Highlighting the 2014 Hypertension Guidelines

New York—The updated hypertension guidelines were a hot button issue at the ASH meeting, with particular contention igniting over the <150/90 mm Hg blood pressure (BP) recommendation for patients ≥60 years of age during a presentation focusing on the guidelines.

Introduction: Kidney Disease
The session began with an overview of the Kidney Disease Improving Global Outcomes Worldwide Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. Sandra J. Taler, MD, FASH, professor of medicine, Mayo Clinic, Rochester, Minnesota, gave the first presentation, held in partnership with the American Society of Nephrology. Dr. Taler said there is not enough clinical evidence of BP management in patients with chronic kidney disease (CKD). Diabetes and CKD are important to consider in conjunction with a patient’s BP, citing the updated 2012 National Kidney Foundation KDOQI guidelines.

When examining studies and guidelines, Dr. Taler recommended that physicians ask themselves, “Is my patient like the study group?” She expressed how it is easy to accept study findings as true, but the individual patient must be assessed against the patients included in the study.

The session then evolved into a discussion of the 2014 evidence-based guidelines for assessing high BP in adults, reported by the panel members appointed to the Eighth Joint National Committee (JNC8), which Raymond R. Townsend, MD, FASH, professor of medicine, associate director, clinical and translational research center, University of Pennsylvania, Philadelphia, Pennsylvania, and Jackson T. Wright, Jr., MD, PhD, FASH, professor of medicine, division of hypertension, Case Western Reserve University, Cleveland, Ohio, spoke about during the session [JAMA. 2014;311(5):507-520].

Dr. Townsend noted that “a lot happened in 2013,” in terms of hypertension guidelines. Following the 2012 KDOQI guidelines, the European Society of Hypertension and the European Society of Cardiology released joint guidelines in 2013. He noted that the different guidelines are developed based on what a particular healthcare group needs to know. The 2014 guidelines developed by the JNC8 are “based on what primary care physicians need to know,” according to Dr. Townsend.

Guideline Highlights
Dr. Townsend discussed the 9 recommendations in the guidelines,
noting that “the first recommendation is the most controversial.” Dr. Townsend pointed out, however, that “guidelines are no substitute for clinical judgment.”

1. In the general population ≥60 years of age, initiate pharmacologic treatment to lower BP at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.

2. In the general population <60 years of age, pharmacologic treatment to lower BP should be initiated at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg.

3. In the general population <60 years of age, pharmacologic treatment to lower BP should be in-
itiated at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg.

4. In the population ≥18 years of age with CKD, initiate pharmacologic treatment to lower BP at SBP
≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg.

5. In the population ≥18 years of age with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg.

6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB).

7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker.

8. In the population ≥18 years of age with CKD and hypertension, initial (or add-on) antihypertensive treatment should include an ACE inhibitor or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension, regardless of race or diabetes status.

9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from 1 of the classes in recommendation number 6.

The first recommendation was contested by many attendees at the meeting’s session, who questioned how this could possibly be recommended. Dr. Townsend said 5 of the 17 panel members of the JNC8 did vote against it; however, more votes were necessary in order for this recommendation to be overturned. Based on the data and studies available, this recommendation was rated “Grade A,” which makes it a strong recommendation.

Dr. Townsend noted that there are “4 ingredients” to using the updated guideline algorithm: (1) age; (2) CKD; (3) diabetes; and (4) ethnicity, including black versus nonblack individuals.

Dr. Wright said there is a lot of confusion among healthcare professionals due to the numerous hypertension and BP guidelines available, noting that healthcare providers must ask themselves, “Which guideline is appropriate to follow in our practice?” He suggested patients and all office staff, not just physicians, be trained and knowledgeable about BP treatment goals and obstacles to care in order to provide the best patient outcomes.—Kerri Fitzgerald