December 05, 2017
By Will Boggs MD
NEW YORK (Reuters Health) - The American College of Cardiology/American Heart Association 2017 hypertension guidelines offer a wealth of detailed recommendations but lack guidance on a variety of important clinical issues, according to two University of Pennsylvania physicians.
In their December 5 Annals of Internal Medicine commentary, Dr. Jordana B. Cohen and Dr. Raymond R. Townsend from Penn’s Perelman School of Medicine, in Philadelphia, suggest that the guidelines provide "both too much and not enough of a good thing."
“I don't think that any cookie-cutter algorithm can direct us on how best to address issues regarding hypertension with our patients,” Dr. Cohen told Reuters Health by email. “The most important thing is to approach each patient as an individual, keeping in mind his or her unique combination of goals of care, comorbidities, prognosis, level of health literacy, and other barriers.”
By lowering the recommended threshold for diagnosing hypertension from 140/90 mmHg to 130/80 mmHg in the general population, the guidelines would triple the prevalence of hypertension for men and nearly double it for women younger than 45. But this younger group is poorly represented in existing trials of aggressive blood pressure (BP) lowering.
Moreover, the recommendations lack guidance on how to manage these low-risk patients when they don't respond to the recommended 3 to 6 months of lifestyle modifications.
“In patients who are young, with few comorbidities, the guidelines bring to light the importance of opening the conversation about healthy lifestyle changes; introducing more extreme measures may be excessive, depending on how elevated their blood pressure is,” Dr. Cohen said. “In patients with many comorbidities, these issues require a conversation about the patients' values, obstacles, pill burden, and balancing the risks and benefits of aiming for a particular goal.”
The new guidelines - available from the American College of Cardiology (http://bit.ly/2jfZHS8) - also emphasize the importance of accurate in- and out-of-office BP measurements and strongly encourage correct methodology. However, the commentators argue, such proper measurement can be extremely challenging in an era of declining insurance reimbursement and hectic clinic workflows.
“Where appropriate, encouraging self-monitoring of blood pressure is also an important use of our time with our patients, as it can be extremely important in our decision-making about management, and can empower them to be more involved in their own care,” Dr. Cohen said.
“The guidelines were clearly extremely meticulous and took a great deal of work to compile,” Dr. Cohen said. “However, given the striking changes made in these guidelines compared to other recent guidelines, and the potential impact they may have on the face of hypertension treatment in our country, we did want to shed light on some of the shortcomings.” She touched on four:
1. Given that the guidelines are long, the small details may overshadow the more important messages about lifestyle modification and home BP monitoring.
2. Many recommendations were applied too broadly, rather than specifically to the subgroups to which they are directly relevant, according to the pertinent trial evidence.
3. Although measuring BP accurately is an important goal for all healthcare providers, it is not always feasible, necessitating cautious interpretation of the guidelines in settings where perfect measurement cannot be achieved.
4. Policy makers, such as those who make decisions on reimbursement for MACRA (Medicare Access and CHIP Reauthorization Act), should consider the issues listed above when selecting reimbursement cutpoints.
"Guidelines are not a substitute for clinical judgment," Dr. Cohen concluded.
Dr. Philip Greenland from Northwestern University Feinberg School of Medicine in Chicago told Reuters Health by email, “I appreciate the concerns expressed here - yet, and this is important, all of their caveats were stated in the new ACC/AHA Guideline, itself.”
“And, in addition, it is always true that guidelines are not ‘rules’; they are recommendations that need to be considered in the context of the individual patient (i.e., clinical judgment),” he said. “The purpose of a guideline is to review the massive literature and provide a roadmap, but even the best maps require an experienced and intelligent user.”
“So, I see no real conflict between the guideline and the evidence, and that is really what is important,” Dr. Greenland concluded. “Why criticize the guideline because doctors do not measure blood pressure correctly? Or because medical visits are too short to provide good quality care?”
Ann Intern Med 2017.
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