Hypertension guidelines aim to lower, reset threshold to 130/80 mm Hg

Thirty million Americans became hypertensive overnight with the introduction of new high blood pressure guidelines from the American College of Cardiology and American Heart Association.

That happened by resetting the definition of adult hypertension from the long-standing threshold of 140/90 mm Hg to a blood pressure at or above 130/90 mm Hg, a change that jumps the US adult prevalence of hypertension from roughly 32 percent to 46 percent. Nearly half of US adults now have hypertension, bringing the total national hypertensive population to a staggering 103 million.

Another 12 percent have what’s now called elevated blood pressure, with a systolic pressure of 120-129 mm Hg but a normal diastolic of less than 80 mm Hg – a group that warrants lifestyle interventions to arrest progression. That leaves a mere 42 percent of American adults now classified as normotensive. In selected subgroups, the prevalence numbers even grow more inflated. Among African American men and women, 55 percent now have hypertension. And among men and women aged 65 years or older, more than three-quarters now have hypertension.

Goal is to transform care: But the new guidelines for preventing, evaluating, and managing adult hypertension do a lot more than just shake up the epidemiology of high blood pressure. With 106 total recommendations, the guidelines seek to transform every aspect of blood pressure in American medical practice, starting with how it’s measured and stretching to redefine application of medical systems to try to ensure that every person with a blood pressure that truly falls outside the redefined limits gets a comprehensive package of interventions.

The new guidelines include not just new approaches to blood pressure measurement and definition, but also a new risk-based approach to making treatment decision, a reduced treatment target of less than 130/80 mm Hg, and new strategies to improve treatment efficiency.

Many of these are “seismic changes.” Particularly cited as seismic are the new classification of stage 1 hypertension as a pressure at or above 130/80 mm Hg, the emphasis on using some form of out-of-office blood pressure measurement to confirm a diagnosis, the use of risk assessment when deciding whether to treat certain patients with drugs, and the same blood pressure goal of less than 130/80mm Hg for all hypertensive patients, regardless of age, as long as they remain ambulatory and community dwelling.

One goal for all adults: “The systolic blood pressure goal for older people has gone from 140 mm Hg to 150 mm Hg and now 130 mm Hg in the space of 2-3 years,”

In fact, the guidelines simplified the treatment goal all around, to less than 130/80 mm Hg for patients with diabetes, those with chronic kidney disease, and the elderly; that goal remains the same for all adults.

“It will be clearer and easier now that everyone should be less than 130/80 mm Hg, you won’t need to remember second target.”

“Some people may be upset that we changed the rules on them. They had a normal blood pressure yesterday, and today it’s high. But it’s a good awakening, especially for using lifestyle interventions.”

Lifestyle, not drugs: Lifestyle optimization is repeatedly cited as the cornerstone of intervention for everyone, including those with elevated blood pressure with a systolic pressure of 120-129 mm Hg, and as the only indorsed intervention for patients with hypertension of 130-139 mm Hg but below a 10 percent risk of cardiovascular disease event during the next 10 years on the American College of Cardiology’s online risk calculator. The guidelines list is six lifestyle goals: weight loss, following a DASH diet, reducing sodium, enhancing potassium, 90-150 min/wk of physical activity, and moderate alcohol intake.

The guidelines may be a “can opener for a recommitment to lifestyle changes” for preventing and managing hypertension.

Team-based care essential: The guidelines also put unprecedented emphasis on using team-based management approach, which means having nurses, nurse practitioners, pharmacists, dietitians, and other clinicians, allowing for more frequent and focused care. It was cited in particular, the VA Health System and Kaiser-Permanente as operating team-based and system-driven blood pressure management programs that have resulted in control rates for more than 90 percent of hypertensive patients. The team-based approach is also a key in the target: BP program that the American Medical Association founded. Target: BP will be instrumental in promoting implementation and every patient with hypertension should have a “clear, detailed, and current evidence-based plan of care.”

“Using nurse practitioners, physician assistant, and pharmacists has been shown to improve blood pressure levels,” and health systems that use this approach have had “great success.” Some systems have used this approach to achieve high levels of blood pressure control. Now that financial penalties and incentives from payers also exist to push for higher levels of blood pressure control, the alignment of financial and health incentives should result in big changes.