The Future of Hypertension Guidelines: Simplified Recommendations and Widespread Treatment

Anne Jacobson

doi:10.1177/155989771008026

Summary

This article discusses hypertension guidelines, current barriers to guideline implementation, as well as potential solutions to more widespread hypertension control.

Cardiology Guidelines
Hypertensive Disease

Physicians and other health care providers who manage patients with hypertension must try to reconcile an array of competing national and international blood pressure (BP) guidelines. More than 20 guidelines that are related to some aspect of BP management are available in Australia alone, said John Chalmers, MD, University of Sydney, Sydney, Australia. In this session on hypertension guidelines, Prof. Chalmers described current barriers to guideline implementation, as well as potential solutions to more widespread hypertension control.

Hypertension guidelines share some themes, such as the benefits of combination therapy. However, most guidelines offer divergent advice on specific strategies for hypertension screening and treatment. In 2010, Ferket and colleagues from Erasmus Medical Center, Rotterdam, The Netherlands, performed a systematic review of clinical guidelines on the management of cardiovascular risk factors, including hypertension [Ferket BS et al. Arch Intern Med 2010]. Across 27 guidelines from around the world, they found “no consensus on recommended target populations, treatment thresholds, or screening tests.” This lack of consensus contributes to poor guideline adherence, with differences across guidelines giving clinicians an excuse for disregarding recommendations in lieu of their own treatment prejudices, Prof. Chalmers said.

Among the many areas of confusion are the different BP thresholds and targets that are described in current guidelines. These include thresholds for initiating antihypertensive therapy (eg, ≥160/90 mm Hg) and targets for antihypertensive treatment (eg, ≤130/80 mm Hg). BP thresholds and targets may vary in different patient groups according to the presence of comorbidities, such as diabetes, chronic kidney disease, and other risk factors. Different guidelines may also offer conflicting recommendations for the same category of patients. Together, these discrepancies can be very confusing and frustrating to the practicing clinician.

New Paradigm for Hypertension Management

Hypertension management may be shifting toward a new paradigm that addresses some of the barriers to guideline implementation. In 2009, Law and colleagues from the Queen Mary University, London, UK, performed a meta-analysis of 147 trials of antihypertension therapy [Law MR et al. BMJ 2009]. Most classes of antihypertension medications had a similar effect in reducing the risk of coronary heart disease (CHD) events and stroke. Antihypertensive treatment provided a similar magnitude of protection against CHD and stroke, regardless of pretreatment BP (≥110/70 mm Hg) or the presence or absence of cardiovascular disease at baseline. For all patients aged 60 to 69 years with a pretreated diastolic BP of 90 mm Hg, treatment with a 3-drug combination regimen at half-standard dose reduced the risk of CHD by 46% and reduced the risk of stroke by 62%. Single-agent treatment provided about half of this benefit. β-blockers provided additional protection following myocardial infarction, and calcium channel blockers (CCBs) provided an incrementally greater reduction in stroke compared with other classes.

According to Law and colleagues, these findings support a strategy of lowering BP in all persons of a certain age (eg, ≥60 years) rather than a strategy of screening patients for hypertension and treating only a subgroup of those who are screened. Under this treatment model, hypertension guidelines should be simplified to include therapy for all patients of a certain age and with all levels of BP. Treatment should start with low-dose therapy and build incrementally in patients who require more intensive BP control. Strong clinical trial evidence supports the use of diuretic therapy in combination with an angiotensin-converting enzyme inhibitor (ACEI), an angiotensin receptor blocker, or a CCB. Alternatively, combination therapy with an ACEI and a CCB may be appropriate for some patients. Many of these combinations are available as low-dose, single-pill, and fixed combinations.

Adopting this strategy for population-level hypertension control may remove many of the current barriers to BP management, including the challenges of identifying at-risk patients, determining when to initiate treatment, and defining treatment targets. In particular, the widespread use of fixed-dose combination therapies will enable many patients to start a low-dose regimen that provides significant protection against CHD and stroke, Prof. Chalmers concluded.

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