New High Blood Pressure Guidelines Say Seniors 60 Up Do Not Need
Treatment Below 150 Over 90
One of three editorials
(below news story) in JAMA says it is likely that there will be
considerable controversy in hypertension treatment for the foreseeable
future; high blood pressure still 140/90
Dec. 18, 2013 – Seniors age 60 and over were given a little more room
before being treated for high blood pressure in a new guideline
developed by an expert panel and published today in the Journal of the
American Medical Association (JAMA). They recommend treatment for
hypertension at 150-over-90 mm Hg, rather than 140/90, which still
remains the defined level for high blood pressure.
People ages 60 and older were focused on in the guidelines because they
"are a unique population and we are concerned about the number of
medications that may be required," according to a report by
Bloomberg News quoting Paul James,
the lead author of the article and chairman of family medicine at the
University of Iowa in Iowa City.
Hypertension is the most common condition seen in primary care and leads
to heart attack, stroke, kidney failure, and death if not detected early
and treated appropriately.
"Patients want to be assured that blood pressure (BP) treatment will
reduce their disease burden, while clinicians want guidance on
hypertension management using the best scientific evidence. This report
takes a rigorous, evidence-based approach to recommend treatment
thresholds, goals, and medications in the management of hypertension in
adults," according to information in the article.
The report, the "2014 Evidence-Based Guideline for the Management of
High Blood Pressure in Adults," is from panel members appointed to the
Eighth Joint National Committee.
The guideline addresses three questions related to high BP management:
1. At what BP should medication be started in patients with
2. What BP goal should patients achieve to know they are
enjoying proven health benefits from their medication?
3. What are the best choices for medications to begin
treatment for high blood pressure?
The nine recommendations in the guideline answer those three questions.
In summary, "There is strong evidence to support treating hypertensive
persons aged 60 years or older to a BP goal of less than 150/90 mm Hg
and hypertensive persons 30 through 59 years of age to a diastolic goal
of less than 90 mm Hg.”
There is, however, “insufficient evidence in hypertensive persons
younger than 60 years for a systolic goal, or in those younger than 30
years for a diastolic goal, so the panel recommends a BP of less than
140/90 mm Hg for those groups based on expert opinion,” the report says.
Also called: Benign
essential hypertension, Essential hypertension, HBP, HTN,
Blood pressure is the
force of your blood pushing against the walls of your arteries.
Each time your heart beats, it pumps out blood into the
Your blood pressure is
highest when your heart beats, pumping the blood. This is called
systolic pressure. When your heart is at rest, between beats,
your blood pressure falls. This is the diastolic pressure.
Your blood pressure
reading uses these two numbers, the systolic and diastolic
pressures. Usually they are written one above or before the
other. A reading of
● 120/80 or lower is
normal blood pressure
● 140/90 or higher is
high blood pressure
● Between 120 and 139
for the top number, or between 80 and 89 for the bottom number
“The same thresholds and goals are recommended for hypertensive adults
with diabetes or nondiabetic chronic kidney disease (CKD) as for the
general hypertensive population younger than 60 years."
"There is moderate evidence to support initiating drug treatment with an
angiotensin-converting enzyme inhibitor, angiotensin receptor blocker,
calcium channel blocker, or thiazide-type diuretic in the nonblack
hypertensive population, including those with diabetes. In the black
hypertensive population, including those with diabetes, a calcium
channel blocker or thiazide-type diuretic is recommended as initial
“There is moderate evidence to support initial or add-on
antihypertensive therapy with an angiotensin-converting enzyme inhibitor
or angiotensin receptor blocker in persons with CKD to improve kidney
The authors emphasize important differences from the past versions of
the guideline. For development of these recommendations, "evidence was
drawn from randomized controlled trials (RCTs), which represent the gold
standard for determining efficacy and effectiveness. Evidence quality
and recommendations were graded based on their effect on important
health outcomes," the authors write. These guidelines also sought to
establish "similar treatment goals for all hypertensive populations
except when evidence … supports different goals for a particular
Also, rather than defining hypertension, the panel addressed threshold
blood pressure for starting treatment.
The report recommends beginning treatment for people aged 60 and older
at a blood pressure of 150/90, and treating to below that level based on
trial evidence, but the authors emphasize that "this evidence-based
guideline has not redefined high BP and the panel believes that the
140/90 mm Hg definition from Joint National Committee 7 remains
reasonable." Lifestyle interventions should be used for everyone with
blood pressures in this range.
They add that with each strategy, clinicians should regularly assess BP,
encourage evidence-based lifestyle and adherence interventions, and
adjust treatment until goal BP is attained and maintained.
"For all persons with hypertension, the potential benefits of a healthy
diet, weight control, and regular exercise cannot be overemphasized.
These lifestyle treatments have the potential to improve BP control and
even reduce medication needs."
"The recommendations from this evidence-based guideline from panel
members appointed to the Eighth Joint National Committee (JNC 8) offer
clinicians an analysis of what is known and not known about BP treatment
thresholds, goals, and drug treatment strategies to achieve those goals
based on evidence from RCTs.
“However, these recommendations are not a substitute for clinical
judgment, and decisions about care must carefully consider and
incorporate the clinical characteristics and circumstances of each
individual patient. We hope that the algorithm will facilitate
implementation and be useful to busy clinicians. The strong evidence
base of this report should inform quality measures for the treatment of
patients with hypertension," the authors conclude.
Editorial: Assessing the Trustworthiness of the Guideline for
Management of High Blood Pressure in Adults
Harold C. Sox, M.D., of the Dartmouth Institute for Health Policy and
Clinical Practice, Hanover, N.H., calls attention to the fact that the
2014 hypertension guideline did not undergo specialty society review as
was originally planned, and he addresses the trustworthiness of the
guideline, and guidelines in general, in an editorial.
He asks "First, what are the key elements of trustworthiness in a
guideline? Second, how does this guideline measure up? Third, what is
the role of expert review of guidelines? Fourth, what is the pathway to
guidelines that the public can trust?"
He ultimately concludes that the panel of guideline authors, by agreeing
to share its record of the review process with anyone who asks, meets
the standard of transparency and review that proper guideline
development now requires. "A rigorous, transparent process for
developing and reviewing guidelines matters a great deal because
guidelines are increasingly driving the practice of medicine."
Editorial: Updated Guidelines for Management of High Blood Pressure -
Recommendations, Review, and Responsibility
Howard Bauchner, M.D., Editor in Chief, JAMA, Chicago, and
colleagues comment on the production of guidelines.
"Producing guidelines in the United States has become increasingly more
complicated and contentious. This likely reflects the strongly held
beliefs of many stakeholders, including physicians and patients.
“For instance, the Infectious Diseases Society of America was embroiled
in complicated legal proceedings after producing guidelines for the
management of Lyme disease. There was a great deal of reaction from
health professionals and the public after the U.S. Preventive Services
Task Force released updated recommendations regarding mammography
screening in women.
“Recently, in June 2013, the NHLBI announced its decision to discontinue
its participation in the development of clinical guidelines, including
the hypertension guideline. (Accordingly, as the authors clearly
indicate, 'This report is therefore not an NHLBI sanctioned report and
does not reflect the views of NHLBI.') Instead, the NHLBI has partnered
with and shifted the responsibility for generating guideline products to
selected specialty organizations, such as the American College of
Cardiology and the American Heart Association, whose recently released
guidelines on assessment of cardiovascular risk and treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk have been met
"Rigorously developed, thoroughly reviewed, evidence-based, trustworthy
guidelines are critical to advance clinical medicine and improve health,
and biomedical journals have a responsibility to disseminate important
guidelines in an objective manner.
“We are pleased to publish the '2014 Evidence-Based Guideline for the
Management of High Blood Pressure in Adults' from the panel members
appointed to the Eighth Joint National Committee (JNC8). 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
Editorial: Recommendations for Treating Hypertension - What Are the
Right Goals and Purpose?
Eric D. Peterson, M.D., M.P.H., of Duke University Medical Center,
Durham, N.C., and colleagues write in an accompanying editorial that
"while it is likely that there will be considerable controversy in
hypertension treatment for the foreseeable future, several critical next
steps are needed."
"First, larger RCTs need to compare different BP thresholds in diverse
patient populations. Ideally, these investigations would be conducted
using the evolving strategies of practical clinical trials designs to
improve their efficiency and real-world generalizability.
“Second, there is an important need to create a national consensus group
to draft an updated comprehensive practice guideline that would
harmonize the hypertension guideline with other cardiovascular risk
guidelines and recommendations, thereby resulting in a more coherent
overall cardiovascular prevention strategy. …
“Third, the process of translating practice guidelines into performance
measures needs to be more deliberate. For example, performance measures
derived from guidelines need to be cognizant of the potential unintended
consequences if treatment goals are set too strict or adherence to these
is too rigid.
“Finally, once the right targets for BP thresholds are determined,
patients and physicians need to work together to consistently achieve
these new goals."
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