The recommendations intended to guide how doctors in the United States treat millions of patients with high blood pressure are about to change in some surprising and potentially controversial ways.
No more pre-hypertension
The updated guidelines, released this morning by an expert scientific panel called the Joint National Commission (JNC), scrap the concept of “pre-hypertension,” the warning zone between 120/80 and 139/89 where patients previously had been advised to make blood pressure-lowering lifestyle changes.
The highly anticipated JNC report published in JAMA, the Journal of the American Medical Association, also does not define high blood pressure in the one-size-fits-all way that its predecessor report did. The previous JNC guidelines, issued a decade ago, classified hypertension as a blood pressure of 140/90 or higher in adults of all ages.
The new guidelines are more nuanced, there is no blanket definition of hypertension. Instead, the JNC sets blood pressure thresholds, based on a patient’s age, beyond which drug treatment to lower blood pressure should begin. The tipping point for most people older than 60 to start medication is 150/90. Most people younger than 60 should begin anti-hypertensive drugs if their blood pressure is 140/90 or higher.
The report’s authors insist they have not re-defined hypertension, and they still assert the value of making diet, exercise and other lifestyle changes to lower high blood pressure and reduce medication needs. The JNC panel also noted that their recommendations shouldn’t trump a physician’s own clinical judgment. But the revised guidelines are certain to raise questions among patients and spark debate among doctors.
Cardiologists may aim lower
“The JNC is a very respected body and whatever they produce is going to command significant attention,” said Cleveland Clinic cardiologist Curtis Rimmerman, MD, who holds the Gus P. Karos Endowed Chair in Clinical Cardiovascular Medicine. “I have to respect their consensus opinion. But there are patients whose blood pressure you want to drive lower than 150/90. An example would be someone with a history of active congestive heart failure.”
“I’m going to continue to treat my patients like I’ve always treated them,” Dr. Rimmerman said. “And I think many cardiologists are going to feel the same way. That means aiming for a lower blood pressure goal than was suggested by this group. I personally think a normal blood pressure is 120/80 or less. As we get older, we liberalize that a little bit, and I don’t have a problem with that, given the increased potential for medication side effects.”
A major health issue
High blood pressure is a massive health concern in the United States, where nearly 78 million adults – or 1 in 3 people – have the condition. Half of those patients do not have their hypertension under control. High blood pressure is a major risk factor for stroke and heart disease.
The changes the JNC recommends are the result of a lengthy, rigorous review of hypertension research conducted since the last guidelines were issued a decade ago, in December 2003. Those clinical trials tracked how thousands of patients with high blood pressure fared in different situations, with varying treatments.
Answering critical questions
With those findings in hand, the JNC panel attempted to address three key questions:
- Is there a threshold blood pressure at which beginning treatment with anti-hypertension drugs will clearly improve patients’ conditions?
- Does lowering blood pressure with medications to a specific target level demonstrably improve patients’ medical outcome?
- And finally, do different blood pressure-lowering drugs and drug types show clear differences in their impact on patients’ outcomes?
The answers, it turns out, are yes, yes and yes.
The clinical trials evidence showed a medical benefit from treating most hypertensive patients 60 and older to reach a blood pressure goal of less than 150/90.
For those younger than 60 with hypertension, the medical evidence supported using medication to drive diastolic pressure – the lower blood pressure number measured when the heart is resting between beats – below 90.
The research findings weren’t strong enough to dictate a systolic pressure target for hypertensive patients younger than 60. (Systolic pressure is the higher number that reflects the beating, pumping heart.) The JNC panel recommended that medications be used to get those younger patients below an overall pressure of 140/90.
Differences in drug impacts
Regarding hypertension medications, the JNC panel’s review found moderate evidence to suggest that their effectiveness varies depending on patients’ racial group. The panel recommended that black hypertensive patients initially be treated with calcium channel blockers or thiazide-type diuretics; suggested drug regimens for non-blacks with high blood pressure include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers or thiazide-type diuretics.
New targets may motivate patients
A possible benefit of the slightly relaxed 150/90 blood pressure ceiling for older patients, Dr. Rimmerman said, is that might encourage more of them to stick with therapy.
“Sometimes it takes up to four medications to get patients under reasonable control,” he said. “They’re taking 10, 12, 14 pills a day, especially considering their non-hypertensive medications. I think some of these people get very discouraged, and then when their blood pressure is not optimally controlled despite all these medications, they wonder if it’s doing any good. I wonder if the JNC is liberalizing this blood pressure goal with the idea that more patients are going to get on board and at least be treated to some degree.”