Goals for older adults: Irreconcilable differences?
How was it that the ACC/AHA guideline and the ACP/AAFP guideline reached such disparate conclusions about the appropriate blood pressure treatment target for patients aged 60 years or older?
Dr. Devan Kansagara
“A critical difference between the two guidelines stems from how potential [treatment] harms and patient values and preferences were considered. Our review and the ACP/AAFP guidelines extensively considered harms and treatment burden associated with lower blood pressure treatment targets. Lower targets did not increase the risk for fractures, falls, or cognitive declines, but they were associated with more symptomatic hypotension, syncope, and greater medication burden. The ACP/AAFP believed that there is likely to be significant variation in how individual patients might weigh the small potential benefit of aggressive blood pressure control against the potential harms and treatment burden. The ACC/AHA guidelines and the systematic review on which they were based did not include an assessment of harms,” Dr. Kansagara said in an interview. Dr. Casey maintained that the ACC/AHA literature review did consider potential harms from treatment.
“The ACC/AHA guidelines also considered results from observational studies. The ACP/AAFP did not. A number of studies show that progressively higher levels of blood pressure are associated with higher rates of cardiovascular disease events and mortality. But some observational studies showed that blood pressures in the low to low-normal range are associated with higher mortality. The problem with observational studies is that there are many reasons why a population with higher blood pressure may have worse outcomes. That does not mean that using medication to reduce blood pressure will improve outcomes.”
Other experts noted that while the ACP/AAFP data review and guideline took the SPRINT results into account, their review occurred too soon to also include two other important analyses that came down in favor of the less than 130/80 mm Hg target and were included in the ACC/AHA review: A meta-analysis of 42 trials with more than 144,000 patients that showed patients treated to a systolic blood pressure of 120-124 mm Hg had significantly fewer deaths and cardiovascular disease events compared with patients with higher achieved blood pressures (JAMA Cardiology, 2017 July;2[7]:775-81); and a second meta-analysis of 17 trials with more than 55,000 patients that showed a target systolic pressure of less than 130 mm Hg produced the best balance of efficacy and safety (Am J Med. 2017 June;130[6]:707-19).
The bottom line, said Dr. Kansagara, is that regardless of which guideline a physician follows, the publication of both last year will mean that “patients and their providers will likely have more conversations about blood pressure treatment. Both guidelines underscore the need to at least consider lower blood pressure targets in patients at high cardiovascular disease risk or in those who have had a cardiovascular disease event.” As a result of the two 2017 guidelines “I think PCPs will pay more attention to blood pressure as a modifiable risk factor.”
Dr. Casey, Dr. Whelton, Dr. Cohen, Dr. Kansagara, and Dr. Ioannidis had no disclosures.
This is part one of a two-part series. Part two will explore how the approach to diagnosis and management of hypertension spelled out in the ACC/AHA guidelines fits into the protocol-driven, data-monitored, team-delivered primary care model that has come to dominate U.S. primary care in the decade following passage of the Affordable Care Act.