Hypertension is one of the most common chronic diseases in the United States, affecting about 65 percent of adults 60 and older and 29 percent of all adults in the country, according to recent CDC data(www.cdc.gov).
To help physicians better manage this far-reaching medical issue, the AAFP and the American College of Physicians (ACP) collaborated to develop an evidence-based clinical practice guideline on appropriate systolic blood pressure (SBP) targets for patients 60 and older who have hypertension. That guideline posted online Jan. 17 in Annals of Internal Medicine(annals.org).
Chief among the joint guideline's recommendations: The AAFP and ACP recommend that physicians initiate treatment in patients 60 and older who have persistent SBP at or above 150 mm Hg to achieve a target SBP of less than 150 mm Hg and so reduce the risk of mortality, stroke and cardiac events. This was designated a strong recommendation based on high-quality evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method(www.gradeworkinggroup.org).
Noting that, "The most consistent and greatest absolute benefit was shown in trials with a higher mean SBP at baseline (greater than 160 mm Hg)," the guideline specifically backed treating hypertension in older adults to moderate targets (i.e., below 150/90 mm Hg) to reduce mortality and cardiovascular risks.
- In a new joint guideline, the AAFP and American College of Physicians recommend that physicians initiate treatment in patients 60 and older who have persistent systolic blood pressure (SBP) at or above 150 mm Hg to achieve a target SBP of less than 150 mm Hg to reduce the risk of mortality, stroke and cardiac events.
- The AAFP and ACP also recommend that physicians consider initiating or intensifying drug therapy in older patients with a history of stroke or transient ischemic attack to achieve a target SBP of less than 140 mm Hg to reduce the risk of recurrent stroke.
- Finally, the groups recommend that physicians consider starting or intensifying drug treatment in some adults 60 and older at high cardiovascular risk to achieve a target SBP of less than 140 mm Hg to reduce the risk of stroke or cardiac events.
"The evidence showed that any additional benefit from aggressive blood pressure control is small, with a lower magnitude of benefit and inconsistent results across outcomes," said ACP President Nitin Damle, M.D., M.S., in a news release.
The guideline was based on a systematic review of published randomized controlled trials for primary outcomes and observational studies for harms only through January 2015 and was subsequently updated with a MEDLINE search through September 2016.
Evaluated outcomes included all-cause mortality, morbidity and mortality related to stroke, major cardiac events, (fatal and nonfatal myocardial infarction and sudden cardiac death) and harms.
The two groups made no diastolic blood pressure target recommendations because the evidence to do so was insufficient.
Other Guideline Recommendations
The guideline included two additional recommendations based on lower-quality evidence; both were graded as weak.
First, the AAFP and ACP recommend that physicians consider initiating or intensifying drug therapy in patients 60 and older who have a history of stroke or transient ischemic attack (TIA) to achieve a target SBP of less than 140 mm Hg to reduce the risk of recurrent stroke.
Moderate-quality evidence supported treating hypertension in patients with previous TIA or stroke to a target SBP of 130 mm Hg to 140 mm Hg compared with treatment to higher targets, with no statistically significant effect on cardiac events or all-cause mortality.
Second, the AAFP and ACP recommend that physicians consider starting or intensifying pharmacologic treatment in some patients 60 and older who are at high cardiovascular risk, based on individualized assessment, to achieve a target SBP of less than 140 mm Hg to reduce the risk of stroke or cardiac events.
According to the two organizations, patients with increased cardiovascular risk include
- those with known vascular disease,
- most patients with diabetes,
- older patients with chronic kidney disease who have an estimated glomerular filtration rate less than 45 mL/min/1.73 m2,
- patients with metabolic syndrome, and
- older patients in general.
"An SBP target of less than 140 mm Hg is a reasonable goal for some patients with increased cardiovascular risk. The target depends on many factors unique to each patient, including comorbidity, medication burden, risk for adverse events and cost," the guideline noted.
Recommended Therapeutic Options
Pharmacologic options to lower SBP include a number of antihypertensive medications. A list of these agents and their respective potential adverse effects follows:
- thiazide-type diuretics (possible adverse effects include electrolyte disturbances, gastrointestinal discomfort, rashes and other allergic reactions, sexual dysfunction in men, photosensitivity reactions, and orthostatic hypotension);
- ACE inhibitors (adverse effects include cough and hyperkalemia);
- angiotensin II receptor blockers (adverse effects include dizziness, cough and hyperkalemia);
- calcium-channel blockers (adverse effects include dizziness, headache, edema and constipation); and
- beta blockers (adverse effects include fatigue and sexual dysfunction).
Additionally, the joint guideline encouraged physicians to consider generic formulations rather than brand-name drugs when prescribing drug therapy because generics offer similar efficacy, reduced cost and often, therefore, better adherence.
And although this guideline didn't specifically address pharmacologic versus nonpharmacologic treatments for hypertension, several nonpharmacologic strategies can be considered. Effective options for reducing blood pressure include lifestyle modifications such as weight loss, dietary changes such as the DASH (Dietary Approaches to Stop Hypertension) diet and increased physical activity.
"Nonpharmacologic options are typically associated with fewer side effects than pharmacologic therapies and have other positive effects; ideally, they are included as the first therapy or used concurrently with drug therapy for most patients with hypertension," the guideline stated.
It's worth noting that most of the studies included in the systematic review measured seated blood pressure after five minutes of rest and used multiple readings.
Furthermore, the guideline pointed out that some patients may have falsely elevated blood pressure readings in clinical settings, known as "white coat hypertension." Therefore, it's key that physicians ensure they're accurately measuring blood pressure before initiating or modifying treatment for hypertension.
"The most accurate measurements come from multiple blood pressure measurements made over time," said AAFP President John Meigs, M.D., of Centreville, Ala., in the release. "These may include multiple measurements in clinical settings or ambulatory or home monitoring."
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