What’s in a number?

The latest guidelines for hypertension are out, and they are causing a very public disagreement among medical experts about who should be treated for high blood pressure.

The medical community has long-awaited “The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)” that was recently published online by The Journal of the American Medical Association (JAMA). It outlines specific recommendations for healthcare providers for initiating and modifying pharmacotherapy for patients with elevated blood pressure. However, to some, the evidence appears to be inconclusive and experts are disagreeing about what that means. The controversy is over the level of blood pressure that should serve as a trigger for treatment. Sounds fairly simple, right? Agree on a number and go with it. But like most medical decisions, it isn’t black-or-white. Instead, healthcare providers are tasked with making high-quality, evidence-based medical decisions amid uncertainty.

Why is blood pressure causing such a ruckus? Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. With more than 76 million Americans with high blood pressure and billions of dollars spent on drugs to treat it, this issue has substantial implications for many patients and huge financial consequences. Patients want to be assured that blood pressure treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence.

The biggest change that will have the most impact on patient care is the new guideline:

People 60 years and older can seek a systolic blood pressure goal (the top number) of 150 or less; it was previously 140 or less.

This is also what sparked the controversy among medical experts. An oversimplification of the debate boils down to risk versus benefit. As we age our blood vessels become stiffer, therefore requiring our heart to pump harder, and this manifests as an elevation of blood pressure. We also become more susceptible to side effects of medication, heart disease, and chronic medical conditions. Medical research clearly shows the correlation between hypertension and life-threatening consequences. And the clinical question is at what point to treat elevated blood pressure? The new guidelines are more relaxed, citing that the risks of antihypertensive medications (like dizziness, falls, fatigue, etc.) are outweighing the benefits of treatment in people over the age of 60. After all, we did take an oath to “first, do no harm”.

The take-home? Know your blood pressure, particularly if you have chronic medical conditions like kidney disease or diabetes (remember, heart disease is the No. 1 killer of women in the US). The US Preventive Services Task Force recommends that all adults be screening for hypertension. If your blood pressure is close to or slightly elevated above normal, 120/80, there is strong evidence and little disagreement that it is preferable to use lifestyle interventions rather than medications. Diet and exercise should always be the first option. And there is also agreement about the large benefit for patients from the treatment of very high blood pressure. The dispute about all of the numbers in between signals clearly that there are options for patients. Consider this a good opportunity for personalizing your treatment according to your preference as the patient. If you prefer not to take medications and want strong evidence of benefit to justify drugs before you take them, then consider opting for the more permissive target level of the new guidelines. On the other hand, if you are willing to take medication daily and want a lower blood pressure even though the evidence of benefit is unclear to some experts, then you would want to go with the lower goal of the previous guidelines. Currently, both options are reasonable.





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