully prevent complications from hypertension,” says Dr. Conlin.

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Source: https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Guidelines for Blood Pressure Targets

Joseph Scarpa and Coauthors

JAMA Network Open | Original Investigation, March 8, 2019

Michael Roerecke and Coauthors

JAMA Internal Medicine | Original Investigation, February 4, 2019

Peter J. Kaboli and Coauthors

JAMA Network Open | Original Investigation, December 14, 2018

Yuanyuan Zhang and Coauthors

JAMA Pediatrics | Research Letter, December 2018

Arman Qamar and Eugene Braunwald

JAMA | Viewpoint, November 6, 2018

Naomi D. L. Fisher and Gregory Curfman

JAMA | Editorial, November 6, 2018

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Thomas T. van Sloten and Coauthors

JAMA | Original Investigation, November 6, 2018

Sarah Melville and James Brian Byrd

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Tamar S. Polonsky and George L. Bakris

JAMA | JAMA Diagnostic Test Interpretation, November 6, 2018

James P. Sheppard and Coauthors

JAMA Internal Medicine | Original Investigation, October 29, 2018

George Howard and Coauthors

JAMA | Original Investigation, October 2, 2018

Kyle Morawski and Coauthors

JAMA Internal Medicine | Original Investigation, April 16, 2018

Robert B. Baron

JAMA Internal Medicine | Invited Commentary, April 16, 2018

Ian H. de Boer and Coauthors

JAMA | Viewpoint, April 3, 2018

Teemu J. Niiranen and Coauthors

JAMA Cardiology | Brief Report, March 21, 2018

Pascal Geldsetzer and Coauthors

JAMA Internal Medicine | Original Investigation, March 2018

Jeong Yun Yang and Coauthors

JAMA Internal Medicine | Teachable Moment, February 26, 2018

Jonathan Graff-Radford and Coauthors

JAMA Neurology | Original Investigation, February 2018

Anita Slomski

JAMA | Clinical Trials Update, January 23/30, 2018

João Delgado and Coauthors

JAMA Internal Medicine | Original Investigation, January 2018

Mattias Brunström and Bo Carlberg

JAMA Internal Medicine | Original Investigation, November 13, 2017

Rakesh Malhotra and Coauthors

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Joshua D. Bundy and Coauthors

JAMA Cardiology | Original Investigation, July 2017

Shakia T. Hardy and Coauthors

JAMA Cardiology | Original Investigation, June 2017

Wan-Chuan Tsai and Coauthors

JAMA Internal Medicine | Original Investigation, June 2017

Dori Steinberg and Coauthors

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Yuichiro Yano and Coauthors

JAMA Cardiology | Original Investigation, April 2017

Jerome H. Chin and Coauthors

JAMA Neurology | Viewpoint, February 6, 2017

Michelle C. Odden and Coauthors

JAMA Internal Medicine | Original Investigation, February 6, 2017

Aram V. Chobanian

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M.J. Friedrich

JAMA | Global Health, January 17, 2017

Mohammad H. Forouzanfar and Coauthors

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News From the Centers for Disease Control and Prevention

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Rachel Puttnam and Coauthors

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Ilana B. Richman and Coauthors

JAMA Cardiology | Original Investigation, November 2016

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JAMA Cardiology | Viewpoint, November 2016

Salim Yusuf and Coauthors

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Thomas A. Dewland and Coauthors

JAMA Internal Medicine | Original Investigation, August 2016

David M. Flatt and Coauthors

JAMA Cardiology | Review, August 2016

Iona Heath

JAMA Internal Medicine | Invited Commentary, July 2016

Jeff D. Williamson and Coauthors

JAMA | Original Investigation, June 28, 2016

Aram V. Chobanian/p>

JAMA | Editorial, June 28, 2016

Timothy B. Plante and Coauthors

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Sarah Lewington and Coauthors

JAMA Internal Medicine | Original Investigation, April 2016

Theodore A. Kotchen and Coauthors

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Athanase Benetos and Coauthors

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Connor A. Emdin and Coauthors

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JAMA | Editorial, August 27, 2014

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AHA: 130/80 mm Hg Is New National BP Target

Guidelines for Blood Pressure Targets

ANAHEIM — After years of contention among professional societies over raising blood pressure targets, national guidelines have reduced the goal from 140/90 mm Hg to 130/80 mm Hg for the general population, including community-dwelling seniors.

The American Heart Association and American College of Cardiology, which took over from the NHLBI's Joint National Commission in 2013, released the 2017 guideline with endorsement from nine other groups with key changes to the threshold, treatment algorithm, and blood pressure (BP) measurement.

BP Classifications

Normal blood pressure remains below 120 mm Hg, but hypertension has been split into stage 1 (130/80 to 139/89 mm Hg) and stage 2 (140/90 mm Hg and higher) with different implications for treatment.

With the new target, the overall prevalence of hypertension among U.S. adults will jump to 45.6% compared with 31.9% the JNC7's 140/90 mm Hg threshold. That represents an additional 31.1 million people — National Health and Nutrition Examination Survey data through 2014 — for a total prevalence of 103.3 million, a simultaneously published study in Circulation indicated.

The targets were the same for older and younger adults, with the caveat that treatment decisions should be individualized for seniors with a high comorbidity burden and limited life expectancy.

The change was largely the SPRINT trial's finding that a target below 120 mm Hg reduced heart attack, stroke, or death in higher-risk older adults, with clear benefit and no evidence of increased risk of falls or orthostatic hypertension in elderly individuals in the trial.

But the SPRINT researchers have cautioned that the blood pressure measurements were taken with a careful automated process and in a clinical trial setting with a motivated population that differs from most clinical settings, such that their findings should not be directly applied to usual practice.

“It's much less evidenced-based than JNC8, but it's important to give advice. You can't study everything. There will never be another SPRINT,” commented Suzanne Oparil, MD, who was a reviewer for the new guideline but had co-chaired the JNC8 effort that resulted in unofficial recommendations after being disbanded by the NHLBI.

That controversial guideline had recommended looser thresholds for most hypertensive individuals 60 or older, starting pharmacologic treatment when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.

“You can't get a direct conversion,” agreed ACC immediate-past president Richard Chazal, MD, “but it's about as 'science-y' as one can get.”

The guideline writing committee selected 130/80 mm Hg as an intermediate target balancing efficacy and safety for the general population, writing committee vice chair Robert Carey, MD, of the University of Virginia in Charlottesville, explained at a press conference. Even without SPRINT, though, the evidence across the more than 900 sources reviewed for the guidelines supported that lower is better for blood pressure, the group emphasized.

BP Treatment

The blood pressure target for treatment also shifted to less than 130/80 mm Hg. However, there were key differences in recommended treatment by hypertension category.

  • Stage 1 hypertension in the 130/80 to 139/89 mm Hg range was recommended for nonpharmacologic (predominantly lifestyle) therapy only unless the patient has clinical cardiovascular disease or at least a 10% 10-year risk of it the ACC/AHA atherosclerotic cardiovascular disease risk calculator already in use for cholesterol treatment decisions
  • Stage 2 hypertension is recommended for blood pressure medication regardless of 10-year risk or cardiovascular disease status
  • Elevated blood pressure (previously prehypertension) in the 120-129 mm Hg systolic range was recommended for non-pharmacologic attention to lifestyle therapy

Lifestyle measures are weight loss, the DASH diet, reducing sodium, increasing potassium through diet, physical activity, and moderate alcohol consumption (limit one drink per day for women, two for men).

Lifestyle change is challenging, acknowledged Paul Whelton, chair of the guidelines writing committee, also speaking at the press conference. However, “we have to come to grips with it, whether somebody can achieve the goals or not we have to provide them with the information and the mechanisms to achieve those goals.”

The Circulation paper estimated a much smaller impact on prevalence of antihypertensive treatment than for overall prevalence because of the distinction by hypertension stage and risk level. It suggested an increase to 36.2%, up from 34.3% of adults with hypertension recommended for antihypertensive medication under the JNC7 guideline, representing an additional 4.2 million people.

“Yes, this will be a new challenge for clinicians as many more patients will be classified as hypertension and need treatment — both lifestyle modifications and, in some, medications,” commented American Society of Hypertension President John Bisognano, MD. “But this is a challenge that is worth taking for the right reasons and is the right approach to take.”

Carey suggested “this guideline may be a can opener” to force change and a re-commitment to lifestyle improvements.

Donald Lloyd-Jones, MD, of Northwestern University in Chicago, predicted it will be a paradigm shift in how blood pressure is treated in the U.S.

BP Measurement

The guidelines reiterated proper measurement techniques for BP measurement, including having the patient sit quietly for 5 minutes before a reading is taken.

Whelton also emphasized that the measurement should be averaged over two or three measurements taken on two or three separate office visits.

A new recommendation was for out-of-office BP measurement to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.

Adoption

The guideline itself was published in Hypertension, as a rambling, 192-page document that might be too much for many physicians to comb through, commented William Cushman, MD, a key SPRINT investigator.

“It’s long because it’s comprehensive,” Whelton said.

Still, “I generally think it is a very good guideline. I agree with most of recommendations,” he told MedPage Today. “I do think more emphasis could be made that the

Source: https://www.medpagetoday.com/meetingcoverage/aha/69247

Blood pressure targets in the elderly

Guidelines for Blood Pressure Targets

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Ideal Target Blood Pressure in Hypertension

Guidelines for Blood Pressure Targets

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New blood pressure guideline could prevent 3 million cardiovascular events over 10 years

Guidelines for Blood Pressure Targets

In 2017, the American College of Cardiology and the American Heart Association released new blood pressure guidelines, lowering hypertension threshold to 130/80 mm Hg from the previous 140/90 mm Hg.

A new study predicts that achieving and maintaining the 2017 guideline blood pressure goals could prevent more than 3 million cardiovascular disease events over ten years.

The results of the study will appear online in the November 19 issue of Circulation.

“Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans,” said the study's lead author Adam Bress, Pharm.D., M.S., assistant professor in Population Health Sciences at University of Utah Health. “Achieving these lower goals will be challenging.”

Bress and his team wanted to explore the impact of achieving and maintaining the lower guideline-recommendations on the public compared to earlier blood pressure and treatment levels, as well as patients' ability to achieve and maintain earlier guideline recommendations.

The team predicted the number of cardiovascular events averted in middle-age adults the blood pressure goals of the 2017 blood pressure guidelines (< 130/80 mm Hg), the seventh Joint National Committee (JNC7) guidelines (< 140/90 mm Hg) and the eighth Joint National Committee (JNC8) guidelines (140/90 mg Hg for patients younger than 60 and 150/90 mm Hg for patients older than 60).

Their analysis projects 3.3 million fewer cardiovascular disease events after achieving and maintaining the 2017 blood pressure goals compared to current blood pressure levels. They also found that achieving and maintaining the JNC7 and JNC8 recommended blood pressure goals would prevent 2.6 and 1.6 million cardiovascular disease events, respectively.

This study made these predictions using several contemporary, population-based databases. The NHANES dataset is a national representative survey of the U.S. adult population and provides population sizes of hypertension treatment groups by blood pressure levels and chronic conditions.

The REGARDS database provides a source for the risk of fatal and nonfatal cardiovascular events.

A recent meta-analysis of 42 randomized blood pressure-lowering clinical trials, consisting of more than 140,000 participants, provides the risk reduction predictions for cardiovascular events achieving and maintaining different blood pressure treatment targets.

The majority of cardiovascular disease events prevented came from those with current blood pressure levels above 140/90 mm Hg. Models assumed that patients achieved and maintained blood pressure goals over the course of the simulation.

Previous studies suggest the initial upfront investment for treating more adults for hypertension leads to health gains and cost savings over the lifetime of treatment. But change does not always come easily.

“A change in longstanding clinical guidelines is disruptive to patients and providers who are accustomed to clinical practice patterns that integrate the earlier guidelines,” said Andrew Moran, M.D., M.P.H.

, associate professor of Medicine at the Columbia University Irving Medical Center and senior author on the paper.

“It is important to project and quantify the range of potential benefits and risks expected if we make these fundamental changes to the way health care providers practice.”

Treating more patients to achieve lower blood pressure goals does have risks. Bress notes that medications often come with side effects, which need to be monitored and managed.

“The number of medication-related adverse events was roughly equivalent to the number of cardiovascular disease events prevented,” Moran said. “But the adverse events tend to be minor and transient, while the avoided cardiovascular events can lead to serious life time health problems and are sometimes even fatal.”

The results are a database that is not representative of the diversity in the country, including information for only white and black patients that are at least 45 years old. It also does not directly account for future changes in blood pressure or changes in antihypertensive medications through time.

“A conversation and shared decision making between provider and patient about benefits and risks of increasing the dose of a medication or adding a new medication to achieve a lower target are important,” Bress said. “Benefits to reduce the risk of heart attacks, stroke and heart failure are clear and may often outweigh risk of minor, transient side-effects.”

Story Source:

Materials provided by University of Utah Health. Note: Content may be edited for style and length.

Source: https://www.sciencedaily.com/releases/2018/11/181119064126.htm

Stricter Blood Pressure Guidelines Could Prevent Cardiovascular Events, but Debate Continues

Guidelines for Blood Pressure Targets

Mary Caffrey

A 2015 study sponsored by the National Institutes of Health made a change in blood pressure guidelines seem inevitable. But there is disagreement between the standards promoted by societies for family physicians and those for cardiologists, leading to confusion for those in daily practice.

A year ago, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated new blood pressure guidelines that lowered the threshold at which some patients should be treated for hypertension, from 140/90 mmHg to 130/80 mmHg.

A new study, published today in the AHA journal, Circulation, finds that change could translate into 3 million fewer cardiovascular disease events over 10 years, compared with earlier guidelines.

1 “Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans,” said lead author Adam Bress, PharmD, MS, assistant professor of Population Health Sciences at University of Utah Health, in a statement. “Achieving these lower goals will be challenging.”

But Bress’ study is just one among several that have come recently, along with commentary that show despite a landmark National Institutes of Health (NIH) study in 2015 that seemed a mandate for lower blood pressure targets, not everyone is on board. The new study additionally says that for the highest-risk cardiovascular patients, the new guidelines could result in an increase of treatment-related serious adverse events, which suggest the need for personalized care.One challenge is the Western diet, which is cited as the cause of rising levels of obesity and diabetes around the world. The assumption that blood pressure must rise with age may not be true, and it may be more closely connected to what we eat.

A study published last week in JAMA Cardiology compared blood pressure of 2 remote South American tribes, one which had no exposure to Western dietary patterns and the other which had some exposure to processed foods with higher levels of salt. Despite similar genetic backgrounds, the tribe that consumed saltier foods had higher blood pressure. Many believe the real key to treating heart disease and diabetes is getting serious about dietary and nutrition policy.

Bress and his team calculated fewer events in middle-aged adults the 2017 blood pressure goals when compared with guidelines in the seventh Joint National Committee, known as JNC7, as with the eighth Joint National Committee (JNC8), which put the cutoff for hypertension at 140/90 mmHg for patients younger than 60 years of age and 150/90 mmHg for those age 60 years and older.

Last month, Franz H. Messerli, MD, and Sripal Bangalore, MD, MHA, writing in the Journal of the American College of Cardiology explained how physicians are justifiably confused.

They offer a case study of a 63-year-old female patient with blood pressure readings that average 148/86 mmHg.

Guidelines between ACC/AHA, which cover 25,000 cardiologists, and those of the European Society of Hypertension and European Society of Cardiology, which cover 75,000 physicians, are not in alignment.2

ACC/AHA guidelines say her blood pressure should be 130/80 mmHg. The European guidelines say her blood pressure should be 140/90 mmHg. But guidelines for the American College of Physicians and the American Association of Family Physicians say she’s just fine at 150/90 mmHg. The guidelines don’t align on how many medications to use when starting treatment, either.

Ironically, all 3 guidelines are the same study; called SPRINT (Systolic Blood Pressure Intervention Trial), this was a large trial by the NIH that stopped early because it became clear that treating patients to a lower blood pressure target was resulting in fewer fatal cardiovascular events.

Despite this, the ACP guidelines insist that treating blood pressure to a target of 130/80 mmHg across a population of older adults will result in “low value care.”Messerli and Bangalore see more frustration ahead. “The above hypertension guideline fiasco eloquently illustrates the potential shortcomings of dogmatic clinical directives and, if anything, is prone to increase the rift between those who preach, those who teach, and those who treat,” they wrote. “Unless we make a concerted effort to do so, as the number of guidelines is increasing more rapidly than does iron-clad evidence, we are prone to see more and more schism among recommendations, confusion among physicians, and anxiety among patients,” the authors concluded.

References

  1. Bress AP, Colantonio LD, Cooper RS, et al. Potential cardiovascular disease events prevented with adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline [published online November 19, 2018]. Circulation. doi: 10.1161/CIRCULATIONAHA.118.035640.

Source: https://www.ajmc.com/focus-of-the-week/stricter-blood-pressure-guidelines-could-prevent-cardiovascular-events-but-debate-continues