Hypertension Management: Making Sense of the Guidelines

At the 2015 annual meeting of the American Pharmacists Association (APhA), Joseph Saseen, PharmD, BCPS, BCACP, and Vincent Willey, PharmD, BCACP, discussed changes to blood pressure guidelines over the past 2 years.

These guidelines include the European Society of Hypertension/European Society of Cardiology (ESH/ESC), Joint National Commission (JNC 8), American Society of Hypertension/International Society of Hypertension (ASH/ISH), American Diabetes Association (ADA) Standards of Medical Care in Diabetes, American College of Cardiology/American Heart Association (ACC/AHA), and Canadian Hypertension Education Program (CHEP) guidelines.

Foremost among these new guidelines are the JNC 8 and ASH/ISH, which are largely consistent in their recommendations.

According to Drs. Saseen and Willey, hypertension affects approximately one-third of adults in the United States and is the most common chronic condition dealt with by health care professionals. It has often been stated that cardiovascular risk and stroke risk double with each 20—mm Hg increase in systolic blood pressure and each 10–mm Hg increase in diastolic blood pressure. Hypertension is also associated with many features of modern life, such as obesity, high-salt diets, and increasing lifespans.

The JNC 8 guidelines were developed based on 3 major questions:

· At what blood pressure level should pharmacotherapy start?

· What should be the treatment goal levels?

· Which medications are best?

Rather than relying on metaanalysis, the JNC 8 panel relied on large clinical studies. Under JNC 8, 4 classes of medications are useful for initial therapy, including thiazides, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), and calcium channel blockers (CCBs), plus other medications based on compelling indications (eg, beta-blockers for heart failure).

Blood pressure goals in older patients (patients older than 60 years and older than 80 years per ASH/ISH) were increased to <150/90 mm Hg; for younger patients, panelists recommend focusing on a diastolic blood pressure goal of <90 mm Hg. In addition, in patients with diabetes, a blood pressure goal of <140/90 mm Hg has been adopted, instead of the previous <130/80 mm Hg goal of JNC 7.

Similarly, patients with chronic kidney disease now have a blood pressure target of <140/90 mm Hg, with ACEIs preferred as initial therapies in patients who are not of African descent, and as add-on therapies to CCBs and/or thiazides in patients of African descent, and especially in patients of African descent with kidney problems.

The guidelines also note that combinations of drugs are usually necessary for control of blood pressure (1 drug is usually insufficient). However, 2-drug combinations of ACEIs and ARBs are not recommended.

While health care professionals have known how to treat hypertension for several decades, Dr. Saseen has seen improvements in hypertension management in the past few years.

“We’re better or more savvy at picking optimal and appropriate combination therapies,” Dr. Saseen told Pharmacy Times at APhA 2015. “We really clearly know that certain combinations are harmful…We’re a little bit smarter on the type of cocktails or combinations that we use to treat the average hypertensive patient.”

Dr. Saseen added that it is important to recognize JNC 8 recommendations for what they really are, Dr. Saseen added.

“I shy away from calling them [JNC 8] guidelines since they aren’t representative of a national organization,” Dr. Saseen said.

In an important departure from past guidelines, and even from JNC 8, the ASH/ISH guidelines recommend use of 2-drug combinations as initial therapy in patients with a blood pressure >160/100 mm Hg at baseline.

These recommendations are not a replacement for clinical judgement, and patient-specific factors and comorbidities should always be taken into account when deciding on the appropriate management of high blood pressure.