#77: Hypertension Guidelines Showdown

January 8, 2018 | By Matthew Watto, MD

Ease the tension around blood pressure goals in older adults and get inside the hypertension guidelines released by the ACP and ACC/AHA in 2017 with the sagacity of Dr. Mary Ann Forciea, MD, MACP, Professor of Medicine at University of Pennsylvania. We cover: how to properly measure blood pressure, how to diagnose hypertension, blood pressure targets, why BP goals differ by society, how to guidelines are written and how to interpret them with a critical eye, plus a hot take on the 2017 ACC/AHA guidelines. Dr. Shreya Trivedi joins as cohost. Special thanks to Hannah Abrams for her wonderful infographics and to Dr Trivedi for compiling our show notes.

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Case from Kashlak Memorial:
70M w/ hypertension (HTN), benign prostatic hyperplasia, severe osteoarthritis presents for primary care follow up. He reports being compliant with his HTCZ 25 mg and amlodipine 5 mg. His blood pressure (BP) is 152/86. Repeat BP in 2 weeks is also similar.

Hypertension Pearls

1. Patient factors to consider in treatment of HTN: Comorbidities, medication burden, risk for adverse events, cost and patient’s own goals for their health.
2. Patients often skip diuretics when leaving house (e.g. doctor’s visit) to avoid incontinence episodes.
3. Shared decision making: Ask patients how interested they are in their BP control, particularly in elderly. Once >2 meds required for BP you must ask patient: What do you want? What are your goals?
4. Three types of blood pressure (BP) monitors: 1) mercury sphygmomanometer, 2) aneroid sphygmomanometer,  3) automatic oscillometric digital sphygmomanometer.
5. Calibration: Wall monitors should be calibrated AT LEAST every 6 months. Handheld aneroid devices at least quarterly! Who does that?!
6. Upper arm BP monitors are better than wrist monitors
7. Oscillometric monitors measure MAP, then use an algorithm to calculate SBP and DBP.
8. Improper technique produces significant changes! E.g. Dr. Forciea  says it’s not unusual to see a 20 mmHg change from the initial BP once patient is seated for 5 minutes.
9. Proper technique: Feet on the floor, back supported, >5 minutes rest, no talking by patient or examiner, no clothing between cuff and arm, no caffeine/exercise/smoking w/in 30 minutes, arm supported and at level of right atrium (mid-sternum), and correct cuff size used (See Table 8 in 2017 AHA/ACC guidelines for full criteria)
10. Automated oscillometric (or office) blood pressure (AOBP): Cuff can inflate without presence of examiner and take average of several readings. In the SPRINT trial, the patient had 5 minutes of quiet seated rest, then the mean of 3 BP measurements with an automated machine was used. Some experts say this likely caused the BP measurements to be about 10 mmHg less than traditional office based BP measurements
11. Home blood pressure monitoring (HBPM): We must coach patients to: Select an accredited BP monitor, utilize proper technique, and calibrate their BP monitor 1-2 times yearly.
12. Ambulatory blood pressure monitoring (ABPM): Patient wears cuff for 24 hours. Report gives average BP, daytime BP and nocturnal BP. Not widely available in US. e.g. Medicare will not pay for ABPM unless it is to rule out white coat hypertension or on dialysis at home.
13. White coat hypertension: Prevalent in about 30-40% of people >65 years of age (Abir Khalil, S et al 2009).
14. Measurement of orthostatics within 1 minute of standing is strongly associated with dizziness, and adverse outcomes (e.g. falls, syncope, etc.) according to a recent study in JAMA (Juraschek 2017)
15. Diastolic blood pressure less than 60 mmHg in older patients is associated increased risk of  MI, stroke, cardiovascular death and all-cause death (Vidal 2016).

Guideline Pearls

1. Guideline (g/l) committees try to ask questions that are troublesome to clinicians and see if there is enough evidence to answer that question
2. Evidence based guidelines: Limited in scope by available evidence. ACP g/l are evidence based and cannot comment on a problem that has insufficient evidence.
3. Consensus based guidelines: Usually written by specialty societies and incorporate both 1) evidence based recs and 2) what experts might do in a given situation, even if evidence/data is lacking.
4. ACP recommendations have two components 1) strength of recommendation and 2) quality of evidence.
5. Strength or “quality” of evidence based on 11 point checklist (e.g. design of study, risk of bias, funding of study, diversity of population, etc.). Quality reported as strong, moderate, or weak.
6. Strength of recommendation (e.g. strong or weak) based on balance of benefits vs. harms. Strong recommendation FOR if clear that benefits >> harms or AGAINST if clear that harms >> benefits. Weak recommendation if benefits and harms are balanced.
7. When reading a society’s guidelines, invest 30 minutes learning how they write g/l.
8. For recommendations, look at BOTH a neutral body as well as specialty society’s recommendations. Notice how they differ, and consider why these differences may exist (e.g. inherent biases, special interests, etc.).
9. Get involved with a specialty society and volunteer for a committee if you are interested in writing guidelines!

2017 ACP Guidelines Recommendations

1. ACP recommends that clinicians initiate treatment in adults aged 60 years or older with systolic blood pressure (SBP) persistently at or above 150 mmHg to reduce the risk for mortality, stroke, and cardiac events  (Grade: strong recommendation, high-quality evidence)
2. ACP recommends that clinicians consider a SBP target of less than 140 mmHg in adults aged 60 years or older with a history of stroke or transient ischemic attack to reduce the risk for recurrent stroke (Grade: weak recommendation, moderate-quality evidence).
3. ACP recommends that clinicians consider in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence).

2017 ACC/AHA Guideline Pearls

1. After ͵≥2 readings obtained on ≥2 occasions, ACC now classifies:
   1. Normal BP is defined as <120/<80 mmHg
   2. Elevated BP 120-129/<80 mmHg
   3. Hypertension stage 1 is 130-139 or 80-89 mm Hg
   4. Hypertension stage 2 is ≥140 or ≥90 mm Hg.  
2. It is recommended that patients sit quietly for 5 minutes with both feet on floor, not using cellphone. Take blood pressure on both arms and use the higher blood pressure.
3. Choose an approved device for HBPM
   1. Make sure the monitor has been tested, validated and approved by the Association for the Advancement of Medical Instrumentation, the British Hypertension Society and the International Protocol for the Validation of Automated BP Measuring Devices.
   2. Make sure their BP monitoring device is calibrated, especially if you are basing treatment decisions on it.
4. Chlorthalidone is the preferred diuretic because of long half-life and proven reduction of CVD risk.
5. See infographic for treatment if BP above target, which has an emphasis on non-pharmacologic therapy.
   1. Weight loss for overweight or obese patients with a heart healthy diet
   2. Sodium restriction and potassium supplementation within the diet
   3. Increased physical activity with a structured exercise program
   4. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink per day.

Goal: Listeners will appreciate nuances to blood pressure targets in elderly, how guidelines are written as well as review the latest ACC guidelines on HTN.

Learning objectives:
After listening to this episode listeners will…

1. Appreciate the pathophysiology of why the geriatric population is more prone to hypertension
2. Recall the importance of technique in blood pressure monitoring
3. Recognize how prevalence white coat hypertension is among elderly
4. Explain the process by which guidelines are written
5. Recognize differences in BP targets among various guidelines based on comorbidities
6. Interpret evidence behind aggressive BP targets but recognize the limitations with the J-curve phenomenon
7. Read guidelines with a critical eye
8. Review, compare and contrast the 2017 ACP and ACC/AHA hypertension guidelines

Disclosures: Dr Forciea was on the writing committee for the 2017 ACP Hypertension Guidelines.  Dr Forciea and The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 The setup
• 02:15 Disclaimer
• 03:32 Picks of the Week
• 08:13 Getting to know Dr Forciea
• 13:35 Broad overview and a clinical case of geriatric hypertension
• 14:45 Brief history on BP targets
• 18:05 How do you measure a blood pressure? What type of monitors are available?
• 22:13 How to standardize BP in the office?
• 23:55  Ambulatory BP monitoring
• 24:55 Home blood pressure monitoring
• 26:11 Standing blood pressure readings and orthostatic hypotension
• 27:53 How guidelines are written
• 30:51 Evaluating evidence quality and strength of recommendation
• 32:35 Timeline and process for guideline generation
• 34:27 How to read guidelines with a “critical eye”
• 36:15 Return to our case of uncontrolled hypertension
• 38:25 Blood pressure targets from ACP guidelines and BP management in frail older adults
• 40:33 Counsel patients on BP targets   
• 42:25 Low diastolic blood pressure
• 45:35 SPRINT and the ACP BP guidelines
• 48:58 Take home points from Dr Forciea
• 50:07 HTN targets and pay for performance in clinical practice
• 51:45 Curbsiders recap the ACP guidelines
• 53:45 Matt and Paul recap the AHA guidelines
• 54:47 AHA definitions of hypertension
• 56:15 Diagnosing hypertension and how to measure a blood pressure
• 60:35 Choosing a blood pressure monitor and HBPM
• 62:29 Blood pressure goals in ACC guidelines
• 66:08 Non-pharmacologic measures
• 69:15 Will we follow these new strict targets?
• 72:45 Outro

Links from the show:

1. Blade Runner 2049 (film)
2. Full Code Pro (app)
3. Holman, R et al. Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2017; 377:1228-1239 (Free Abstract)
4. Practically Radical (book) by William C Taylor
5. Glass Houses (book) by Louise Penny
6. Raymond Townsend MD, Professor of Medicine, Director of Hypertension Program UPENN
7. Consumer Reports article on BP monitors (Subscription required)
8. JAMA Clinical Reviews podcast on Understanding the new hypertension guidelines
9. Tips for Choosing a BP monitor from Heart.org http://heartinsight.heart.org/Summer-2016/Tips-for-Choosing-a-Blood-Pressure-Monitor/
10. List of validated HBPM from British and Irish HTN Society https://bihsoc.org/bp-monitors/for-home-use/ . Tips on using this list found here https://bihsoc.org/bp-monitors/
11. Qaseem, A., Wilt, T. J., Rich, R., Humphrey, L. L., Frost, J., & Forciea, M. A. (2017). Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians Pharmacologic Treatment of Hypertension in Adults. Annals of Internal Medicine, 166(6), 430-437. (Free)
12. Adam S. Cifu, Andrew M. Davis. Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. JAMA. 2017;318(21):2132–2134. doi:10.1001/jama.2017.18706 (FREE)
13. Whelton, PK et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017;HYP.0000000000000065, originally published November 13, 2017 (FREE)
14. #ACCJournal Club from Twitter December 20, 2017 #ACCJournalClub
15. Agarwal, R. Implications of Blood Pressure Measurement Technique for Implementation of Systolic Blood Pressure Intervention Trial (SPRINT). J Am Heart Assoc. 2017 Feb; 6(2): e004536. Published online 2017 Feb 3. doi:  10.1161/JAHA.116.004536 (FREE)
16. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies The Lancet , Volume 360 , Issue 9349 , 1903 – 1913 (Subscription required)
17. Angeli, Fabio, et al. “White-coat hypertension in adults.” Blood pressure monitoring 10.6 (2005): 301-305.
18. Juraschek, Stephen P., et al. “Association of History of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults.” JAMA internal medicine 177.9 (2017): 1316-1323.
19. Kavey, Rae-Ellen W., et al. “American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood.” Circulation 107.11 (2003): 1562-1566.
20. Vidal-Petiot, Emmanuelle, et al. “Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study.” The Lancet 388.10056 (2016): 2142-2152.
21. Cabrera D et al. More Than Likes and Tweets: Creating Social Media Portfolios for Academic Promotion and Tenure. JGME August 2017, Vol. 9, No. 4, pp. 421-425. (FREE)