番茄社区

Not all of the panel members appointed to the Eighth Joint National Committee (JNC 8) behind the most recent hypertension guidelines agreed with loosening blood pressure treatment thresholds for most older patients.

The guidance, which was published last month in the Journal of the American Medical Association, contained a recommendation that the threshold for initiating anti-hypertensive treatment and the goal below which systolic blood pressure should be lowered should be raised to 150 mm Hg from 140 mm Hg for individuals 60 and older who did not have diabetes or chronic kidney disease (CKD).

But in a commentary in Annals of Internal Medicine, , of University Hospitals Case Medical Center in Cleveland, and four of the other panelists presented their case for why the . Their disagreement was noted in the original guideline publication but the reasons behind it were not detailed.

"We, the panel minority, felt that evidence was insufficient to increase the systolic blood pressure goal from its current less than 140 mm Hg level, concerned that raising the goal may in fact cause harm by increasing the risk of cardiovascular disease and partially undoing the remarkable progress in reducing cardiovascular mortality in Americans greater than 60 years old," they wrote.

Wright said to 番茄社区, "The intent of the article [in Annals] was not to attack the guideline published in JAMA last month. As authors of that guideline, I and my co-authors strongly support that document, its evidence-based approach, and its other recommendations."

The concerns of Wright and the other dissenting members of the panel centered around the following points:

• The evidence was insufficient to support raising the threshold and, thus, it should not have been changed.
• A higher blood pressure target likely would lessen the intensity of anti-hypertensive treatment in certain high-risk groups, including blacks, those with multiple cardiovascular risk factors (other than diabetes or CKD), and those with clinical cardiovascular disease.
• Using a higher threshold could potentially undo the gains that have been made over recent decades in cardiovascular disease, and, in particular, death from stroke.
• The loosening of the threshold would be applied to older individuals, who already have a greater risk of cardiovascular events compared with their younger counterparts.
• The safety of bringing systolic blood pressure below 140 mm Hg has been established in randomized trials.

"In the absence of definitive evidence defining the optimal systolic blood pressure target, observational studies and randomized controlled trial data that the panel did not systematically review more strongly support the less than 140 mm Hg goal, especially in high-risk individuals," Wright and his colleagues wrote, noting that other recent guidelines from Europe, Canada, and the U.S. stuck with the lower goal.

They agreed, however, with some other guideline-drafting organizations that using a less strict treatment goal among individuals 80 or older -- who would be more likely to be affected by frailty -- makes sense.

The impact of the latest guidance -- and the disagreement among the panel members -- remains unclear, but it is possible that clinicians will wait for hypertension recommendations from the American Heart Association and the American College of Cardiology, which are expected to be completed by early 2015.

From the American Heart Association:

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