Thoughts on the new blood pressure guidelines

The new blood pressure (BP) guideline, released recently in JAMA, has simplified blood pressure management and likely decreased both the number of patients needing treatment and the number of medications they need. Many commentaries have begun to flood the Internet, so of course I must add my thoughts.

First, please read Harlan Krumholz thoughts: 3 Things to Know About the New Blood Pressure Guidelines.

Here are my main thoughts:

1. This guideline panel commissioned evidence reviews — and as one of the editorials states, this gives us more confidence in the guideline. Somewhat amazingly, most of the guideline does not have a strong evidence base. The authors show great honesty in their assessment of the evidence quality. Few of these recommendations should become performance measures. Current BP performance measures encourage overtreatment.

2. The best data exist for increasing the goal BP for 60 and older to 150/90. How many patients older than 60 currently take medications to lower their BP of 140-149 to reach a goal < 140? We have significant overuse of antihypertensives in that population.

3. The guideline supports any of 4 classes for initial treatment: thiazides, ACE-I, calcium channel blockers (CCBs) or ARBs. Clearly the data do not support beta blockers as a standard treatment. I am disappointed that they do not discuss the differences in thiazides (I strongly prefer chlorthalidone to hydrochlorothiaze) nor do they comment on the differences among CCBs.

4. They do make distinctions in first line therapy for black patients. At least one critic that I read pointed out that racial distinctions are hazardous at best.

5. This guideline differs greatly from previous guidelines. The committee has, in my opinion, carefully absorbed the many opinion pieces about guidelines and the IOM recommendations.

We really do not have adequate data to answer many questions about hypertension. I like the simpler recommendations that clearly should decrease overprescribing.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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