Dec. 15, 2022, 1:40 p.m. News Staff — The AAFP, following a review of several randomized, controlled trials, has published a new clinical practice guideline on appropriate blood pressure treatment targets for adults with hypertension. The guideline applies to individuals with hypertension (with or without cardiovascular disease), and focuses on target blood pressure levels rather than specific treatments.
Based on its review, the AAFP strongly recommends that clinicians treat adults who have hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause and cardiovascular mortality. The AAFP also recommends that clinicians consider treating adults who have hypertension to a blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction, based on evidence showing a small additional benefit with this lower target.
The guideline is the signature piece of the Academy’s newly updated Hypertension Clinical Guidance and Practice Resources webpage, which features additional clinician resources, patient education materials and more.
“This guideline is important because there are multiple competing guidelines with different recommendations for blood pressure treatment targets,” explained Sarah Coles, M.D., an associate professor in the Department of Family, Community and Preventive Medicine at the University of Arizona College of Medicine, Phoenix, and program director at the Colorado Plateau Family and Community Medicine residency program, North County HealthCare in Flagstaff, Ariz. “The AAFP guideline provides clear, evidence-based recommendations for optimal blood pressure targets for adults with hypertension.”
Coles also served as the guideline panel chair. In addition to coauthoring the guideline, she helped develop the clinical questions, review the evidence and systematic reviews and develop recommendations.
The hypertension clinical practice guideline contains two recommendations.
First, the AAFP recommends that clinicians treat adults with hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause mortality and cardiovascular mortality. This is a strong recommendation based on high-quality evidence. While treating to a lower blood pressure target of less than 135/85 mm Hg may be considered based on patient preferences and values, the lower target does not provide additional benefit at preventing mortality.
The systematic review found no significant differences in total serious adverse events between the lower and standard target groups, but did note a significant increase in all other adverse events (such as syncope and hypotension) when treating to a lower systolic target. Overall, the lower target group had an absolute risk increase of 3% for all other serious adverse events compared with the standard target group.
Second, the AAFP recommends that clinicians consider treating adults with hypertension to a lower blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction. This is considered a weak recommendation and is based on moderate-quality evidence. Although treating to a standard blood pressure target of less than 140/90 mm Hg reduced the risk of MI, there was a small additional benefit observed with a lower blood pressure target; however, there was no observed additional benefit in preventing stroke.
Coles noted several key takeaways for FPs to consider when implementing the recommendations.
“High-quality evidence shows that treating adults with hypertension to a target blood pressure of less than 140/90 mm Hg reduces the risk of all-cause and cardiovascular mortality,” she said. “Treating a lower blood pressure target does not provide any additional benefit to mortality or stroke risk. This holds true for adults with and without preexisting cardiovascular disease.
“Treating to a target of less than 135/85 can further reduce the risk of MI by about four fewer MIs per 1,000 patients. However, treating to a lower blood pressure target does come with harms. People treated to a lower blood pressure target increased rates of adverse events, including syncope and hypotension, with a number needed to harm of 33 over 3.7 years. On average, each patient would need to take one additional medication to get to the lower target. This could increase cost, medication adverse effects and drug-drug interactions.
“Because the potential benefit is small and there are increased risks, family physicians should use shared decision-making when considering treating to a lower blood pressure goal to reduce MIs. These discussions should include a patient’s risk of MI, potential for increased harms for lower targets, costs, and patient values and preferences.”
While it is generally agreed that reducing morbidity and mortality and minimizing the risks of harms from medical intervention should be the goals of any hypertension treatment program, reaching agreement on the ideal blood pressure targets to treat hypertension has proved extremely challenging.
The Academy endorsed the Eighth Joint National Committee guidelines for hypertension management in adults in 2014, and reaffirmed it in 2019.
Independent of the JNC8 guidelines, the AAFP and the American College of Physicians in 2017 developed a joint guideline that provided evidence-based recommendations for treating hypertension in adults older than 60 years.
Also in 2017, the American Heart Association, the American College of Cardiology and nine partnering organizations released a guideline on the prevention, detection, evaluation and management of hypertension in adults, but the AAFP chose not to endorse it, opting instead to continue endorsing the JNC8 guidelines.
In the interim, the Departments of Veterans Affairs and Defense, the National Institute for Health and Care Excellence and other organizations also published guidelines on hypertension with differing blood pressure targets.
Coles said the AAFP has chosen not to endorse these guidelines due to concerns about methodological rigor, conflicts of interest and lack of consideration for harms, which has generated considerable uncertainty for family physicians and others who manage hypertension.
Based in part on these concerns, the AAFP’s Commission on Health of the Public and Science appointed a guideline development group, which analyzed the evidence from a 2020 Cochrane systematic review and conducted a target literature search of additional trials. The primary objective was to determine whether lower blood pressure targets were associated with lower morbidity and mortality compared with standard blood pressure targets.
In constructing the guideline, the development group focused on patient-centered clinical outcomes such as total mortality, cardiovascular-related mortality, cardiovascular events such as stroke and myocardial infarction, and adverse events. The group also used a modified version of the Grading of Recommendations Assessment, Development and Evaluation system to rate the quality of evidence for each outcome and the overall strength of each recommendation.
The authors and the guideline development group noted several gaps in the existing research. They called for additional studies that would, among other things,
Since all AAFP clinical practice guidelines are scheduled for review five years after completion (or earlier if new evidence is available), the authors said any new research into these and other areas will provide important information for future guidelines.
Coles noted that the AAFP endorses a number of recommendations from the U.S. Preventive Services Task Force on the topic, including those on screening for hypertension in adults and the use of healthy diet and physical activity to prevent cardiovascular disease in individuals with CVD risk factors.
Coles also highlighted several resources on familydoctor.org, such as patient-centered articles on lifestyle changes for blood pressure control, blood pressure medications and ambulatory blood pressure monitoring.
The guideline authors also advised clinicians and policymakers to consider how social determinants of health can affect patient care, leading Coles to recommend another well-known Academy resource.
“Access to safe environments to exercise, healthful foods and financial resources are important factors in blood pressure control,” she added. “I encourage everyone to use resources from The EveryONE Project to screen for social determinants of health and connect people to community resources to address other factors that may contribute to health issues.”