New Hypertension Guidelines Controversial, But Beneficial

Joshua D. Bundy, PhD, MPH

A study comparing the 2017 American College of Cardiology/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults with the previous 2014 guidelines found that the new guideline significantly increased the prevalence of hypertension by 31.3 million (13.5%) US adults.

The 2017 guidelines, announced last fall at the AHA Scientific Sessions, defined hypertension as blood pressure (BP) at or above 130/80 mm Hg, while the 2014 guidelines identified hypertension for patients with BP ≥140/90 mm Hg.

According to these definitions, the 2017 guidelines identified the prevalence of hypertension as 45.4% (95% CI, 43.9%-46.9%), representing 105.3 (95% CI, 101.9-108.8) million US adults. This was significantly higher than estimates according to the 2014 guidelines, which indicated a prevalence of 32.0% (95% CI, 30.3%-33.6%) or 74.1 (95% CI, 70.3-77.9) million individuals.

Compared to the full achievement of the 2014 guideline, the fulfillment of the 2016 guideline would reduce major cardiovascular disease (CVD) events, including nonfatal strokes, nonfatal myocardial infarction, and cardiovascular deaths, by 23% annually in US adults ≥40 years.

If all Americans 40 years an older met the 2017 guidelines treatment goals for systolic BP, 610,000 major CVD events and 334,000 total deaths could be prevented annually, estimated study authors Joshua D. Bundy, PhD, MPH; Katherine T. Mills, PhD, MSPH; Jing Chen, MD, MSc; et al.

“While both estimates are based on several assumptions, the major message is that the more complete achievement of either guideline treatment goal substantially reduces CVD events in the United States,” wrote Lawrence J. Fine, MD, DrPH; David C. Goff, MD, PhD; and George A. Mensah, MD in an editorial response to the study.

“We estimated that the reductions of CVD events and total deaths were greater under the 2017 hypertension guideline even when fewer patients achieve the BP treatment target compared with the 2014 hypertension guideline,” added Bundy, et al.

Additionally, the study authors included estimates of the adverse events likely to occur as a result of the full implementation of the 2017 guidelines. They estimated the number of adverse events including hypotension (62; 95% CI, 37 to 86), syncope (32; 95% CI, 9 to 54), electrolyte abnormality (31; 95% CI, 11 to 51), and acute kidney injury or acute renal failure (79; 95% CI, 25 to 134).

While the risks exist, the authors noted that the numbers needed to harm for adverse events are considerably larger than the numbers needed to treat for CVD and all-cause mortality risk reduction.

“These risks are real but are convincingly infrequent and pale in comparison with the burden of stroke, heart failure, and death,” wrote Clyde W. Yancy, MD, MSc, and Gregg C. Fonarow, MD in an editor’s note. “We would surmise that treatment of hypertension per the 2017 Hypertension Guidelines is safe.”

The editorial authors also called attention to the need for efforts to prevent hypertension, beginning in childhood and young adulthood. Citing prospective cohort data from Coronary Artery Risk Development in Young Adults (CARDIA) study, they point out that preventing hypertension may be possible and would reduce the need for pharmacologic treatment later in life.

“Preventing childhood obesity, reducing adult weight gain, and healthier diets, such as the Dietary Approaches to Stop Hypertension (DASH)/low-sodium dietary pattern, may all be important in an effective strategy for reducing hypertension prevalence, thereby reducing the number of individuals who require medications,” said Fine and colleagues.

Based on the risk and benefits presented by Bundy, et al., the editors called for barriers to the 2017 guidelines to fall.

“It is our opinion that the time is on us to implement,” wrote Yancy and Fonarow.

The study, “Estimating the Association of the 2017 and 2014 Hypertension Guidelines With Cardiovascular Events and Deaths in US Adults,” was published in JAMA Cardiology.