November 14, 2017

Nearly 50% of US adults have high blood pressure under new guidelines: What you need to know

Daily Briefing

    Read Advisory Board's take on this story.

    The American Heart Association (AHA) and the American College of Cardiology (ACC) on Monday released guidelines that lower the threshold for high blood pressure from 140/90 mm Hg to 130/80 mm Hg, the first change to the hypertension threshold in 14 years.

    Under the new guidelines, 45.6% of U.S. residents—or roughly 103.3 million individuals—have high blood pressure, according to the guideline authors. Under the old guidelines, about 31.9% of U.S. residents—or 72 million people—had high blood pressure.

    Nine medical groups endorsed the new guidelines:

    • American Academy of Physician Assistants;
    • American College of Preventive Medicine;
    • American Geriatrics Society;
    • American Pharmacists Association;
    • American Society of Hypertension;
    • American Society of Preventive Cardiology;
    • Association of Black Cardiologists;
    • National Medical Association; and
    • Preventive Cardiovascular Nurses Association.

    Methodology

    The data to support the new guidelines come largely from the Systolic Blood Pressure Intervention Trial (SPRINT), a National Heart, Lung and Blood Institute-sponsored study of more than 9,300 individuals over age 50 who were at high risk of heart disease. Individuals in the study were assigned to lower their systolic blood pressure (SBP)—the top number on the reading, which refers to the pressure on blood vessels when the heart contracts—to either less than 120 mm Hg or less than 140 mm Hg.

    The trial found incidence of heart attack, failure, and stroke fell by one-third and death fell by almost one-quarter among those who sought to get their SBP to 120 mm Hg. Richard Chazal, the former president of ACC, said further study has shown the benefit appears to apply to younger individuals, too. However, the SPRINT study also found that while heart health improved when participants got their SBP below 120 mm Hg, their risk of kidney disease was nearly twice as high.

    New guidelines for blood pressure classification

    The guidelines eliminate a category called "pre-hypertension" that classified SBP between 120 mm Hg and 139 mm Hg and diastolic blood pressure (DBP)—the lower number on the reading, which refers to the pressure on blood vessels when the heart relaxes—between 80 mm Hg and 89 mm Hg.

    Under the new guidelines, an individual's blood pressure is considered:

    • Normal if SBP is less than 120 mm Hg and DBP is less than 80 mm Hg;
    • Elevated if SBP is between 120-129 mm Hg and DBP is less than 80 mm Hg;
    • Hypertensive (stage 1) if SBP is between 130-139 mm Hg or DBP is 80-89 mm Hg;
    • Hypertensive (stage 2) if SBP is 140 mm Hg or higher or DBP is 90 mm Hg or higher.

    The new guidelines state that individuals whose SBP and DBP readings are in different categories "should be designated to the higher ... category."

    Guidelines for treatment

    In terms of treatment, the authors recommended that individuals with:

    • Elevated blood pressure address it through lifestyle changes—such as improving their diet, exercising more, losing weight, drinking less alcohol, reducing sodium intake, and lowering stress;
    • Stage 1 hypertension address it through lifestyle changes, unless they are found to have a 10% or higher 10-year risk of cardiovascular disease based on an ACC/AHA calculator or other complicating factors, in which case medication should be used; and
    • Stage 2 hypertension address it with medication, regardless of 10-year risk status.

    According to the authors, the updated guidelines are intended to encourage people to begin managing their blood pressure sooner, before complications occur. The authors explained that many of those affected by the change are younger, noting that prevalence of high blood pressure is projected to increase threefold among men under age 45 and double among women under age 45.

    However, Robert Carey, a professor of medicine at the University of Virginia School of Medicine and co-chair of the group that produced the new report, said while the overall number of people with hypertension increases significantly under the new guidelines, the overall number of people considered new candidates for medication likely will increase by a small amount—an estimated 4.2 million. Instead of medication, the authors said they hoped that many individuals with early-stage hypertension can manage their condition through lifestyle changes, "To Your Health" reports.

    According to Chazal, "An important cornerstone of these new guidelines is a strong emphasis on lifestyle changes as the first line of therapy." He added, "There is an opportunity to reduce risk without necessarily imposing medications."

    Separately, Carey said, "We're recognizing that blood pressures that we in the past thought were normal or so-called pre-hypertensive actually placed the patient at significant risk for heart disease and death and disability." He added. "The risk hasn't changed. What's changed is our recognition of the risk."

    Implementation

    The Wall Street Journal reports that implementing the new guidelines may prove challenging, as government data show that almost half of U.S. residents with high blood pressure under the old criteria were unable to get it below 140/90 mm Hg.

    The authors recommended a team-based approach to care and use of technology, such as telehealth, to track blood pressure. Carey said, "We don't necessarily need the involvement of the physician every time."

    Meanwhile, the American College of Physicians and American Academy of Family Physicians (AAFP) earlier this year set 150 as the target SBP number for individuals 60 and older with hypertension who are otherwise healthy. For older adults with risk of cardiovascular complications, they recommended SBP under 140. According to the Journal, it was unclear whether the organizations would update their recommendation to account for the new guidance.

    Ada Stewart, a family physician and AAFP board member, said, "We will review [the guidelines] in detail" and determine whether changes are in order.

    Reaction

    Donald Lloyd-Jones of Northwestern University said he thinks the guidelines mark a paradigm shift in blood pressure treatment in this country.

    At the same time, Suzanne Oparil, who was a reviewer for the new guidelines, said it might prove difficult for physicians to change practice quickly. "There's not enough emphasis placed on hypertension," she said. "People will settle on any old number you get any old way, and that's not appropriate."

    Meanwhile, William Cushman, a key investigator in SPRINT, said he "agree[s] with most of [the] recommendations." However, he added, "I do think more emphasis could be made that the <130/80 mm Hg goal is reasonable, but SBP <120 mm Hg may be more appropriate if BP is taken properly with an automated manometer (not with how BPs are often measured in practice)."

    Separately, former CDC director Tom Frieden, said the "big news about this guideline is it should end forever any debate about whether people should be treated with medicines once they hit 140/90." He added that until now, there has been "a perspective that it's not that big of a risk, but that's just wrong."

    Frieden continued, "The fact is lower is better. Even what we considered mild hypertension before is a deadly disease"  (Bernsgtein/Cha, "To Your Health," Washington Post, 11/13; Phend, MedPage Today, 11/13; McKay, Wall Street Journal, 11/13; AHA/ACC guidelines executive summary, 11/13; Kolata, New York Times, 11/13; Beasley, Reuters, 11/13).

    Advisory Board's take

    Megan Tooley and Aaron Mauck, Cardiovascular Roundtable

    The new blood pressure guidelines will add greater urgency to prevention and early intervention efforts, hopefully paving the way for new disease management approaches to encourage lifestyle changes in individuals who otherwise appear healthy. The guidelines will also help convince some providers of the importance of managing hypertension in the case of mild elevations in younger adults, whose blood pressure is often overlooked.

    However, the guidelines will not fully eliminate debates over when treatment should begin or what the ideal approach to treatment will entail. Some providers will continue to question whether treatment at a blood pressure reading of 130 over 80 is necessary or feasible, despite evidence suggesting that even minor elevations pose a significant risk. Effective blood pressure control presents significant disease management challenges, often requiring careful regulation of medication coupled with lifestyle changes. These challenges have been difficult to overcome in the past, and the expansion of the at-risk category will only mean many more patients to manage.

    Nevertheless, the new guidelines underscore a growing emphasis on prevention as the cornerstone of effective cardiovascular care. They double-down on an emerging population health perspective that takes into account numerous risk factors in its approach to patient identification and treatment. In order to treat such a large patient population effectively, health systems must hardwire strategies to promote enduring lifestyle changes to reduce long-term risk.

    To learn more about care management best practices, download our research report, “Blueprint for Cardiovascular Care Management.”

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    To learn more about how managers can help frontline clinicians tap into patients' motivation to change, download our toolkit, “Motivational Interviewing 101.”

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