NEW YORK – The rise of the medical home along with the publication of large clinical trials will likely influence updated Joint National Committee guidelines for the management of hypertension, according to several experts at the annual meeting of the American Society of Hypertension.
Updated guidelines may and should address home and ambulatory monitoring of blood pressure, greater reliance on global risk assessment, a revision of target blood pressures in high-risk groups, greater use of individualization in setting pressure targets, greater clarity on when to start drug therapy, earlier use of fixed-dose combination antihypertensive therapy, revocation of beta-blockers as frontline therapy, and specific recommendations on how to overcome therapeutic inertia, they said.
The panel of experts explored how hypertension management has evolved since the Seventh Report of the Joint National Committee (JNC 7) was published in 2003. According to the National Heart, Lung, and Blood Institute, JNC 8 is expected to be released next year. None of the panelists are members of the JNC guideline panel.
The so-called medical home – where a patient stays within a care system with a primary care physician coordinating care – is causing a "paradigm shift," according to Dr. Jan Basile, professor of medicine at the Medical University of South Carolina in Charleston. "We’ve always been paid for face-to-face interactions, and we really need to be paid for energy and effort," he said. "For example, why aren’t we incentivized to use novel means of tracking blood pressure at home through telemonitoring and other techniques?"
The reorganization of primary care and the publication of JNC 8 may create significant opportunities to get nonphysician members of the medical home team, such as nurses, pharmacists, and dieticians, more involved in controlling blood pressure, the panelists said. Dr. Angela Brown, assistant professor of medicine at Washington University, St. Louis, noted that hypertensive patients in her clinic already receive 6 months of dietician counseling. Dr. Leonard Fromer, a family physician and University of California, Los Angeles, faculty member, noted his network recently launched five care team pilot programs in large integrated networks.
Dr. George Bakris
Ambulatory monitoring may also play a more prominent role in the revised guidelines, according to Dr. George Bakris, president of the American Society of Hypertension and professor of medicine at the University of Chicago. "Ambulatory blood pressure is most likely going to be recommended for everyone who has documented nuanced hypertension, and the reasons for that include blood pressure variability, the dramatic increase in the appreciation of masked hypertension, and the dipping and nondipping phenomenon, all of which contribute to higher mortality," he said. Dr. Bakris was a member of the JNC 7 executive committee.
Personalized follow-up is also important to make sure patients get their medications and take them as directed, Dr. Basile said. "I or someone from my office staff often calls patients within 48 hours and asks them, ‘Have you filled your prescription? Are you taking the medications? Are you having any problems taking them?’ Someone in the medical home needs to do that."
Dr. Brown suggested that routine screening for albuminuria should become part of the global assessment for the hypertensive patient in the primary care setting. "It is very important from a risk assessment standpoint because it may guide our therapy," Dr. Brown said.
Dr. Basile wasn’t convinced. "I’m not sure we can afford to spend money on knowing how sick the patient is unless we can show that intervening in those we wouldn’t normally treat would make a difference," he said. Dr. Basile noted that the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed that when systolic blood pressures reached 120 mm Hg, microalbuminuria "melted away."
With regard to blood pressure targets, Dr. Bakris said he expects JNC 8 to continue the target of 140/90 mm Hg or less for most patients, and actually to also recommend that as a target for patients with diabetes and chronic kidney disease (currently recommended at 130/80 mm Hg or less in JNC 7). "It’s going to be less than 140/90 mm Hg for most people except for those with advanced kidney disease who have proteinuria," he said. In patients aged 80 years and older, the target pressure may be less than 150/80 mm Hg, according to Dr. Basile.
Meanwhile, Dr. Basile noted that the latest American Diabetes Association guidelines set the target for diabetics at 130/80 mm Hg, and that treatment should be tailored to the individual. "Individualization is going to be a very important word because perhaps, as in ACCORD, if your patient has had a stroke or is stroke prone, you might want to drive the blood pressure lower," Dr. Basile said. "But if the patient is not [stroke prone], you may not want to be as aggressive."