The 2017 Blood Pressure Guideline: A View from the Exam Room

Thomas Kottke, MD, MSPH, HealthPartners Institute of Education and Research; Co-investigator, ESCALATES

 

Based on knowledge acquired since the publication of Joint National Committee 7 guidelines nearly 15 years ago, a new hypertension guideline was released in early November 2017.123 As I reviewed the guideline, I asked myself, “What does it mean for my patients and what does it mean for my practice?” Since few will want to read this 283-page document, I’ve identified a few bullet points that will be most salient for clinicians and that caught my eye as an office-based cardiologist:

  • The guideline redefines high blood pressure. Instead of the old standard of above 140/90:
    • “Normal BP” is now less than 120/80
    • “Elevated BP” is 120-129 mm Hg systolic and <80 mm Hg diastolic;
    • “Stage 1 hypertension” is 130-139 mm Hg systolic and 80-89 mm Hg diastolic;
    • “Stage 2 hypertension” is ≥140 mm Hg systolic and ≥90 mm Hg diastolic.
  • With these definitions, about 45% of Americans have hypertension instead of the 1/3 with the previous definition.4
  • The guideline emphasizes the importance of accurate BP measurement by (1) using automated devices with the correct cuff size; (2) basing treatment on the average of 2-3 BP measurements on different occasions; and (3) using home or ambulatory BP measures to guide treatment recommendations.
  • The treatment goals have also changed:
    • For primary prevention, the guideline recommends using the 10-year ASCVD risk cut point of 10% to initiate pharmacologic treatment for BPs in the 130-139/80-89 range.
    • For patients with stable ischemic heart disease, most patients with diabetes or renal disease or at risk of heart failure, the treatment goal is <130/80 mm Hg.
    • For community-dwelling adults ≥65 years of age, the treatment goal is 130 systolic, but the guideline does not define a diastolic goal for these people.
  • The guideline recommends particular medications:
    • Chlorthalidone is preferred on the basis of prolonged half-life and proven trial reduction of cardiovascular disease (but don’t forget to monitor the electrolytes);
    • Initiation of drug therapy with 2 first-line agents of different classes is recommended for patients with stage 2 hypertension who have an average BP more than 20/10 mm Hg above their BP target;
    • Spironolactone and eplerenone are recommended for resistant hypertension (but watch the patient’s potassium);
    • Treatment with an ACE inhibitor or an ARB is recommended to slow kidney disease progression;
    • In black adults with hypertension but without HF or CKD, including those with DM, the guideline recommends initial treatment with a thiazide-type diuretic or calcium channel blocker (CCB).

 

Treating to the new guidelines would be considerably less cost-effective than to the old ones, and it can be difficult to believe so many more people will have a disease. However, even with the more aggressive treatment goals, treating hypertension is in the range of 10 times more cost effective than treating severely hyperlipidemic patients with PCSK9 inhibitors.5 This is mainly due to the fact that generic anti-hypertensive medications are available in every pharmacologic class.

 

I have no doubt that we’ll see lots of back and forth about the treatment goals in the coming months. I expect that they will particularly focus on patients with diabetes and the elderly, but the 2017 guideline gave me new insights about hypertension and how I can treat my patients more effectively.


 

  1.  The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. New England Journal of Medicine. 2015;373(22):2103-2116.
  2. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.
  3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017.
  4. Muntner P, Carey RM, Gidding S, et al. Potential U.S. Population Impact of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. J Am Coll Cardiol. 2017.
  5. Arrieta A, Hong JC, Khera R, Virani SS, Krumholz HM, Nasir K. Updated cost-effectiveness assessments of pcsk9 inhibitors from the perspectives of the health system and private payers: Insights derived from the fourier trial. JAMA Cardiology. 2017.