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Hypertension Guidelines Consensus Statement

Darrell Hulisz, RPh, PharmD
Eric Eisenmann

April 1, 2017

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have collaborated to release updated hypertension practice guidelines. These guidelines specifically address systolic blood pressure targets for patients aged 60 years and older. The full guidelines were published online January 17th in the Annals of Internal Medicine. A similar guideline summary is published in the March/April issue of the Annals of Family Medicine.

ACP and AAFP's updated guidelines suggest targeting a systolic blood pressure less than 150 mmHg in patients aged 60 years and older to reduce risk for stroke, adverse cardiac events and death. The authors present this as a strong recommendation with high-quality evidence. This recommendation is consistent with the hypertension treatment guidelines from the Eighth Joint National Committee (JNC 8). However, the ACP and AAFP's guidelines make a novel recommendation to target a lower systolic blood pressure of 140 mmHg in a select group of patients aged 60 and older. Select patients include those with a history of stroke, transient ischemic attack (weak recommendation with moderate-quality evidence), or those patients that have high cardiovascular risk (weak recommendation with weak-quality evidence). The ACP and AAFP also present several clinical considerations as a part of their review. One of these clinical considerations is to favor the prescription of generic drugs, which they suggest will improve medication access for patients. The ACP and AAFP also recommend verifying clinical blood pressure readings are accurate. Because blood pressure readings may be falsely elevated in the clinic setting, the ACP and AAFP recommend multiple, ambulatory measurements as the most accurate method of assessing patients' blood pressures.

Hypertension, or high blood pressure, affects roughly 30% of adults and 70% of adults over the age of 65 worldwide. Risk factors for developing hypertension include older age, family history, obesity, physical inactivity, tobacco use and drinking too much alcohol (2 drinks/day for men and one drink/day for women). The JNC 8 recommends a target systolic blood pressure <150 mmHg and diastolic blood pressure <90 mmHg in patients aged 60 and older without chronic kidney disease or diabetes. These guidelines recommend targeting a systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg in all other adult patients. Untreated, hypertension can lead to coronary artery disease, heart failure, ischemic and hemorrhagic stroke, chronic kidney disease and hypertensive emergencies such as hypertensive encephalopathy. Treated for hypertension too aggressively, patients may experience hypotension, or low blood pressure, which can lead to syncope and falls. Since the release of the JNC 8 guidelines, studies have sought to determine if more aggressive hypertension management could be more beneficial to patient outcomes and outweigh the risks of aggressive therapy.

The Systolic Blood Pressure Intervention Trial (SPRINT) is an example of one of these studies; the SPRINT trial compared intensive blood pressure management (<120/80) versus standard therapy.4 Enrolled patients had a baseline systolic blood pressure of 130 mmHg or higher with an increased cardiovascular risk, but without diabetes. This trial found tighter blood pressure control resulted in a lower risk of myocardial infarction, other acute coronary syndromes, stroke, heart failure, death from cardiovascular causes and all-cause mortality. However, this trial also found tighter blood pressure control resulted in increased rates of serious adverse events including hypotension, syncope, and acute kidney injury. Published in June 2007, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial interestingly did not find the same significant benefits of more intensive blood pressure management in patients with diabetes.5 These trials are among the studies reviewed by the updated ACP and AAFP evidence-based guidelines.

A recent meta-analysis stresses the importance of weighing the benefits against the risks of lowing blood pressure targets in elderly patient populations. A target blood pressure of 140/90 was shown to lead to increased risk of hypotension and syncope. However, these authors did not see an increased risk for dementia, falls, or fractures in patients with tighter blood pressure control.

Overall, the updated guidelines from the ACP and AAFP do not radically alter existing blood pressure management or goals. Systolic blood pressure management to less than 150 mmHg in patients aged 60 and under has been shown to decrease the rate of cardiovascular complications, and was already the recommendation of JNC 8. The ACP and AAFP uniquely suggest there is a small benefit of more intensive management at a systolic blood pressure target of 140 mmHg in a select group of patients aged 60 and older with elevated cardiovascular risk. Similarly, JNC 8 had already recommended this stricter goal in patients aged 60 or older with chronic kidney disease or diabetes. Thus, it is important to assess the benefits of intensive therapy against the risks in each patient treated for hypertension. More intense therapy may lead to hypotension and syncope, which could be particularly problematic in some patients aged 60 and older.