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Experts debate implications of relaxed BP target for high-risk patients
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When the panel convened for the Eighth Joint National Committee issued a recommendation that the systolic BP target for adults aged 60 years and older without diabetes or kidney disease be relaxed from 140 mm Hg to 150 mm Hg, it set off a firestorm of debate that continues today.
Based on their interpretation of evidence from randomized controlled trials, a majority of the panel concluded that there was no evidence of additional clinical benefit to support a systolic BP target <150 mm Hg in that older population. However, five members appointed to the panel disagreed and published a paper explaining their views. At about the same time, the American College of Cardiology and American Heart Association declined to endorse the recommendation for this new goal.
Now, a new review published in the Journal of the American College of Cardiology discusses implications of the new BP target for high-risk groups, including black adults, women and the elderly. Cardiology Today asked its Editorial Board and other experts for their perspective on the relaxed goal in high-risk populations.
Elijah Saunders, MD, FACC, FACP, FAHA, FASH; Cardiology Today Editorial Board
I do not agree with the new recommendation to change the systolic BP target in certain populations. The JNC 8 panel came up with this recommendation of 150/90 mm Hg through evidence-based data because of the lack of studies supporting 140/90 mm Hg. However, we didn’t get to the 140/90 mm Hg target originally because of those kinds of studies; rather, it was based on observations from actuarial societies and insurance companies. These data documented a fairly sharp increase in mortality, mostly from CVD, at 140/90 mm Hg. When we started doing clinical trials, and in our offices, we began to use the goal of <140/90 mm Hg.
Elijah
Saunders
One reason to stay with 140/90 mm Hg is that we have done well with it. Hypertension is the main cause for stroke, and the rates of stroke incidence, morbidity and mortality have gone down. I think you have to attribute that to BP control. It is hard to find studies to support that, so you have to go by observation, meta-analyses and other evidence that doesn’t come from randomized controlled trials (RCTs). Another reason is, given that many patients do not reach 140/90 mm Hg, if we went to a goal of 150/90 mm Hg, many doctors will start to accept 155 to 160 mm Hg systolic/95 to 100 mm Hg diastolic, just like they accept 145/95 mm Hg or 148/92 mm Hg as being OK today, especially with patients whose BP is difficult to control.
Hypertension is one of the risk factors we have a handle on. There are effective therapies that can control and reduce the burden of hypertension. Does it make sense to relax on one of the risk factors for which treatments have been proven to be beneficial in the people at highest risk: older people, women, African Americans and people with concomitant diseases? It is ill-advised to reduce a goal for the populations that need it most.
Amy L. Woodruff, MD, FACC; Texas Heart Institute
Amy L.
Woodruff
Lack of evidence of benefit is not absence of benefit. The 2014 recommendations will put women at a differentially higher risk, as most hypertensive adults aged 60 years and older are women, which the JNC 8 panel does not recognize in its recommendations. In addition, the traditional systolic BP goal of <140 mm Hg can potentially provide greater public health protection against CVD, the leading cause of death among women in the United States, with little evidence of major harm. Also, hypertension is a significantly stronger risk factor for HF among women in comparison with men, so this more relaxed recommendation puts women at greater risk for HF.
I recommend that older women be treated to the traditional systolic BP goal of <140 mm Hg. However, clinical judgment is still the integral part in the treatment of hypertension. A systolic BP goal of <150 mm Hg for frail patients could be beneficial and would be a reasonable alternative to the blanket recommendation of relaxing the goal for the general population aged 60 years and older.
Paul L. Douglass, MD, FACC, FSCAI; Cardiology Today Editorial Board
The report from the panel members appointed to the JNC 8 cites a lack of compelling evidence supporting the previous goal recommendation. However, it offers little evidence to support raising the current goal to the new goal of 150/90 mm Hg for individuals aged older than 60 years. There is very little debate that the development of age-related elevations in BP has a linear, consistent, and continuous correlation to increasing CV risk over time.
Despite the overwhelming data supporting BP lowering to reduce CV risk, the exact level of reduction is not well established. Nevertheless, previous guidelines have resulted in a significant decrease in hypertension-related morbidity and mortality. However, vulnerable segments of the population (women, African Americans, elderly) have not benefited to the same degree. The Association of Black Cardiologists has advocated for an even lower BP goal to 130/85 mm Hg, because of the greater prevalence and burden of CVD in African-American adults.
Paul L.
Douglass
I am concerned that liberalization of BP treatment goals would result in negative, unintended and adverse consequences if adapted by health care providers. It would seem prudent to await the guidelines that are forthcoming from the ACC/AHA and other societies before discarding a strategy that is evidence-based and successful. A clearer answer lies in the completion of two RCTs: SPRINT and ESH-CHL-SHOT. These trials offer the hope of a more definitive identification of optimal BP treatment goals. Until then, clinical judgment and experience, along with maintenance of the 140/90 mm Hg treatment goal for most patients, excluding the frail and those aged older than 80 years, may be the most prudent course of action.
My grandmother suffered a stroke after years of untreated hypertension. She died 6 months later. The recommendation to raise the treatment goal for patients older than 60 years, despite clinical outcomes data to the contrary, will place many at additional CV risk. My grandmother in her aggregate characteristics (elderly black woman) represented our most vulnerable, who have a disproportionate burden of disability and death that is often translated through elevated BP and who require our most ardent vigilance. Maintaining the current treatment goal of 140/90 mm Hg may enable us to save more grandmothers.
Nieca Goldberg, MD; NYU Langone Medical Center
Nieca
Goldberg
The 2014 hypertension recommendations from members of the disbanded JNC 8 panel are troubling to me as a cardiologist who focuses on preventing CV risk in women. Given the increased morbidity and mortality associated with uncontrolled hypertension in women and older adults, my practice will continue to follow the current guidelines of systolic BP 140 mm Hg. Treatment should be based on the individual patient, with emphasis on lifestyle changes and medical therapy where indicated.
Future guidelines should address the benefits and risks in treatment for hypertension with respect to racial and gender disparities. It was unreasonable for the panel to suggest the recommendations should equally apply to all 60-year-olds.
Disclosures: Saunders reports speaking for Arbor Pharmaceuticals, Forest Pharmaceuticals, Novartis and Takeda. Douglass, Goldberg and Woodruff report no relevant financial disclosures.