So About Those New Blood Pressure Guidelines…
Posted on Wednesday, January 31st, 2018
You’ve probably heard the one about the change in blood pressure guidelines. It was issued late last year by the American Heart Association (AHA) and the American College of Cardiology (AAC), and it garnered a lot of media attention. A lot.
Suddenly, millions of Americans became newly eligible for drugs to get their BP below the new magical number of 120/80.
Just as with lowered blood sugar thresholds for diabetes (or, ‘pre-diabetes’), and lower bone density thresholds for osteoporosis (or, ‘osteopenia’), the new ACC/AHA guidelines qualify millions of us for a ‘disease‘ we apparently did not have the day before the guidelines were released.
But what didn’t get so much attention is that large segments of the medical community disagreed with the revised guidelines.
The American Academy of Family Physicians (AAFP), for instance, refused to accept them. This organization of roughly 130,000 physicians expressed concern about how much weight was given to a single problematic study, as well as potential conflicts of interest.
More, their own reviews with the American College of Physicians (ACP) showed that while “there might be a small benefit of lower treatment targets in reducing cardiovascular events,”
no benefit was observed in all-cause mortality, cardiovascular disease mortality, myocardial infarction or renal events. Therefore, the AAFP and ACP recommended considering treatment to lower targets for some patients in the context of shared decision-making.
“Family physicians approach hypertension treatment on an individualized basis, taking into account patients’ histories, risk factors, preferences and resources,” AAFP President Michael Munger, M.D., told AAFP News. “We will maintain making informed decisions with patients while considering potential benefits and harms.”
Similarly, a recent commentary in the New England Journal of Medicine argued against a one-size-fits-all approach, as though a single health measure could ever be appropriate for all patients; as though the blood pressure goal of a 30-year old should be the same as that of an 80-year old. Such guidelines, they said, are “problematic.”
Some people with blood pressures of 130 to 139/80 to 89 mm Hg who are at higher cardiovascular risk may benefit from earlier intervention, but though such a broad-brush approach may be fine from a public health perspective, it could overburden our primary care physician workforce. Proper blood-pressure measurement is critical but time consuming. The unintended consequence may be that many people, now labeled as patients with hypertension, receive pharmacologic therapy that’s unlikely to provide benefit given their low absolute risk, and they may therefore experience unnecessary adverse events.
Dr.Kenny Lin of Georgetown University would seem to agree.
There’s some point where lower is not better, and I think we’re probably getting close to that point…. If you’re going to make something a ‘disease’ you better have the evidence to support that, and you better have something significant to offer the patient that translates into quality of life. If my patients hit a blood pressure of 130/80 I’m already talking to them about lifestyle changes. So how does redefining this as a ‘disease’ — the new hypertension — really help them? I don’t think we should be labeling people as hypertensive — or even pre-hypertensive — unless the evidence is strong that in doing so, and treating accordingly, we’re going to truly make a difference. In this case, I don’t think we have that evidence.
The situation with these guidelines offers a stark reminder of why individualized medicine matters so much.
You are a person. Blood pressure is just one piece of your total health story – just as root canal teeth, cavitations, or amalgams are just one piece. Each part of your current health status needs to be seen in the context of your total health story – all the challenges you may be facing, all the qualities that are in your favor.
The big picture matters.
PS: Dr. Brownstein offers another great critique of the creation of new patients through ever-changing health guidelines. We encourage you to hop over to his blog and check it out.
Image by Joey Parsons, via Flickr