Contrasting Views on Blood Pressure Recommendations for Patients Over 60

At PriMed West in Anaheim, California, Karol E. Watson, MD, PhD, Professor of Medicine/Cardiology, Co-director, UCLA Program in Preventive Cardiology, discussed recent increases in the rate of cardiovascular deaths in the United States and reviewed strategies for the prevention of heart disease to an audience of primary care physicians.

These strategies involve control of hypertension, cholesterol levels, and obesity, and recommendations for diet and exercise.

Watson reviewed the tremendous progress over the past few decades in reducing mortality from two biggest killers in the US, heart disease and cancer. However, after decades of decline, Watson showed data demonstrating that heart disease mortality rates flattened 2011 to 2014 and actually increased in 2015.

Addressing hypertension, specifically the changes made by the 8^th Joint National Committee (JNC 8) in 2014 to relax the previous blood pressure goal of less than 140/90 for patients over the age of 60, Watson explained that a minority of the JNC 8 disagreed with the new recommendation and wrote their own, separate guidance: “We, the panel minority, believed that evidence was insufficient to increase the SBP goal from its current level of less than 140 mg Hg. — partially undoing the remarkable progress in reducing cardiovascular mortality in Americans older than 60 years.”

As these recommendations were being made, Watson said, data from a study (SPRINT) of hypertensive high-risk patients (130 to 180 mm Hg) over the age of 50 were simultaneously released contrasting intensive (goal < 120 mm Hg) versus standard (goal <140 mm Hg) control of hypertension. “The intensively treated group showed a 25% relative risk reduction (RRR) for the primary outcome (myocardial infarction, stroke, heart failure, acute coronary syndrome, and CV death). Even more amazing, they had a 27% reduction in total mortality.”

Watson also reviewed serious adverse events in the SPRINT study (hypotension, syncope, electrolyte abnormalities, and acute kidney injury/renal failure) that were seen significantly more often with the intensively treated patients. However, Watson was not put off by this safety data. “When they looked at the risk/benefit ratio, they still favored treating to the more intensive level of goal to reduce cardiovascular events.” Watson added, “In general, the more intensive the pharmacological therapy, the more side-effects you are going to get. That’s true with everything, not just hypertension — dyslipidemia, diabetes, [etc.]”

Watson illuminated her points on prevention of heart disease by use of a fictional case study of a 61-year-old white male with hypertension (149/82), BMI of 35, and gout. Regarding whether intensive treatment would be warranted for the patient in the fictional case study, she said, “You have to make sure that the risk/benefit balance still favors treatment. In this case, it definitely did, so my recommendation would be to treat this patient intensively with amlodipine to control his hypertension.”

Watson concluded, “Prevention is where medicine gets hard. To prevent something that may or may not happen in the future is difficult. Preventive medicine also requires us to treat people who are not sick, so the first principle is to do no harm. The good news is that prevention works. And many preventive therapies that reduce risk of heart disease also work on dementia and cancer.”