Editorial Raises Concerns With Recommendations to Increase SBP in Elderly

Some panel members appointed to the Institute of Medicine's Eighth Joint National Committee (JNC8) to develop new hypertension guidelines are speaking out against the recommendation to raise the threshold at which older adults begin taking medication to control hypertension. In an editorial published Jan. 13 in the Annals of Internal Medicine, several members explain why they voted against relaxing systolic blood pressure (SBP) targets to 150 mmHg for patients aged 60 and older without diabetes mellitus or chronic kidney disease (CKD).

The JNC8 recommendations published in December 2013 in the Journal of the American Medical Association, suggest that in absence of definitive evidence, raising the SBP goal from its current <140 mmHg level was the optimal approach. However, according to the authors of the new Annals of Internal Medicine editorial, there were some panel members that felt there was insufficient evidence to increase the SBP goal, citing concerns that raising the goal may increase the risk of cardiovascular disease and negatively impact the "remarkable progress" being made in reducing cardiovascular mortality in older Americans. "Because of the overall evidence, including the RCT data reviewed by the panel, and decline in CVD mortality, we concluded that the evidence for raising a BP target in high risk populations should be at least as strong as the evidence required to lower the recommended BP target," the editorial authors stated. "In addition, one target would simplify implementation for clinicians."

The editorial does agree, however, with recommendations that SBP < 150 mmHg for frail individuals ≥ age 80 is a reasonable alternative approach to addressing concerns that elderly patients are at higher risk for treatment-related serious events. The authors also add that "a target SBP < 140 mmHg for patients <80 years would also be in line with guidelines from Europe, Canada, the ACCF/AHA, the United Kingdom, and the ASH/ISH."

Moving forward, the ACC and the American Heart Association (AHA) Task Force on Practice Guidelines has begun the process of developing the collaborative model to updating the national hypertension guidelines in partnership with the National Heart, Lung, and Blood Institute (NHLBI) which will provide an updated systematic evidence review, informed by the relevant critical clinical questions. In a joint statement, the ACC and AHA said they are seeking appropriate partners to begin this work in early 2014. From there, the writing group will draft recommendations followed by a peer and stakeholder review process. Once the review process is complete, the ACC/AHA and partnering organizations will publish the guidelines in 2015 for clinicians to follow as the national standard for hypertension prevention and treatment. "Until this process is complete and the revised hypertension guidelines are formally published, the ACC/AHA recognize the most recent hypertension guidelines, published in 2004 by the Joint National Committee (JNC 7), as the national standard," they said.

Clinical Topics: Prevention, Hypertension

Keywords: National Heart, Lung, and Blood Institute (U.S.), Blood Pressure, Hypertension, Institute of Medicine (U.S.)

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