New guidelines relax blood pressure goals

BMJ 2013; 347 doi: (Published 24 December 2013) Cite this as: BMJ 2013;347:f7621
  1. Michael McCarthy
  1. 1Seattle

In a major revision to treatment goals, an expert panel has concluded that older hypertensive patients, those aged 60 years or older, should be treated to a blood pressure target of less than 150/90 mm Hg, rather than 140/90 mm Hg as recommended in previous guidelines.1

The panel, the Eighth Joint National Committee, was made up of 17 experts initially convened by the US National Heart, Lung, Blood Institute (NHLBI) to update existing recommendations for the management of hypertension. The panel limited its evidence review to randomized controlled trials.

For younger patients, those 30 through 59 years of age, the panel recommended a diastolic treatment goal of under 90 mm Hg, but found there was insufficient evidence to set a goal for systolic blood pressure for patients younger than 60 years or for a diastolic goal for those under 30.

However, based on expert opinion, the panel recommended a threshold for beginning treatment for both these groups of 140/90 mm Hg.

The panel set the same treatment thresholds and goals for patients with diabetes and non-diabetic chronic kidney disease instead of the lower targets set for these patients in previous Joint National Committee guidelines.

The panel writes: “It is important to note that this evidence-based guideline has not redefined high BP [blood pressure], and the panel believes that the 140/90 mm Hg definition from JNC 7 [Seventh Joint National Committee] remains reasonable. The relationship between naturally occurring BP and risk is linear down to very low BP, but the benefit of treating to these lower levels with antihypertensive drugs is not established.”

As for treatment, the panel found there was “moderate evidence” to support starting treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in non-black hypertensive patients, including those with diabetes. A calcium channel blocker or thiazide-type diuretic is recommended as initial treatment for black patients, the panel said.

“The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug” from the list of recommended drug classes,” the panel said.

In an accompanying commentary, however, Eric Peterson of Duke University Medical Center in Durham, North Carolina, and colleagues expressed concern over the panel’s decision to rely solely on evidence from randomized controlled trials.2

“Prior guidelines were generally based on the totality of evidence, including observational studies, RCTs [randomized controlled trials], and meta-analyses, as well as expert opinion,” they note, and these data suggested that the risk of cardiovascular events in untreated adults increased rapidly as systolic blood pressure rises above 140 mm Hg.

Although there is limited direct evidence from randomized controlled trials to demonstrate the benefits of the 140 mm Hg threshold, they write, “Does the absence of evidence lead to the conclusion of evidence of absence?”

Also controversial was the decision not to have the guidelines reviewed by the American Heart Association (AHA) and the American College of Cardiology (ACC). The panel had been commissioned by the NHLBI in 2008 and their draft had undergone external review orchestrated by the institute, but in June 2013, just when the committee’s revision was complete, the NHLBI decided to turn over its guideline development processes to select professional societies, in this case to the AHA and ACC.

The panelists write: “Importantly, participation in this process required that these organizations be involved in producing the final content of the report. The panel elected to pursue publication in- dependently to bring the recommendations to the public in a timely manner while maintaining the integrity of the predefined process. This report is therefore not an NHLBI sanctioned report and does not reflect the views of NHLBI.”

In an accompanying editorial, JAMA editors, Howard Bauchner, Phil B Fontanarosa, and Robert M Golub, defended the journal’s decision to publish the panel’s findings.3 “We anticipate debate and discussion about the clinical application of these recommendations and the related policy issues. JAMA welcomes this responsibility, and indeed, embraces the opportunity to provide evidence-based recommendations to help clinicians improve the care of their patients,” they wrote.


Cite this as: BMJ 2013;347:f7621