Evidence-based Hypertension Guideline Garners AAFP Endorsement

September 10, 2014 09:15 am Chris Crawford

The AAFP has endorsed a new hypertension guideline(jama.jamanetwork.com) from panel members appointed to the Eighth Joint National Committee (JNC 8) that addresses initiating and modifying pharmacotherapy for patients with elevated blood pressure (BP). First published online last December by JAMA: The Journal of the American Medical Association, the guidelines outlined nine specific treatment recommendations.

[Doctor taking patient's blood pressure]

Lead author and family physician Paul James, M.D., of Iowa City, Iowa, thoroughly explained the recommendations to AAFP News in a Dec. 18 story, noting that members of the guideline panel, appointed by the National Heart, Lung and Blood Institute (NHLBI) in 2008, focused on answering three questions:

  • 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?

In a recent interview, James clarified that he considered these questions to be "the three most important questions that doctors in America consider" for hypertension because they help family physicians best assist patients in effectively managing their high BP, and, therefore, avoiding premature death from cardiovascular disease.

Story highlights
  • The AAFP has endorsed an evidence-based guideline outlining nine recommendations for initiating and modifying pharmacotherapy for adult patients with elevated blood pressure (BP).
  • In general, patients ages 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.

"(These questions) also help physicians identify who is most likely to benefit from the treatments they prescribe, what medications have the most evidence to support their use and what goal blood pressure should we be striving for with our patients," he noted.

Guideline Overview

An external methodology team reviewed and summarized the evidence, focusing on studies that examined adults ages 18 or older with hypertension, including studies that involved numerous prespecified subgroups, such as patients with diabetes, coronary artery disease, or chronic kidney disease (CKD). Studies that involved older adults and those with other demographic or risk factors also were included.

Randomized controlled trials (RCTs) involving at least 100 subjects were considered "the gold standard for determining efficacy and effectiveness," according to the authors.

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.

James said the recommendations for goal blood pressures in younger patients are an example where expert opinion was used in the absence of RCT data to inform recommendations.

"While we have strong evidence to recommend goal blood pressures be less than 90 mmHg for those older than age 30, there are simply no studies in those younger than 30 that met our criteria," he said. "Similarly, there are no RCTs that met our review criteria for systolic blood pressure goals in those patients less than age 60. In these instances, the panel deliberated on how best to provide clinical recommendations to physicians in the absence of data by generalizing from other age groups."

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, and patients should be treated to a goal SBP lower than 150 mmHg and a goal DBP lower than 90 mmHg.
  • In the general population younger than 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 patients 18 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), 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 patients 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 recommendation applies 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 concurrently. 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.

Additional Resources
JAMA Editorial: "Assessing the Trustworthiness of the Guideline for Management for High Blood Pressure in Adults(jama.jamanetwork.com)
(Dec. 18, 2013)

JAMA Editorial: "Recommendations for Treating Hypertension: What Are the Right Goals and Purposes?"(jama.jamanetwork.com)
(Dec. 18, 2013)

JAMA Editorial: "Updated Guidelines for Management of High Blood Pressure: Recommendations, Review, and Responsibility"(jama.jamanetwork.com)
(Dec. 18, 2013)


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