Updated Hypertension Guidelines

Cardiopulmonary Exercise Testing (CPX)
12 September, 2016
Dr. Christian Gmelin – Nuevo Internista en la Clínica Picasso
Dr. med. Christian Gmelin – New Specialist in Internal Medicine at Clínica Picasso
4 August, 2017

Updated Hypertension Guidelines

65% of US adults aged 60 years and older have hypertension, and only about half (52.5%) have controlled blood pressure levels (defined as less than 140/90 mm Hg). “Over 15% of persons with hypertension are unaware of their condition.

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have released a joint practice guideline on systolic blood pressure targets for people aged 60 years and older with hypertension.

The guidance calls for physicians to start treatment for patients who have persistent systolic blood pressure at or above 150 mmHg to achieve a target of less than 150 mmHg to reduce risk for stroke, cardiac events, and death. The recommendation was rated strong, with high-quality evidence.

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, APS´s President Nitin said in a new release.

However, in some cases, a lower systolic target should be considered, according to the guidelines (systolic BP < 140mmHg).

If patients have a history of stroke or transient ischemic attack or have high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve systolic blood pressure of less than 140 mm Hg to reduce risk for stroke and cardiac events. The authors note, however, that this recommendation was rated weak, with moderate-quality evidence.

High cardiovascular risk generally includes patients with diabetes, vascular disease, metabolic syndrome, or chronic kidney disease, as well as older adults.

Lower Targets Also Have Risks In a supporting evidence review doctors warn that the benefits of a lower threshold (less than 140/90) should be weighed against risk. Tighter control may prevent, on average, roughly 10 to 20 events for every 1000 high-risk patients treated over 5 years across a population. But the trade-off may be higher costs and greater risk for hypotension and fainting. On the other hand, it seem that lower targets are unlikely to increase the risk for dementia, fractures, and falls or reduce quality of life. There are 2 big trials which compared benefit of a systolic target of less than 120 mmHg vs less than 140 mmHg and found substantial reductions in cardiac events and deaths with tighter control. One showed a benifit with a reduction of mortality and cardiac events (SPRINT STUDY) and the other study (ACCORD) did not confirm any benefit.

So finally we may accept also blood pressures up to 150mmHg in low risk patients. The guidelines also mention “white coat“ syndrome, which can skew blood pressure readings. Before changing any treatment plan physicians should ensure that they are getting the most accurate numbers over time.

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