The American Heart Association and American College of Cardiology, along with numerous other professional societies, have released new guidance on hypertension. The 105-page document updates guidance from 2017.
Here are a few highly selected likes and worries.
Things I Like
Accurate measurement of blood pressure. The authors place great emphasis on the accurate measurement of blood pressure (BP). This includes a picture of a patient who is sitting, feet on the floor and arm resting on a table. Adjacent to the picture is an 8-point list of how to take a BP.
It boggles my mind how badly BP is taken in the healthcare setting. I don’t think I’ve ever witnessed it done properly — not once, in 30 years of practice. I am not sure how the culture evolved not to care about accurate BP measurement. We have time-outs, sepsis protocols, and quality measures for numerous conditions, and yet, something as simple as accurate recording of a vital sign is virtually ignored. Mediocrity has been codified as standard when it comes to measuring BP. A healthcare system could improve its quality overnight if it made accurate BP recording a point of emphasis. Good on the authors.
Home-based BP monitoring. A corollary of accurate BP measure is the class 1/evidence level A recommendation to supplement office BP measures with home-based monitoring. While this makes sense, it’s actually supported by multiple RCTs which, taken together, show that home monitoring of BP plus lifestyle interventions leads to clinically significant BP reduction that persists for at least 12 months. The authors emphasize that cuffless technology options that are often embedded in wearable devices are not reliable enough for clinical use.
One caveat the authors did not mention, but which I find important, is practical guidance on use of home BP devices. I have seen people who spend far too much of their life recording and pondering their BP. Patients need clear education regarding the natural fluctuations of BP, and that the goal is to reduce average BP over days to weeks. We want patients to have good BP and good lives. More often than not, I find myself telling patients to use their home BP cuff less, not more.
Single-pill combination drugs. My view of single-pill combination drugs has changed. I used to be against combining agents in a single pill because it can be hard to change course. The guidelines give a class 1 recommendation for using combination pills for patients with stage 2 hypertension (systolic BP ≥ 140 mm Hg and diastolic BP ≥ 90 mm Hg). I like this call on both efficacy (it probably will take multiple drugs) and efficiency grounds; having only one pill and one prescription to fill and refill is important.
Renal denervation caution is warranted. Renal denervation (RDN) is on the precipice of becoming cardiology’s biggest blemish — even worse than left atrial appendage occlusion. Doctors and hospitals are coiled and ready to deploy this procedure to the millions with high BP. The only thing maintaining sanity is the reluctance of payers — thankfully.
Here is a quote from the guideline document:
While some trials showed a small but significant reduction in 24-hour ambulatory SBP by 3 to 5 mm Hg over the sham arm, others failed to reach their primary endpoint. Although broader indications are approved for the RDN devices by the FDA, given the relatively short duration of follow-up in clinical trials with modest BP-lowering effects and the absence of CVD outcome trials, RDN should not be considered as a curative therapy for hypertension or full replacement for antihypertensive drugs.
I would have been stronger, but this is decent. The problem comes in that RDN makes the colored recommendation box, albeit with the lowest 2b level. I call this a problem because procedure-loving doctors only need it to be recommended. The level of recommendation does not matter in the real world of US medicine.
I reiterate: RDN trials found either no significant or clinically small reductions in systolic BP. There are no sham-controlled efficacy data beyond a few months and not even a hint of clinical outcome data. A middle-aged person does not require BP control for 3 months; they need it for 3 decades. RDN was a nice idea, but before a single dollar is paid to a doctor or hospital for this procedure, we should have far more persuasive evidence. I would have left it out of the colored box of recommendations.
Two Things I Worry About
Summary statements and colored boxes. The document begins with take-home messages. I take from this that the writers think clinicians are not capable of reading the document. These efforts to dumb down medicine, which are not specific to hypertension guidelines, worry me greatly.
Hypertension is one of the most common and modifiable risk factors for cardiovascular health. Clinicians should be encouraged and expected to read the details of the document — including the references. Few things could be more important in the prevention of cardiovascular disease than extreme knowledge of hypertension.
I feel the same way about the colored boxes of recommendations, which attempt to simplify what is complex. I believe it best to provide the narrative review and references — with a table, perhaps — but jettison the summary boxes, because the vast majority of patients do not fit into such algorithms.
Risk-based recommendations use the new PREVENT risk score. A major feature of this guideline is to base treatment not only on BP measures but also on overall cardiovascular risk. For instance, for patients with stage 1 hypertension and a 10-year PREVENT risk score of < 7.5%, the recommendation is for lifestyle interventions only. Risk-based intervention is a decent idea; my worry here is the use of the new PREVENT score.
PREVENT is a new AHA initiative; it replaces the pooled cohort equation (PCE). Proponents of the score cite its many advantages. These include broader outcomes, such as heart failure, atrial fibrillation, stroke, as well as atherosclerotic events. PREVENT is also derived from more diverse and contemporary data that include kidney function and social determinants of health. These factors are believed to lead to improved calibration between expected and observed event rates.
The provocative feature of PREVENT in the statin decision was that more accurate calibration — with less risk overestimation — led to fewer patients being labeled statin eligible. Similar concerns arise in the hypertension guideline. Will use of PREVENT lead to undertreatment?
Another highly provocative feature of PREVENT is that it does not include race as a determinant of risk. While this may satisfy equity concerns, some cite strong associations of race and risk in hypertension — and not considering race may lead to undertreatment of vulnerable people.
I am neither a statistician nor an epidemiologist, but decreeing a new risk score that could affect so many patients, and the most important modifiable cardiovascular risk factor, seems like a major risk. The authors give this a class 1/evidence level B rating, but I find no trials comparing PREVENT and PCE as risk modifiers.
I am not saying it is wrong to use PREVENT; rather, I am saying that even a little undertreatment of BP could be a public health disaster.
Let me know what you think in the comments section.
John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence.
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