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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 3-5

Implications of 2017 hypertension guidelines for Indian patients


Department of Cardiology, AIIMS, New Delhi, India

Date of Web Publication4-May-2018

Correspondence Address:
Prof. Rajiv Narang
Department of Cardiology, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_19_18

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  Abstract 

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg.The new guideline adopts a key component of the 2013 cholesterol guideline and incorporates overall cardiovascular risk. The AAFP has decided to not endorse the recent hypertension guideline because it gave undue importance to the SPRINT trial and cardiovascular risk which was not validated and would lead to overtreatment. The guidelines are discussed in this article.

Keywords: Commentary, hypertension, new guidelines


How to cite this article:
Narang R, Srikant S. Implications of 2017 hypertension guidelines for Indian patients. J Pract Cardiovasc Sci 2018;4:3-5

How to cite this URL:
Narang R, Srikant S. Implications of 2017 hypertension guidelines for Indian patients. J Pract Cardiovasc Sci [serial online] 2018 [cited 2018 May 20];4:3-5. Available from: http://www.j-pcs.org/text.asp?2018/4/1/3/231933


  Introduction Top


In 2017, the American Heart Association updated the hypertension guidelines.[1] The major change was that systolic blood pressure of 130 mmHg or more or diastolic of 80 mmHg or more is considered hypertension and needs to be controlled [Table 1] and [Table 2]. Hence, persons with systolic blood pressure of 130–140 mmHg and/or diastolic 80–90 mmHg are now classified as hypertensive, while they were earlier classified as prehypertensive by Joint National Committee 7 criteria.[2] This relabels a large number of people as having elevated blood pressure and warranting lifestyle changes. The 2017 guideline also emphasizes individualized cardiovascular risk assessment. They use 10 year cardiovascular disease (CVD) risk calculation to decide on treatment threshold.[3] This will also mean that most elderly patients would get treated with medications earlier. Use of a risk calculator for blood pressure (BP) treatment may overestimate risk in many individuals and perhaps lead to overmedication. Whether a CVD risk calculator can decide when to treat hypertension is debatable.
Table 1: Blood pressure cut-offs

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Table 2: Treatment goals

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The basic question is whether intensive treatment of hypertension is better than less aggressive approach. Although SPRINT trial showed it to be beneficial, ACCORD and Secondary Prevention of Small Subcortical Strokes trials did not find a significant benefit.[4],[5],[6] Greater emphasis seems to have been given to the SPRINT data in 2017 guidelines. Another aspect is that Stage 1 hypertension becomes a very narrow range and normal variability of blood pressure may make a person in and out of this stage [Figure 1]. It is common these days for patients to record blood pressure at home with oscillometric devices and to bring to the clinic a chart of those readings, some of which may be in Stage 1 and others in elevated blood pressure range. Narrowness of stages may make this classification difficult to implement.
Figure 1: Stages of hypertension

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The American College of Physicians has set the threshold for treatment at 150 mmHg for average-risk older (>60 years) people.[7] It was estimated that this new guideline would classify almost 46% of middle-aged Americans as hypertensive as compared to 32% as per the previous guidelines.[8] In addition, the prevalence of high blood pressure is expected to triple among men under the age of 45 years, and double among women under the age 45 of years and would result in almost 20 million of them getting started on medication. Other major guideline-making associations like the American College of Physicians/NICE/ESC have not as yet accepted this guideline.


  Other Highlights of These Guidelines Include Top


Screen for other risk factors

Screen for risk factors such as smoking, diabetes, dyslipidemia, obesity, wrong diet, stress, and sleep apnea.

Investigations

Basic testing for hypertension includes fasting blood glucose, blood cell count, lipids, metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.

Screening for secondary causes

Of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug resistant (≥3 drugs), abrupt onset, age <30 years, target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, heart failure, coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, and albuminuria).

Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension, and alcohol-induced hypertension. Others include pheochromocytoma, Cushing's syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation.

Treatment

Nonpharmacologic therapy: weight loss, sodium restriction, and potassium supplementation, increased physical activity, and restrict alcohol. Use of medications is recommended in patients with clinical CVD and an average systolic BP (SBP) ≥130 mmHg or a diastolic BP (DBP) ≥80 mmHg. Use of medication is also recommended for an SBP ≥140 mmHg or a DBP ≥90 mmHg.

Targets

For adults with confirmed hypertension and known CVD or 10-year atherosclerotic CVD (ASCVD) event risk of 10% or higher, a BP target of <130/80 mmHg is recommended. For adults with confirmed hypertension but without additional markers of increased CVD risk, a BP target of <130/80 mmHg is recommended as reasonable.

Principles of drug therapy

Initial therapy includes thiazide diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Two first-line drugs of different classes are recommended with Stage 2 hypertension. The primary change in recommendations regarding pharmacologic therapy is the elimination of beta-blockers from first-line therapy for patients with primary hypertension. For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended.

The strategy is to first follow standard treatment guidelines for CAD, heart failure with preserved ejection fraction (HFpEF), previous myocardial infarction, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mmHg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.

Chronic kidney disease

BP goal should be <130/80 mmHg. In those with Stage 3 or higher CKD or Stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated. In adults with acute intracranial hemorrhage and SBP >220 mmHg, it may be reasonable to use intravenous drug infusion to lower SBP. In acute ischemic stroke, BP should be lowered slowly to <185/110 mmHg before thrombolytic therapy.

Diabetes mellitus

Antihypertensive drug treatment should be initiated at ambulatory blood pressure ≥130/80 mmHg with a treatment goal of <130/80 mm Hg. In adults with diabetes mellitus and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.

Age-related issues

Although the new guideline lowers the blood-pressure goal for people over 65 years, it suggests that 30-year-old and 80-year-old should have the same goal. Treatment of hypertension is recommended for adults (≥65 years of age), with an average SBP ≥130 mmHg with SBP treatment goal of <130 mmHg. In addition, the new guideline does not consider isolated systolic hypertension, which is a major problem among many people over 70 years. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, is reasonable for decisions regarding the intensity of BP lowering and choice of antihypertensive drugs.


  Conclusion Top


The new guidelines in 2017 have mainly reset the treatment threshold to 130/80 mmHg. Most part of the guidelines summates the current knowledge on drug therapy and disease management along with the promotion of team-based system approaches for better diagnosis and management. Rather than advocate a specific target for all adults, the focus should be on choosing blood pressure targets that allow for “a choice based on a patient's risk profile, susceptibility to harms, and treatment preferences.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, 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. pii: S0735-1097 (17) 41519-1.  Back to cited text no. 1
    
2.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, 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;289:2560-72.  Back to cited text no. 2
    
3.
ASCVD Risk Estimator Plus. Available from: http://www.tools.acc.org/ASCVD-Risk-Estimator-Plus/. [Last accessed on 2017 Apr 01].  Back to cited text no. 3
    
4.
SPRINT Research Group, Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.  Back to cited text no. 4
    
5.
ACCORD Study Group, Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-85.  Back to cited text no. 5
    
6.
SPS3 Study Group, Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, et al. Blood-pressure targets in patients with recent lacunar stroke: The SPS3 randomised trial. Lancet Lond Engl 2013;382:507-15.  Back to cited text no. 6
    
7.
Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017;166:430-7.  Back to cited text no. 7
    
8.
Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT Jr., et al. Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018;71:109-18.  Back to cited text no. 8
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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