The New American Heart Association Hypertension Guidelines: Good for Who?

In November of 2017 the American Heart Association expert panel reconfigured the guidelines on blood pressure.  The panel, led by Dr. Paul Whelton, states that the committee sifted over thousands of documents and studies to come up with their new and improved guidelines for treatment of hypertension.

The first change in the guidelines was the actual definition of what constitutes hypertension in the first place.  For decades, there was a cut-off between hypertension, and normal blood pressure.  That cut-off was at 140/90 mm Hg.  The upper number, 140 milligrams of pressure was considered the bottom of borderline hypertension – the point where doctors would make a decision on lifestyle and medical interventions.  This usually meant that a prescription to lose weight, and perhaps take a prescription medication was in order.  The former being the first line of defense. 

However – this new set of guidelines takes a cut-off, and puts in into categories that actually lowers the borderline of hypertension 10 milligrams of pressure, and puts blood pressure readings into the following four categories:

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Table 1:  New hypertension categories devised by the American Heart Association committee.

Dr. Whelton states that these are more in tune with the current consensus of what should be considered high blood pressure.  He made the following comments during his interview at the American Heart Association meeting on the new guidelines:

“In order to have a more accurate measure, persons should take their blood pressure on a more regular basis.  This would guard against white coat syndrome, where a reading may be abnormally high due to being in the doctor’s office, or readings that may be abnormally high outside of the doctor’s office”

Dr. Whelton also defined the table above as a new hypertension classification system, where a new category risk group was added.  That would be the “low risk” group of 120-29/80-89 section.  The low risk group should be contained from elevation through lifestyle interventions – such as exercise, diet, and weight management.  He states that the Stage 1 group (130-39/80-89) group should be using both lifestyle and medication to control their status.  This would reduce their 10% higher risk of a cardiovascular event then the normal groups (which would include heart attack, stroke, and PVD). 

The consensus of the AHA hypertension group was to redefine old guidelines based on newer information, to “empower” individuals to know more about their blood pressure status, and to take control over it by getting more readings, and to push more education through the American Heart Association, which Dr. Whelton calls a “Treasure Trove” of information for patients.

The Devil is in the Details

In many areas of medicine, there is a push to sell more and more medications.  We see this through “direct to consumer advertising”, new diagnostic criteria for diseases (adding more), developing newer and more costly medications for the same type of condition, and adding mandating medications (vaccines) for specific types of situations (such as employment, or school enrollment). 

Even though Dr. Whelton discusses combing over thousands of studies, most of the guidelines of this new recommendation come from the 2015 SPRINT study funded through NIH.  This report looked at a cohort of over 9,000 people with high blood pressures, and were randomized to drug treatment of approximately three medications, vs. the standard (control) treatment – which actually had an average of two medications throughout the study.  The investigators stopped the trial early because the types of adverse events (heart attacks, strokes, etc) in the treatment group was less than the control.  “Less than 120 systolic pressure had lower rates of fatal and non-fatal events than controls.  5.2% vs. 6.8% suffered an incident.  What this actually means is that the study treated 62 people with multiple medications to lower the effects to benefit one person (statistically) – everyone else had no benefit.  This is how the American Heart Association looks at data – how much intervention was necessary to lower the all cause morbidity to 61 persons.  Also - the effects of multiple medications in the treatment group produced serious adverse events such as hypotension, syncope, electrolyte abnormalities, kidney injuries and failure.  This is a primary example of doing a large study that may benefit the drug companies (all subjects were on medications), vs. doing a true control trial with a lifestyle intervention that may have better outcomes for the patients. 

The question to ask here is – do these guidelines truly reflect a change in the risk for developing a cardiovascular event such as a heart attack, or is it yet another method to add more medications to a larger percentage of persons who were (until November) within a “normal range” of blood pressure measures.

Most health professionals who learn about blood pressure readings in medical school or in other allied health programs know that blood pressure is one of the most fluctuating measurements in medicine.  A blood pressure reading of 120/80 can easily increase to 150/96 after climbing stairs – depending on fitness level and body weight.  Dr. Whelton is correct that multiple readings should take place, and in my opinion, one after the other, especially if the reading is too high.  The beauty of purchasing a portable blood pressure cuff on Amazon or other site allows anyone to take a reading – relax and breathe, then take another reading.  Hopefully it will lower by five to 10 points systolic.  I am also a big fan of working on the diastolic number, which measures the pressure of the artery walls at rest.  If they are too stiff and readings are too high (90 mm Hg or more) there is increased risk by performing moderate ADLs, vs. a normal diastolic reading, and an upper / systolic reading of 160 when stair climbing that can be lowered more easily.

Some critics, such as a recent article in AARP journal, discuss the fact that by changing the hypertension levels downward, seniors already on six medications may now face taking a seventh for their blood pressure, when it may be physiologically unwarranted. 

Other doctors say that the new guidelines will be unrealistic for patients to follow.  Dr. Matt Muldoon of the University of Pittsburgh MC states that “anytime these types of changes are put into place, it’s a boon for the drug companies”

I feel he is correct.  Here’s why.  First – if a blood pressure is taken and either the systolic or diastolic readings are high (say over 140/90 at rest), and we retake them and they are still high, then the first item of business would be to advise the person to begin a lifestyle change after we have assessed their current physical and emotional situation, and may see a need to make some types of changes.  Number one would be exercise.  No – walking through the grocery store is not exercise.  The new paradigm in fitness is more high intense exercise broken up into segments.  Even in seniors, this type of exercise regime is becoming more accepted.  It’s just modified to fit the person.  Second is to take a hard look at the nutritional status, and really make changes not just in calories, but types of foods (organic vs. inorganic), types of calories (meats and fats vs. carbohydrates), grocery store foods (processed vs. fresh from the farm), and other issues – smoking, alcohol, sugars, etc. 

There is a real tipping point happening in medicine and health care in the US.  More people are realizing that multiple medications, vaccines, and surgical treatments are not what we think they are.  Medicine in American is “overkill” – both figuratively and literally.  As more people access technology (like home blood pressure monitors), they can affect their own changes in health independent of a physician.  In order to maintain the status quo – things like changing blood pressure standards move the pendulum.  What health systems and pharmaceuticals may not realize is that the momentum is already moving in the opposite direction. 

References

http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497446.pdf

https://www.aarp.org/health/conditions-treatments/info-2014/new-blood-pressure-guidelines-raise-controversy.html

http://professional.heart.org/professional/ScienceNews/UCM_496965_2017-Hypertension-Clinical-Guidelines.jsp

http://triblive.com/news/healthnow/12950746-74/expert-new-blood-pressure-guidelines-unrealistic

http://healthimpactnews.com/2017/dr-brownstein-new-blood-pressure-guidelines-creates-millions-of-new-customers-for-big-pharma/

SPRINT Research Group.  Randomized trial of intensive vs. standard blood pressure control.  New Eng. J. Med.  2015. 373:2103-16.