Physicians rarely fight openly about the best ways to practice good medicine. That’s because doctors tend to accept the recommendations put forth by their professional organizations.
All that changed over the last several weeks. New guidelines (released on December 18 in JAMA) for treating people with high blood pressure have pitted the expert panel that created the revisions against cardiologists at the American Heart Association (AHA) and the American College of Cardiology (ACC).
In a nutshell, the Eighth Joint National Committee’s (JNC 8) recommendations for managing hypertension relaxes the targets established more than a decade earlier by the JNC 7. Instead of requiring doctors to treat everyone over the age of 60 if their blood pressure is greater than 140/90, the new guidelines say the target is 150/90 or less. That means that millions of people may no longer need to take pills if their systolic blood pressure (the upper number) is under 150.
This has made some cardiologists furious. They want to keep the old target at 140 or less for everyone, regardless of a patient’s age.
The furor over the new hypertension guidelines follows an equally divisive set of guidelines issued a few weeks earlier by the AHA and the ACC for cholesterol control with statins. Dr. Steve Nissen, Chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic, said on our radio show earlier this month that it was an error to create a CV Risk Calculator that puts so many more people on statins without first vetting it publicly: “I think it was a strategic mistake and it will mean that the guidelines will largely be ignored by the medical community.”
The American College of Cardiology and the American Heart Association have taken a very aggressive treatment approach to both hypertension and heart disease, regardless of the evidence. Their experts want more people on statins and more people taking blood pressure medicines. But the sand is shifting beneath them.
The experts who eased the standards for people over 60 spent five years combing the medical literature before releasing their new recommendations. If anything, they may not have relaxed the targets enough.
On August 15, 2012, the Cochrane Collaboration released a report titled “Benefits of Antihypertensive Drugs for Mild Hypertension Are Unclear.” This panel of experts reviewed all the available studies and concluded:
“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs [randomized controlled trials]. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”
You can read more about the Cochrane Collaboration publication at this link.
Let’s get one thing straight. Lower blood pressure is better than higher blood pressure when it comes to good health. But there are surprisingly few good studies demonstrating that medications make a difference for people in the mild to moderate range. (Meds do save lives for those with significant hypertension.)
But drugs have side effects. If a medicine makes an older person dizzy, that can lead to a fall and a broken hip. This can lead to permanent disability or death. Here is a link to more information about this complication of blood pressure medications.
What is the bottom line on the new guidelines for hypertension? First and foremost come lifestyle changes. There is solid evidence that exercise and weight loss can help bring blood pressure down. So can the foods you eat. The DASH (Dietary Approaches to Stop Hypertension) diet has been proven to help lower blood pressure. And vegetables like beets or teas made with hibiscus can also help control hypertension. Here is a link to more information about natural ways to mange high blood pressure with:
We think the new hypertension guidelines are a step in the right direction. Putting the brakes on “disease creep” where the bar keeps being lowered to the point that everyone is diagnosed with something, is not doing the American public any favors. We think common sense, lifestyle changes and sensible use of medications is the best way forward.
We welcome your thoughts on the new guidelines below in the comment section.