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When Guidelines Cause Hypertension

      The 2017 ACC/AHA Hypertension Guidelines
      • Whelton PK
      • Carey RM
      • Aronow WS
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.
      lowered the threshold for diagnosing hypertension from a blood pressure of ≥140/90 mm Hg to ≥130/80 mm Hg. In the United States, this effectively increases the number of adults diagnosed as “hypertensive” from 72 to 103 million.
      • Bakris G
      • Sorrentino M
      Redefining hypertension–assessing the new blood-pressure guidelines.
      It has been stated that “by reclassifying people formerly considered to have pre-hypertension as having hypertension, the Guidelines create a new level of disease affecting people previously deemed healthy.”
      • Bakris G
      • Sorrentino M
      Redefining hypertension–assessing the new blood-pressure guidelines.
      The fundamental problem with this approach is that the Guidelines treat high blood pressure as a disease rather than a major cause of diseases, such as stroke and myocardial infarction. The distinction between a cause of disease and the disease itself is important. Setting an arbitrary blood pressure cut-off to distinguish “healthy” from “diseased” individuals is a flawed concept. Blood pressure in older adults is endemically high and, if lowered, reduces the incidence of blood pressure–related diseases. Acknowledging this would avoid falsely classifying millions of people as “patients” when virtually all older adults stand to benefit from lower blood pressure. Requiring measurement of blood pressure to determine who should receive preventive medication needlessly medicalizes millions of people and simultaneously denies potentially life-saving blood pressure reduction to millions more.
      Setting an arbitrary blood pressure cut-off for diagnosing hypertension distracts attention from the value of broadly lowering blood pressure, thereby reducing the population burden of blood pressure–related diseases such as stroke, myocardial infarction, and kidney failure—all leading causes of death and disability worldwide.
      A population-based preventive medicine approach to reducing blood pressure would avoid labeling people as “hypertensive” while simultaneously preventing many from becoming patients. It is already widely accepted that population-wide dietary salt reduction to lower blood pressure is beneficial. Notwithstanding rare contraindications, nearly everybody middle aged and over would benefit from a daily blood pressure–lowering medication by preventing a heart attack or stroke, provided, of course, that they do not die of a noncardiovascular disorder first. Ample evidence supports this approach.
      Clinical trials have found that low-dose, combination blood pressure medication is effective.
      • Law MR
      • Wald NJ
      • Morris JK
      • Jordan RE
      Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.
      The rare side effects it causes can easily be managed through symptom reporting. The benefits are substantial: for example, in patients aged 50 years or older, lowering blood pressure by 10 mm Hg diastolic (or 20 mm Hg systolic) roughly halves the incidence of stroke.
      • Law MR
      • Wald NJ
      • Morris JK
      • Jordan RE
      Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.
      Prospective Studies Collaboration
      Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
      In light of these facts, the goal for people above a specified age should be to lower blood pressure in all and measure it in some rather than measure blood pressure in all and reduce it in some, as is currently practiced. Of course, blood pressure measurement can be easily carried out when requested by people on medication, or when prompted by symptoms such as dizziness. However, measurement of blood pressure should not be required to determine eligibility for preventive treatment.
      In addition to substantially reducing the incidence of heart attack and stroke, adopting an age-based population strategy would markedly lower health care costs.

      Garber S, Gates S, Keeler E, et al. Redirecting Innovation in US Healthcare: Options to Decrease Spending and Increase Value. Santa Monica, CA: RAND Health; 2014.

      Individuals would no longer be required to undergo a physical examination, risk assessment, pretreatment screening, and serial blood testing to determine their eligibility for preventive medication. Countless families, and society at large, would be spared the expense of hospital admission, long-term care, and premature death from preventable heart attacks, strokes, and hypertensive kidney disease. This age-based population strategy is not conceptually different from advising women to take folic acid supplements periconceptionally to prevent neural tube defects, or prophylactically administering antimalarials to travelers and local citizens in parts of the world where the disease is endemic.
      Asserting that blood pressure reduction should not be determined by an individual's blood pressure may strike many as counterintuitive, but it is based on 3 observations: 1) the relationship between blood pressure and cardiovascular disease is a continuous function, increasing in a log-linear manner from the lowest levels of blood pressure recorded in a population;
      Prospective Studies Collaboration
      Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
      • Law MR
      • Morris JK
      • Wald NJ
      Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.
      2) there is, from a practical perspective, no threshold below which lowering blood pressure does not confer some reduction in risk; and 3) the magnitude of benefit from lowering blood pressure depends on an individual's underlying level of risk, which is predominantly determined by age rather than initial blood pressure level. In fact, from about age 20 years on, an individual's risk of sustaining a first heart attack or stroke approximately doubles every 7 years
      • Law M
      • Wald N
      • Morris J
      Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy.
      (Figure). We cannot reduce age, but we can lower blood pressure.
      Fig 1
      FigureRelative risk of a first heart attack or stroke according to age. Based on Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess. 2003;7(31):1-94.
      Once-a-day preventive medication can, on average, lower blood pressure levels in people aged 60 years to levels typically seen in 20 year olds. The case for a paradigm shift in managing high blood pressure is not new. It is underpinned by more than a decade of evidence from observational epidemiologic studies and randomized clinical trials.
      • Law MR
      • Wald NJ
      • Morris JK
      • Jordan RE
      Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.
      Prospective Studies Collaboration
      Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
      Resistance to change is due to several factors, including the misconception that hypertension is a disease rather than a cause of multiple diseases, failure to recognize that elevated blood pressure is “usual” among older adults, a “treat to target” mind-set grounded in the false premise that achieving a “target” blood pressure is optimal care, and decades of teaching about the management of “hypertension”. Unfortunately, the failure to rethink our approach and take appropriate action is denying tens of millions the benefits of preventive care.
      In addition to perpetuating the status quo, the 2017 ACC/AHA Hypertension Guidelines are too long (481 pages including supplements), too prescriptive, and far too complex. Clinical guidelines should guide, not instruct; they should encourage progress rather than hold it back. Abandoning the view that hypertension is a disease in favor of regarding it as a cause of a disease and hence, adopting a population-based preventive approach, would encourage the development of simpler guidelines. Combining “hypertension” and “dyslipidemia” guidelines into a unified guideline would promote a broad-based approach to preventing cardiovascular disease and recognize that, with few exceptions, whenever medication is justified for lowering blood pressure, it is also justified for lowering low-density lipoprotein cholesterol. An age-based strategy that combines blood pressure– and low-density lipoprotein cholesterol–lowering medication would produce substantial gains in years of disease-free life without a heart attack or stroke.
      • Wald NJ
      • Morris JK
      Quantifying the health benefits of chronic disease prevention: a fresh approach using cardiovascular disease as an example.
      If the practice of medicine is as evidence based as we claim it to be, we should recognize that our long-standing approach to the diagnosis and treatment of hypertension has not produced the desired results. The Centers for Disease Control and Prevention endorsed the estimate that high blood pressure is the primary or contributing factor in the deaths of about 1000 Americans each day. Moreover, by categorizing people into 2 classes (“hypertensive” and “normotensive”), this will be an underestimate of the true disease burden arising from the continuous increase in risk associated with increasing blood pressure. Rather than continue to do the same thing and expect a different result, it's time to embrace a population-based paradigm that is simpler, cheaper, and likely to be much more effective.

      References

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        • Carey RM
        • Aronow WS
        • et al.
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        • Sorrentino M
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        • Wald NJ
        • Morris JK
        • Jordan RE
        Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.
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        • Prospective Studies Collaboration
        Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
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      1. Garber S, Gates S, Keeler E, et al. Redirecting Innovation in US Healthcare: Options to Decrease Spending and Increase Value. Santa Monica, CA: RAND Health; 2014.

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        • Morris JK
        • Wald NJ
        Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.
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        • Wald N
        • Morris J
        Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy.
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        • Morris JK
        Quantifying the health benefits of chronic disease prevention: a fresh approach using cardiovascular disease as an example.
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