{"id":40707,"date":"2013-12-18T16:36:22","date_gmt":"2013-12-18T21:36:22","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=news&p=40707"},"modified":"2013-12-18T16:36:22","modified_gmt":"2013-12-18T21:36:22","slug":"bp","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/12\/18\/bp\/","title":{"rendered":"Missing High Blood Pressure Guideline Turns Up in JAMA"},"content":{"rendered":"

After \u00a0years of delay and many twists and turns,\u00a0the hypertension guideline originally commissioned by the NIH has now finally been published in\u00a0JAMA<\/em><\/a>. The evidence-based document contains a major revision of hypertension treatment targets and includes new and somewhat simplified recommendations for drug treatment.<\/p>\n

The previous U.S. hypertension guideline was published more than a decade ago. After many delays, the new guideline was ready for publication earlier this year, but then\u00a0the NIH decided to get out of the guidelines business<\/a>. The\u00a0American Heart Association\u00a0and the American College of Cardiology assumed responsibility for the development and publication of cardiovascular guidelines and last month\u00a0published four new cardiovascular guidelines, with the notable exception of the hypertension guideline. As\u00a0an accompanying\u00a0JAMA\u00a0<\/em>editorial<\/a>\u00a0explains: \u00a0“Rather than submit the hypertension guideline for review by these organizations, the panel members submitted the guideline to JAMA<\/em>, where it underwent both internal and external peer review.”<\/p>\n

The big headline of the new guideline\u00a0is an important change in treatment targets. The previous guideline recommended that all adults have a target systolic blood pressure below 140 mm Hg. For people with diabetes or kidney disease,\/ the target was even lower, <130 mm Hg. In the new guideline, the target remains the same for adults under 60 but eliminates the lower target for people with diabetes and renal disease. Most importantly, however, for people 60 and over the new guideline establishes a more conservative, easier-to-achieve target of 150 mm Hg or lower.<\/p>\n

The authors write that they have not established a new\u00a0definition<\/em>\u00a0of hypertension: “the panel believes that the 140\/90 mm Hg definition from JNC 7 remains reasonable.” Lower is still better, at least when it occurs naturally: “The relationship between naturally occurring\u00a0BP\u00a0and risk is linear down to very low BP.” The change in target is based, instead, on the lack of evidence showing that drug treatment to the lower levels is better.<\/p>\n

For nonblack adults, the guideline recommends starting drug treatment with an\u00a0ACE\u00a0inhibitor, an\u00a0ARB, a calcium-channel blocker, or a\u00a0thiazide-type diuretic. For blacks, the guideline recommends starting with a calcium-channel blocker or a thiazide-type diuretic. \u00a0People with chronic kidney disease should receive an ACE inhibitor or an ARB. (Although once a cornerstone of antihypertensive therapy, beta-blockers are no longer recommended for initial treatment.)<\/p>\n

If goal blood pressure is not achieved after a month, then the guideline recommends increasing the drug dose or adding a second drug. Blood pressure should be monitored until the treatment goal is reached. A third drug can be added if necessary, but an ACE inhibitor and an ARB should not be used together.<\/p>\n

One important difference between the hypertension guideline and the AHA\/ACC guidelines released last month is the approach to risk assessment. Where the AHA\/ACC recommendations were based on an assessment of total cardiovascular risk, the hypertension guideline is more narrowly focused on blood pressure. Also, as noted in\u00a0another accompanying editorial<\/a>, following the new hypertension guideline will lead to less treatment for elderly people, while the AHA\/ACC guidelines lead to more treatment in these patients. “Such divergent philosophies may cause confusion among clinicians and patients alike,” write\u00a0Eric Peterson, J. Michael Gaziano, and Philip Greenland.<\/p>\n

The guideline offers a frank admission that many of the recommendations are based on expert opinion and not clinical trial evidence.<\/p>\n","protected":false},"excerpt":{"rendered":"

After \u00a0years of delay and many twists and turns,\u00a0the hypertension guideline originally commissioned by the NIH has now finally been published in\u00a0JAMA. The evidence-based document contains a major revision of hypertension treatment targets and includes new and somewhat simplified recommendations for drug treatment. The previous U.S. hypertension guideline was published more than a decade ago. […]<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[],"tags":[],"class_list":["post-40707","post","type-post","status-publish","format-standard","hentry"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/40707","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=40707"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/40707\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=40707"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=40707"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=40707"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}