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ACP, AAFP recommend ‘less aggressive’ systolic BP target for older patients with hypertension
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The ACP and American Academy of Family Physicians jointly released an evidence-based clinical guideline on the appropriate systolic BP target for adults aged 60 years and older for the treatment of hypertension, recommending that a less aggressive treatment target may be optimal for otherwise healthy patients.
“Hypertension … is a very common chronic disease in the United States,” Amir Qaseem, MD, PhD, MHA, of the ACP, and colleagues wrote. “The overall prevalence of hypertension among U.S. adults is 29%, and it increases to 64.9% in adults aged 60 years or older.”
“Appropriate management of hypertension reduces the risk for cardiovascular disease, renal disease, cerebrovascular disease and death. However, determining the most appropriate BP targets, particularly for adults aged 60 years or older, has been controversial,” they added.
The guideline, published in Annals of Internal Medicine, is based on a systematic review of 21 randomized, controlled trials and three observational studies that evaluated the benefits and harms of higher vs. lower BP goals for the treatment of hypertension in older adults. The included trials and studies also assessed outcomes including all-cause mortality, morbidity and mortality related to stroke, harms and major cardiac events such as fatal and nonfatal myocardial infarction and sudden cardiac death. The ACP and American Academy of Family Physicians (AAFP) made three essential recommendations for adults aged 60 years or older:
- Initiate treatment in older patients with persistent systolic BP at or above 150 mm Hg to lessen the risk for mortality, stroke and cardiac events (high-quality evidence);
- Consider initiating or intensifying pharmacologic treatment in older patients with a history of stroke or transient ischemic attack to reach a target systolic BP of less than 140 mm Hg to lessen the risk of recurrent stroke (moderate-quality evidence); and
- Consider initiating or intensifying pharmacologic treatment in some older patients at high cardiovascular risk to reach a target systolic BP of less than 140 mm Hg to lessen the risk for stroke or cardiac events (low-quality evidence).
“The evidence showed that any additional benefit from aggressive [BP] control is small, with a lower magnitude of benefit and inconsistent results across outcomes,” Nitin S. Damle, MD, MS, MACP, president of ACP, said in a news release. “Most benefits of targeting of less than 150 mm Hg apply to individuals regardless of whether or not they have diabetes.”
The organizations noted that “white coat hypertension” or falsely elevated readings in clinical settings may occur in some patients; subsequently, physicians must ensure that they are accurately measuring BP before initiating or changing treatment for hypertension.
“The most accurate measurements come from multiple [BP] measurements made over time,” John Meigs, Jr., MD, president of AAFP, said in the release. “These may include multiple measurements in clinical settings or ambulatory or home-monitoring.”
The ACP and AAFP advised that physicians select treatment goals based on a periodic discussion of the benefits and harms of specific BP targets with the patient. They also recommended that physicians select generic formulations over brand name drugs with similar efficacy, yet lower costs when prescribing drug therapy due to better adherence rates.
Recommendations for diastolic BP targets were not made by the ACP and AAFP due to insufficient evidence. – by Alaina Tedesco
Disclosure: Qaseem and colleagues report support from the ACP operating budget. The researchers report primary funding from the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research Development and Quality Enhancement Research Initiative.
Perspective
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Michael A. Weber, MD
I think the intent of the guideline was to chiefly influence primary care physicians – people practicing family medicine or internal medicine. I don’t think these recommendations were targeted at specialists, though they will be looked at by a wide audience.
I suspect the general reaction to these guidelines will be somewhat skeptical. This guideline basically regurgitates what was recommended by the panel convened for the Eighth Joint National Committee (JNC 8). By now, most experts in hypertension feel those recommendations were of questionable validity. It seems as though the people who wrote the new guideline depended on the same evidence and wrote a recommendation almost identical to the JNC 8 panelists, which is that in people over age 60 years, a baseline systolic BP of > 150 mm Hg should be treated to a level of < 150 mm Hg. They say this is based on high-quality evidence, but those trials were not designed for this purpose, particularly SHEP and Syst-Eur. Those two trials were landmark studies showing the benefit of treatment in people over age 60 years, but they were not designed to answer the questions of what is the optimal threshold for treatment and what is the optimal target for treatment in older people. Good as those trials were, they do not provide fully relevant evidence in the context of the question being asked.
I found it surprising that the SPRINT trial, which was designed to answer the question of the optimal target for treatment for people with high BP, was not used as core evidence. The average age of patients in SPRINT was 68 years, so it definitely fit the same age group as SHEP and Syst-Eur. In addition, in SPRINT, there was a prespecified subgroup analysis of patients aged 75 years or older. SPRINT clearly concluded that aiming for a systolic BP target of < 120 mm Hg gave superior results in terms of mortality and CV outcomes compared with a target of < 140 mm Hg. This guideline acknowledges the existence of SPRINT, so why did it largely ignore it? The guideline authors even acknowledge that patients in SPRINT aged 75 years or older had a significant reduction in mortality and CV endpoints if their systolic BP target was < 120 mm Hg (mean achieved systolic BP, 122 mm Hg). As far as I’m concerned, when there is evidence of a powerful mortality benefit and a powerful CV benefit, we should be perfectly willing to accept some level of adverse events as the cost of these very powerful benefits. As it happened, adverse events in SPRINT were relatively modest in the aggressively treated group compared with the standard-therapy group. There was some increase in symptomatic hypotension, faintness and dizziness and some adverse renal outcomes, but the absolute incidence of those events was far less than that of the powerful benefits.
An issue with SPRINT, also mentioned in the guideline, was the use of an unusual method for measuring BP: A BP cuff was attached to a patient in a quiet room and all clinical personnel then left the room. After a 5-minute rest period, the cuff automatically inflated and took three readings at 1-minute intervals. The readings were automatically averaged to become the official reading. That may be an interesting approach to BP management, but it gives a reading lower than the usual office BP, even when the office BP is measured carefully. How much is that difference? My interpretation is that the SPRINT values are 5 mm Hg to 10 mm Hg lower than a well-measured office reading. For the older subpopulation in SPRINT who achieved a target of 122 mm Hg, that translates to about 130 mm Hg if measured conventionally. Many others have come to similar conclusions. The authors of the present guideline state the difference is 10 mm Hg to 15 mm Hg, which translates to about 135 mm Hg, which suggests a target of < 140 mm Hg. Either way, the finding from SPRINT suggests a target of 130 mm Hg or possibly a bit higher, but not the < 150 mm Hg target recommended by ACP/AAFP. In fairness, the ACP/AAFP authors did state that for people with stroke, transient ischemic attack or other compelling CV history, it may be reasonable to target < 140 mm Hg rather than < 150 mm Hg. The problem with that is that in SPRINT, the mere fact of being 75 or older was itself considered enough of a risk factor for inclusion in the trial. So if one is being a purist, it can be argued that for those aged 75 or older, we should target around 130 mm Hg and be happy with achieving a systolic BP in the 130s. So I would not be comfortable requiring that patients must have some documented CV history to allow a target of < 140 mm Hg. I think < 140 mm Hg, specifically getting down toward 130 mm Hg, should be the rule for everybody over age 60. Of course, if a patient cannot tolerate BP being lowered into that range, then it’s necessary to back off and get the BP down as low as the patient is comfortable with.
The authors also cite ACCORD, which asked the same question as SPRINT except that it only studied patients with diabetes, and did not show a benefit of a target of < 120 mm Hg vs. a target of 140 mm Hg. We must take into account, however, that there is a difference between patients who have diabetes and those who don’t, and many trials have shown that. Just because ACCORD and SPRINT had different results doesn’t mean that one or both are wrong. It means they studied different patient populations: diabetic and non-diabetic. It’s not an inconsistency. I agree that for patients with diabetes, a systolic BP target of < 140 mm Hg is just fine. I would not want to push patients with diabetes to lower levels, because that is possibly associated with a J-curve effect for CV events.
Despite its blemishes, the evidence from SPRINT is very compelling. It was designed exactly for the purpose of establishing BP target levels, and represents a high level of evidence.
Therefore, there should be caution in considering these ACP/AAFP recommendations.
I don’t expect this guideline to influence the upcoming American College of Cardiology/American Heart Association hypertension guideline. The ACC/AHA authors are using their own rigorous methods and considering all available and relevant data. I expect that these forthcoming recommendations will differ from those of JNC 8 and ACP/AAFP.
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