In a world that grows more complex every day, wouldn't it be a welcome change to have just one thing become a little simpler? Well, when it comes to busy family physicians managing their patients' hypertension, a newly released guideline could go a long way toward accomplishing that goal.
"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.jamanetwork.com)" published online Dec. 18 by JAMA: The Journal of the American Medical Association, outlines nine specific recommendations for initiating and modifying pharmacotherapy for patients with elevated blood pressure (BP).
According to lead author and family physician Paul James, M.D., of Iowa City, Iowa, rather than tackle the entire panoply of what is known or assumed about diagnosing and treating hypertension, the diverse group of members appointed to the guideline panel by the National Heart, Lung and Blood Institute (NHLBI) in 2008 focused instead on answering three key questions:
- A new evidence-based guideline outlines nine specific recommendations for initiating and modifying pharmacotherapy for patients with elevated blood pressure (BP).
- Among those recommendations is one stating that, in general, patients 60 and older should start treatment to lower BP at a systolic blood pressure of 150 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher and treat to below those thresholds.
- The guideline also outlines which medications are best for specific patient populations based on factors such as age, race and health status.
- In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
- In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
- In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?
"So, it's really, 'At what BP do you start medication?' and then, 'At what BP do you maintain medication?'" James said in an interview with AAFP News Now. "And then the third question was, 'What are the medications (or antihypertensive drugs) that doctors should use to get to goal?'
"We considered these the three most important questions that any doctor in American needs to know the answer to."
From the outset, the panel committed to following the pathway to guideline development outlined in the Institute of Medicine report Clinical Guidelines We Can Trust. This approach entailed using rigorous evidence-based methods to develop evidence statements and recommendations for BP treatment based on a systematic review of the literature, while focusing on meeting guideline user needs, especially the needs of primary care clinicians.
Overview of Guideline's Recommendations
The evidence review and summarization was performed by an external methodology team panel and focused on studies that examined adults 18 or older with hypertension, including studies that involved numerous prespecified subgroups, such as patients with diabetes, coronary artery disease, previous stroke and chronic kidney disease (CKD). Studies that focused on older adults also were included, as were those that examined both men and women, various racial and ethnic groups, and smokers.
The guideline panel chose to review only randomized controlled trials (RCTs) involving at least 100 subjects "because they are less subject to bias than other study designs and represent the gold standard for determining efficacy and effectiveness," the authors wrote.
Although panel members attempted to reach consensus on all recommendations, a two-thirds majority was considered acceptable, with the exception of recommendations for which no RCT evidence was eligible for review. For these areas, recommendations were based on expert opinion and required approval by 75 percent of panel participants.
A condensed version of the guideline's nine recommendations follows. Details of the strength of evidence grading system the panel used are discussed in an online supplement(jama.jamanetwork.com) to the guideline.
- In the general population ages 60 and older, pharmacologic treatment to lower BP should be initiated at a systolic blood pressure (SBP) of 150 mmHg or higher or a diastolic blood pressure (DBP) of 90 mmHg or higher. Patients should be treated to a goal SBP lower than 150 mmHg and a goal DBP lower than 90 mmHg. If treatment results in lower achieved SBP and is not associated with adverse effects, treatment does not need to be adjusted.
- In the general population younger than age 60, initiate pharmacologic treatment at a DBP of 90 mmHg or higher or an SBP of 140 mmHg or higher and treat to goals below these respective thresholds.
- In the population ages 18 years or older with diabetes or CKD, initiate pharmacologic treatment at an SBP of 140 mmHg or higher or a DBP of 90 mmHg or higher and treat to goals below these respective thresholds.
- In the general nonblack population, including those with diabetes, initial treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).
- In the general black population, including those with diabetes, initial treatment should include a thiazide-type diuretic or a CCB.
- In the population ages 18 or older with CKD and hypertension, initial (or add-on) treatment should include an ACE inhibitor or an ARB to improve kidney outcomes. This applies to all patients in this population regardless of race or diabetes status.
- Finally, the main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of initiating treatment, increase the dose of the initial drug or add a second drug from one of these four classes. The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided.
This final recommendation includes a caveat that ACE inhibitors and ARBs should not be used concomitantly. If goal BP cannot be reached using the above-named drugs because of a contraindication or the need to use more than three such drugs to reach goal BP, antihypertensive drugs from other classes may be used.
Referral may be indicated for patients in whom goal BP cannot be reached using the above strategy or to manage complicated patients for whom additional clinical consultation is needed.
Takeaways for Family Physicians
According to James, the chief message to family physicians is that the new guideline stands to simplify the management of high blood pressure in their patients.
"No. 1, it's going to simplify the goals (of treatment because) there are only two goals to remember. No. 2, I do think a lot of physicians who take care of the elderly have been concerned over the years about the potential for causing harm by overtreating blood pressure." It's certainly not uncommon for elderly patients to become dizzy on standing because of the antihypertensive medication or medications they take. Such patients, James noted, are at an increased risk for falls and their sequelae.
From that perspective alone, he noted, "I think many people who take care of the very elderly will think these guidelines make more sense."
Overall, "I think we've simplified the drug regimen for family doctors," said James, although certain aspects of the new guideline may have some clinicians doing a double-take, he acknowledged.
"One thing that family doctors may not realize is that beta blockers, which are a tried-and-true and beloved medication for treating high blood pressure, actually got pushed down to the second tier. That may come as a surprise to many of them."
Admittedly, the release of the 2014 guideline likely will raise some eyebrows, and not just for its content. Unlike past guidelines developed by expert panels convened by the NHLBI, the new guidance document was not endorsed by any government agency or professional organization before publication. That's because in the face of a controversial decision NHLBI officials made in June that would have delayed publication of the long-awaited guideline, the authors decided to pursue publication independently, a fact they address in the guideline itself.
But that's really not germane to the important conversation that now needs to take place, said James. "The science part of this is the part I want people to focus on now.
"One of the things I'm hoping is that groups like the Academy and the American College of Physicians would look at the process (we used) and see that it's very different from other guidelines and that it had very active participation by primary care doctors."
That process already has begun.
"The report from the JNC 8 panelists is among the most anticipated guidelines of the past several years and addresses a top priority topic for family physicians and their patients," said Steven Brown, M.D., of Phoenix, chair of the AAFP Commission on Health of the Public and Science.
"The AAFP will make an official decision about endorsement within the next few months after review of the guideline using our rigorous endorsement methodology."
That said, Brown added, "On initial review, there seem to be substantial improvements in the approach of the guideline panel, in accordance with the Institute of Medicine's 2011 recommendations on how to write 'Clinical Guidelines We Can Trust.'(www.iom.edu)
"Major improvements in the approach used by JNC 8 panel members include
- restricting decision-making to evidence from systematic reviews of randomized controlled trials with patient-oriented outcomes;
- providing a strength of recommendation and level of evidence for all recommendations, and, when there is limited evidence on which to base recommendations, the guideline panel clearly states recommendations are based on expert opinion;
- involving a diverse group of clinicians, including primary care physicians and experts in evidence-based medicine; and
- limiting the focus of the review to the most important questions facing physicians and their patients, as well as clearly communicating a reasonable number of recommendations."
For his part, James welcomes the scrutiny.
"My belief is that this is going to cause a significant debate, and my impression is that groups like the Academy are going to engage in that debate about what is the best way to develop guidelines; how can we be sure that we don't wind up with guidelines that are just focused and run by one specialty organization; and how can we be sure that we have the right people developing these who we respect and who are really looking out for the best interests of our patients."
JAMA Editorial: "Assessing the Trustworthiness of the Guideline for Management of High Blood Pressure in Adults"(jama.jamanetwork.com)
(Dec. 18, 2013)