Dr. Patricia Yarberry Allen is a collaborative physician. This week, she asks cardiologist Timothy C. Dutta, Clinical Assistant Professor of Medicine at Weill Cornell Medical College, to clear up a woman’s confusion over the guidelines for management of high blood pressure issued last month.

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Dear Dr. Pat:

I do not know what is happening to health care. New recommendations for every condition or for preventive care seem to be trumpeted in the news daily. I am 62 and have had “borderline” high blood pressure for the last five years. My GP kept trying to get me to lose weight so that I would not need drugs to control my blood pressure, but that never happened, I am ashamed to say. I weigh 162 pounds and am five feet four inches. I never was athletic, and I don’t exercise. Even though there is a lot of high blood pressure in my family, and most family members have been on, or are on, drugs to control their pressure, I just like to cook and like to eat like the rest of my family, and my weight and borderline blood pressure have stayed the same.

Each time I visited my GP he would discuss the dangers of borderline high blood pressure and warn me that I would have to start medical treatment or risk strokes and heart disease soon if weight loss did not prevent the blood pressure from climbing. But I saw him recently and he had a brand new script to speak from. My blood pressure was its usual 148/90. And he said, “New studies, new guidelines, different recommendations for people over 60, and see you in a year.”

Is this the result of the Affordable Care Act’s cost-cutting initiative?  And what about “lose the weight or else”?  Is that no longer important?

Janet

 

Dr. Pat Responds

Dear Janet:

Organizations of physicians and scientists do review recommendations for preventive care and treatment suggestions periodically. Otherwise we would still be doing ultra-radical mastectomies as the primary way to treat breast cancer, for example!

New suggestions for medical care do cause great anxiety in patients and some concern for the doctors on the front lines who want to give their patients the most effective medical and cost-effective care. All doctors must continue their education and remain up to date with reviews of journal articles, attendance at educational forums in their local areas, and, when possible, attendance at important national meetings for their specialty at which the latest information is discussed and understood.

These new recommendations are part of evidence-based medical care. They will ultimately prevent big pharma from influencing the care of patients. And they will help with cost control in cases where there is no improvement in outcomes as a result of older guidelines for treatment.

Now to that weight question. Sometimes doctors just get tired of telling their patients to stop having three glasses of wine a night and living like a couch potato, and of begging them to lose weight. You are 62 and you know what is best for you. Get up and out. Cut out the fatty foods and curb those portions. We will never have an evidence-based guideline change that advises patients to be overweight.

I have asked Dr. Timothy Dutta, a cardiologist who is a member of our Medical Advisory Board, to discuss hypertension and to explain the new recommendations.

Dr. Pat

 

Dr. Dutta Responds:

Dear Janet:

These guidelines have been a subject of conversation in my office recently as well. The history of hypertension and its association with diseases is important to understand.

Hypertension (high blood pressure) was recognized as a risk factor for heart attack over 50 years ago; that recognition marks the beginnings of preventive medicine.  Hypertension may have been the earliest condition in modern medicine for which patients who have no symptoms are prescribed medication to help prevent a future event.  About 20 percent of Americans will be diagnosed with hypertension, so there is a lot of familiarity with the condition, and last month’s new guidelines  generated headlines and lots of discussion.

The last time major hypertension guidelines were published was in 2003. They were called JNC 7  (The Report of the 7th Joint National Committee). They have now been updated with JNC 8,  published in December 2013. JNC 8 is an effort to rely more on data from clinical trials and less on expert opinion to establish recommendations. This is called evidence-based medicine, and these new hypertension guidelines made a determined effort to move toward evidence-based recommendations.

I will discuss three changes in the new guidelines: (1) a more lenient category of blood pressure management for patients greater than age 60; (2) the eliminations of the category called prehypertension; and (3) the removal of a class of blood pressure drugs called beta blockers from the list of first-line agents.

A Blood Pressure Goal of 150/90
For Patients Older Than 60?

The biggest headline from the new guidelines is a more lenient blood pressure goal for patients older than age 60. JNC 8 recommends a target BP of 150/90 for patients over the age of 60.  European guidelines and other organizations have already recommended more lenient blood pressure control in older patients—that is, for patients older than age 80.

The evidence cited in JNC 8 was data from trials showing that individuals over age 60 did not get a greater benefit from lowering their systolic blood pressure to less than 150. Without a benefit, to lower the blood pressure further would place patients on treatment unnecessarily and put patients at risk for side effects.  However, the data is conflicting here, and other studies do show a benefit from making the systolic blood pressure less than 140.  There is disagreement even among the guideline authors on this. Several of the guideline authors just  published a paper stating that their position was in disagreement with this recommendation.

What is the correct answer?  My opinion is to individualize it for each patient. If a patient is easily treated to a blood pressure less than 140, then there is no reason to back off on treatment.  On the other hand, if a patient is greater than age 60 and having a difficult time getting the blood pressure down, then it may be acceptable to be more lenient with the goal rather than to add larger doses of medications and endure side effects.

What Happened to Pre-Hypertension?
Another departure from JNC 7 is the elimination of the category “pre-hypertension.” That label, which was given to patients with blood pressure of 120 to140, has come and gone with the old JNC 7 guidelines. “Pre-hypertension” identified a group of patients as being at greater risk for future hypertension, so that they could receive closer monitoring and begin lifestyle changes.  Pre-hypertension has been eliminated without much commentary in the JNC 8 publication. The JNC 8 publication states only that its emphasis is on the thresholds to start medication.

What Happened to Beta Blockers?
Lastly, beta blockers, one of the oldest classes of blood pressure drugs, are no longer first-line agents. In simple terms, these drugs block the effects of adrenalin and have been one of the standard-bearers of blood pressure management for decades. Many drugs have come along since, and seem to be better first choices.  The accumulation of data shows now that the other classes of drugs, ACE inhibitors, ARBs, calcium channel blockers, and diuretics, are usually better choices.   Beta blockers remain recommended as add-on or as second-line therapy. There are specific circumstances when I would use them first, but their side-effect profile of fatigue, sexual side effects, and interference with blood sugar have moved them away from a  first-line choice. 

Conclusions
How should the new guidelines be put into practice?  My opinion is that all guidelines should be a starting point to begin management of a patient, but management needs to be individualized.  It is rare that any given patient fits neatly into guidelines, but they do provide a framework for management, and after ten years without an update to the hypertension guidelines, this update was due.

Dr. Dutta