2017 ACC/AHA Blood Pressure Treatment Guideline Recommendations and Cardiovascular Risk
Why the study?
The 2017 ACC/AHA guideline provided updated recommendations for antihypertensive medication initiation and intensification, but the CVD event risk among adults recommended versus not recommended these interventions needed to be determined.
Does recommendation for antihypertensive medication initiation or intensification by the 2017 ACC/AHA BP guideline accurately identify adults at high risk for cardiovascular events?
Study Design
Type
Cohort (n=29,218)
Multicenter
Yes
Structured PICO
Does recommendation for antihypertensive medication initiation or intensification by the 2017 ACC/AHA BP guideline accurately identify adults at high risk for cardiovascular events?
P
Population
29,218 community-dwelling adults aged ≥45 years from the US REGARDS cohort, followed for cardiovascular events to assess risk based on 2017 ACC/AHA BP guidelines.
E
Exposure
Recommended for pharmacological antihypertensive treatment initiation or intensification according to the 2017 ACC/AHA BP guideline (based on BP ≥130/80 mmHg and estimated CVD risk).
C
Comparator
Not recommended for pharmacological antihypertensive medication initiation or intensification according to the 2017 ACC/AHA BP guideline.
O
Outcome
Cardiovascular disease (CVD) events (composite of non-fatal or fatal stroke, non-fatal or fatal myocardial infarction, coronary heart disease death, or heart failure hospitalization).hard clinical
Main Result
Absolute Event Rate: 20.5% vs 3.4%
Limitations
- Participants may have initiated or intensified antihypertensive medication after baseline assessment
- Results may not be generalizable to other race groups or adults <45 years of age
- BP was measured during a single visit using an aneroid sphygmomanometer
- Loss to follow-up may not have been at random
- Data on side effects associated with antihypertensive medication were not available
- Participants may have initiated or intensified antihypertensive medication treatment after their baseline assessment, potentially underestimating risk.
- Results may not be generalizable to other race groups, nursing home residents, or adults <45 years of age.
- BP was measured during a single visit using an aneroid sphygmomanometer, which is susceptible to calibration issues.
- No data available on side effects associated with antihypertensive medication.
- Loss to follow-up may not have been at random.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We're excited about these guidelines. We think that they will empower clinicians. We think they'll empower adults, especially those with elevated and high blood pressure, [but] also those with normal blood pressure who want to prevent going into that elevated sphere.... We're confident that if the guideline is implemented it will improve the cardiovascular health of our adult community in the United States.”
“It specifically has as a goal that if [a patient has] greater than 10% 10-year cardiovascular risk, you should be more aggressive with treatment. That may sound obvious, but previous guidelines assumed that, never really defined it and never put it into context. This guideline does that, and it's a very important step forward.”
“the challenge is to get blood pressure measured accurately in clinical practice. The way SPRINT was conducted, blood pressure was measured using a standardized protocol that we can't often afford in practice: resting for 5 minutes, no talking, no looking at your iPhone. Each practice needs to think about these protocols carefully and try to incorporate them into practice. If they ignore that, it could potentially increase the risks of the treatment, because you could potentially have more side effects from overtreatment if you don't measure blood pressure carefully.”
Implication
Implementing the 2017 ACC/AHA BP guidelines correctly directs antihypertensive medication initiation and intensification to adults at the highest absolute risk for incident cardiovascular events and mortality.
Abstract
Background: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline provides updated recommendations for antihypertensive medication initiation and intensification. Objective: Determine the risk for cardiovascular disease (CVD) events among adults recommended and not recommended antihypertensive medication initiation or intensification by the 2017 ACC/AHA BP guideline. Methods: We analyzed data for black and white REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants (age ≥45 years). Systolic BP (SBP) and diastolic BP (DBP) were measured twice at baseline (2003–2007) and averaged. Participants not taking (n=14,039) and taking (n=15,179) antihypertensive medication were categorized according to their recommendations for antihypertensive medication initiation and intensification by the 2017 ACC/AHA guideline. Overall, 4,094 CVD events (stroke, coronary heart disease and heart failure) occurred by December 31, 2014. Results: Among participants not taking antihypertensive medication, 34.4% were recommended pharmacological antihypertensive treatment initiation. The CVD event rate per 1,000 person-years among participants recommended antihypertensive medication initiation with SBP/DBP ≥140/90 mmHg was 22.7 (95%CI 20.3–25.0). Among participants with SBP/DBP 130–139/80–89 mmHg, the CVD event rate was 20.5 (95%CI 18.5–22.6) and 3.4 (95%CI 2.4–4.4) for those recommended and not recommended antihypertensive medication initiation, respectively. Among participants taking antihypertensive medication, 62.8% were recommended treatment intensification. The CVD event rate per 1,000 person-years among participants recommended treatment intensification was 33.6 (95%CI 31.5–35.6) and 22.4 (95%CI 20.8–23.9) for those with SBP/DBP ≥140/90 mmHg and 130–139/80–89 mmHg, respectively. Conclusions: Implementing the 2017 ACC/AHA guideline would direct antihypertensive medication initiation and intensification to adults with high CVD risk.
Discussion
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Cite This Study
Colantonio et al. (2018) conducted a cohort in Hypertension (n=29,218). Meeting 2017 ACC/AHA guideline criteria for antihypertensive medication initiation or intensification vs. Not meeting 2017 ACC/AHA guideline criteria for initiation or intensification was evaluated on CVD events (stroke, CHD, and heart failure) per 1,000 person-years among untreated participants with BP 130–139/80–89 mmHg. Among adults not taking antihypertensives with BP 130-139/80-89 mmHg, those recommended for treatment initiation by the 2017 ACC/AHA guideline had a CVD event rate of 20.5 per 1,000 person-years compared to 3.4 for those not recommended.