Tip 28. (January 2018)
A new hypertension guideline with significant implications for GP’s and their patients
In my May 2016 Tip (26), I reviewed the SPRINT trial (ref 1), which showed that in high-risk hypertensives, a group randomised to achieve a systolic blood pressure close to 120mmHg had significantly better cardiovasular outcome over 3.5 years than a group randomised to achieve a systolic blood pressure < 140mmHg.
The results of this trial (and other recent studies) have been incorporated in the latest hypertension management guideline which has been put out by a collaboration of most of the authoratitive American bodies, including the American College of Cardiologists, the American Heart Association, and the American Society of Hypertension (ref 2.)
The guideline incorporates new definitions:
Normal = < 120mmHg + < 80mmHg
Elevated = 120 - 129 + < 80
Stage 1 = 130-139 +/- 80-89
Stage 2 = >= 140 +/- >=90
The therapeutic recommendations are for pharmacological treatment of patients with Stage 1 hypertension (130-139 +/- 80-89) whose 10 year risk exceeds 10% on the Atherosclerotic Vascular Diease Risk Estimator (ref 3). For patients with Stage 1 whose risk falls below that threshold, lifestyle intervention is recommended, and pharmacological treatment is recommended for all patients with Stage 2 hypertension.
The practical implication of this are enormous; - the new definition, at a stroke, increases the incidence of hypertension in US adults from 32% to 48%. (Similar for NZ). And although there is the provision for treating patients with Stage 1 hypertension whose 10-year risk is below 10%, in fact, the majority of your patients with Stage 1 will have 10-year risk > 10%.
The other important implication, of course, is that the treatment targets are now lower; < 130/80 for all, which means that existing patients will need stronger treatment.
I recommend this new guideline to you. It is based on the best and most up-to-date research available.
The take home message is that you need to diagnose hypertension in more individuals, and to aim for lower target blood pressures. Lower blood pressure in effect means more medication. In the SPRINT trial, the intensive treatment arm who achieved a mean systolic blood pressure of 121.5mmHg were on a mean of 3 antihypertensive drugs, compared with the standard treatment arm who achieved a mean SBP of 134.6mmHg were on a mean of 2 antihypertensive drugs.
1. The SPRINT Research Group*
A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103-2116November 26, 2015DOI: 10.1056/NEJMoa1511939
2. 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. J Am Coll Cardiol, [E-pub ahead of print]. 2017 Nov
For Previous “Tips” Click on PDF Links BelowBelow the tips are a series of brief topical news-items and comments on hypertension mattersfrom 2009
Tip 1 (May 2009) Resistant HypertensionYour Link
Tip 2 (May 2009) ChlorthalidoneYour Link
Tip 3 (June 2009) Management of hypertension in patients aged over 75 yearsYour Link
Tip 4 (July 2009) Sensible Combination TherapyYour Link
Tip 5 (August 2009) What tests should I do before starting antihypertensive therapy?Your Link
Tip 6 (September 2009) Treating hypertension in the metabolic syndromeYour Link
Tip 7 (October 2009) Treating hypertension in patients with chronic kidney disease (CKD-3)Your Link
Tip 8 (November 2009) Ambulatory and Home BP monitoring in the management of hypertensionYour LinkYour Link
Tip 9 (December 2009) The Importance of PrehypertensionYour Link
Tip 10 (Jan-Feb 2010) Always measure waist circumferenceYour Link
Tip 11 (March2010) Renin and Aldosterone Measurements in HypertensionYour Link
Tip 12 (April 2010) Measure Vitamin D levelsYour Link
Tip 13 (May 2010) Importance of blood pressure treatment algorithms and regular titration visits to achieve blood pressure targets Your Link
Tip 14 (June 2010) Aim to achieve blood pressure Targets within 3 monthsYour Link
Tip 15 (July 2010) Management of Global Cardiovascular Risk - "Keep it Simple"Your Link
Tip 16 (February 2011) Accurate Blood Pressure MeasurementYour Link
Tip 17 (June 2011) Waitemata Hypertension Clinic Cardiovascular Risk Factor Management GuidelineYour Link
Tip 18 (January 2012) Effective use of beta and alpha blockersYour Link
Tip 19 (April 2012) Underdiagnosis of hypertension in young peopleYour Link
Tip 20 (December 2012) Don't even think about sympathetic denervation until patients have been thoroughly evaluated for refractory hypertensionYour Link
Tip 21 (October 2013) Publically funded sympathetic denervation at WDHBYour Link
Tip 22 (February 2014) Thiazide-induced hyponatraemiaYour Link
Tip 23 (August 2014) Forget about renal denervation - at least for nowYour Link
Tip 24 (December 2014) Ambulatory BP monitoring in special populationsYour Link
Tip 25 (June 2015) More on 24-hour ambulatory blood pressure monitoringYour Link
Tip 26 (May 2016) Implications of the SPRINT trial for hypertension management in general practiceYour Link
Tip 27 (February 2017) Metabolic benefits of thiazide diureticsYour Link
Comment "Erratic availability of chlotthalidone in NZ" (2009)Your Link
Comment "Vitamin D and hypertension" (2010) Your Link
Comment "Listerner article on cardovascular (2012)Your Link
Comment "The JNC-8 Guidelines" (2014)Your Link
Comment "Be sceptical of buzz phrases like best practice and best evidence"(2014) Your Link
Comment "Renal sympathetic denervation at North Shore Hospital on hold - for now" (2014) Your Link
Comment "Lack of specialist hypertension services in NZ" (2010) Your Link
Comment "Catheter-based sympathetc denervation for hypertension" (2012)Your Link
Comment "Old men making rules to treat themselves" (2010) Your Link
Comment "ACCORD trial blood pressure arm results" (2010) Your Link
Comment "The NZ cardiovascular risk guideline - again" (2011) Your Link
Comment "Nurse titration clinics" (2010) Your Link
Comment "Ambulatory and home BP monitoring in the diagnosis of hypertension" (2010) Your Link
Comment "24-hour ambulatory BP monitoring" (2009) Your Link
Comment "Treating hypertension in patients with CKD-3" (2010) Your Link
Comment "Where are we with beta blockers" (2009) Your Link
Comment "High NZ stroke rate" (2011) Your Link
Comment "A really useful hypertension website" (2009) Your Link