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Despite perceived differences, international hypertension guidelines 'mostly similar'
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BOSTON — Despite recent controversy over BP targets for adults aged 60 years and older, international guidelines for hypertension are “mostly similar,” according to a speaker at the Cardiometabolic Health Congress.
The five guidelines or scientific statements on BP released since 2011 contain similar information on the definitions of hypertension, initiation of drug therapy, target BP goals in people with and without diabetes, and the effectiveness of specific diuretics, George L. Bakris, MD, FAHA, FASN, professor of medicine and director of the University of Chicago Medicine Comprehensive Hypertension Center, said during a presentation. Compared with recommendations issued more than a decade ago, the newer guidelines no longer recommend beta-blockers as first-line therapy, with the exception of guidelines from the European Society of Hypertension and European Society of Cardiology, which recommend first-line beta-blocker therapy for patients with CVD, according to Bakris.
George L. Bakris
Perception differs from reality
The perception of discordance among the recent guidelines likely derives from a recommendation made by panel members appointed to the committee that wrote the 2014 Expert Panel Report — which would have been the Eighth Joint National Committee (JNC 8) — that target systolic BP goals for people aged 60 years and older without diabetes or chronic kidney disease should be <150 mm Hg instead of <140 mm Hg. This “caused a tremendous amount of controversy,” said Bakris, a member of the Cardiology Today Editorial Board.
Thereafter, many questioned why the authors of the 2014 Expert Panel Report chose to stratify their recommendations by patient age of older or younger than 60 years. In most studies and guidelines, “older” patients are defined as those aged at least 65 years, Bakris said.
Further complicating the issue, there are only two randomized controlled trials that looked at BP goals in elderly patients “which actually got below 140 mm Hg [systolic BP], and those trials were both negative,” Bakris said. “All the other trials … that have older populations never really got below 140 mm Hg. They were close, but not there. If you want to … stick to the tenets of evidence, [a goal of] 150 mm Hg over 90 mm Hg is defensible. Now, there are a lot of [goals] on which there are no data, so this is very restrictive, but it is true to the evidence.”
A rebuttal report published by a minority of the authors of the 2014 Expert Panel Report noted that there is evidence from prospective cohort studies that reducing systolic BP to <140 mm Hg has a benefit for patients aged older than 60 years, he said.
Targets for patients with diabetes
Another difference among the guidelines is recommended diastolic BP targets for patients with diabetes. Most guidelines recommend <90 mm Hg, but the ESH/ESC recommends <85 mm Hg and the American Diabetes Association recommends <80 mm Hg, Bakris said here. This derives from findings related to the diabetes subgroup of the Hypertension Optimal Treatment (HOT) trial, but most guideline-writing bodies prefer not to base recommendations on subgroup analyses, he said. – by Erik Swain
For more information:
Bakris GL. CVD Prevention Guidelines Update: Clinical Impact and Current Controversies. Presented at: Cardiometabolic Health Congress, Oct. 22-25, 2014; Boston.
Disclosure: Bakris reports receiving consulting fees from AbbVie, AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Janssen Pharmaceuticals, Medtronic, Oreixgen and Relypsa.