AAFP Decides to Not Endorse AHA/ACC Hypertension Guideline

The AAFP has decided to not endorse the recent hypertension guideline from the American Heart Association (AHA), the American College of Cardiology (ACC) and nine other health professional organizations.

The AAFP wasn't involved in the development of the new guideline(hyper.ahajournals.org) and continues to endorse the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,(jamanetwork.com) developed by panel members appointed to the Eighth Joint National Committee (JNC8).

David O'Gurek, M.D., chair of the AAFP's Commission on Health of the Public and Science (CHPS), which recommended non-endorsement of the AHA/ACC guideline, told AAFP News the commission used the same process and criteria to review both the AHA/ACC and JNC8 guidelines.

"Based on the methodology, applicability and consistency within the JNC8 guideline, the AAFP felt strongly that the JNC8 upheld the scientific rigor that provided strong recommendations to family physicians and patients on appropriate treatment of hypertension," O'Gurek said.

Published online Nov. 13 in the AHA's Hypertension journal, the new AHA/ACC guideline covers detection, prevention, management and treatment of high blood pressure (HBP). Specifically, it calls for HBP to be treated with lifestyle changes and with medication as needed beginning at 130/80 mm Hg rather than the previous commonly accepted threshold of 140/90 mm Hg.

According to the AHA, the new threshold would lead to 46 percent of the U.S. adult population being categorized as having hypertension. Using the previous threshold, that figure would be 32 percent of American adults.

O'Gurek said there were a number of reasons the AAFP decided to not endorse the AHA/ACC guideline, including that the bulk of the guideline wasn't based on a systematic evidence review.

Additionally, although the guideline's recommendations were given an evidence quality grade, they weren't grounded in an assessment of the background resources, he said. Finally, substantial weight was given to the Systolic Blood Pressure Intervention Trial (SPRINT), but other trials were minimized.

Lack of Systematic Review

All clinical practice guidelines considered for endorsement by the AAFP go through a structured review process by the AAFP's CHPS with Board of Directors approval.

In this case, the commission reviewed the AHA/ACC guideline and concluded that it didn't meet the Academy's criteria for endorsement or affirmation of value.

The guideline provided more than 100 recommendations, but a systematic review performed as part of the guideline's development considered only four key questions. Also, harms of treating a patient to a lower blood pressure were not assessed in the systematic review.

On a related note, in January, the AAFP and the American College of Physicians (ACP) published their own clinical practice guideline that focused on hypertension in adults older than 60.(annals.org)

That joint guideline's chief recommendation was that physicians initiate treatment in patients 60 and older who have persistent systolic blood pressure (SBP) at or above 150 mm Hg to achieve a target SBP of less than 150 mm Hg to reduce the risk of mortality, stroke and cardiac events.

The systematic reviews for both the AAFP/ACP guideline and the AHA/ACC guideline suggested there might be a small benefit of lower treatment targets in reducing cardiovascular events. However, 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."

Additional Reasons for Non-endorsement

Although the AHA/ACC guideline's recommendation statements were graded according to strength of evidence, assessments of the quality of individual studies or systematic reviews weren't provided.

For example, the new guideline offered a strong recommendation for using the unvalidated atherosclerotic cardiovascular disease risk assessment tool previously developed by AHA and ACC to determine whether medications should be initiated for BP control. However, this recommendation wasn't based on evidence that using the tool in this way improves outcomes.

Finally, the AAFP's CHPS voiced concerns related to the use of the SPRINT trial in the AHA/ACC guideline. First, the guideline gave the SPRINT trial considerable weight while minimizing results from other trials.

"The SPRINT trial was an important trial, but needs to be considered in the context of the totality of the evidence," the CHPS said.

Additionally, the commission said conflict of interest is a major concern in judging the trustworthiness of guidelines and plays a key role in the AAFP's assessment of guidelines. In the case of the AHA/ACC guideline, the guideline panel commissioned the chair of the SPRINT trial steering committee to chair its work, when, notably, the SPRINT trial served as the foundation for the guideline panel's recommendations to change BP treatment targets.

Furthermore, several other AHA/ACC guideline panel members had intellectual conflicts of interest, which were not considered in the guideline's preparation.

"The AAFP chose not to participate in this guideline development given significant concerns about the guideline methodology, including the management of intellectual conflicts of interest of guideline participants," O'Gurek said.

Positives From AHA/ACC Guideline

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that even with its shortcomings, the AHA/ACC guideline covered some important points.

"It highlights the importance of accurate assessment of blood pressure before making a diagnosis and makes some helpful suggestions to ensure accurate measurement," she said.

The guideline emphasized the importance of home BP monitoring using proper technique and validated devices. The authors recommended recording the average of two to three blood pressure readings at least two times a day to get an accurate measure and avoid the phenomena of white-coat hypertension and masked hypertension.

In a Nov. 15 AAFP News story, Frost agreed with this practice, saying that taking blood pressure in the clinical setting isn't the best predictor of outcomes. She recommended taking BP measurements at different times of day, in different settings, for a more accurate representation of a patient's BP.

In addition, the AHA/ACC guideline discussed the importance of healthy lifestyle choices to minimize hypertension risk, "which the AAFP thinks is important for all individuals, whether or not they have a diagnosis of hypertension," Frost said.

Addressing Patients' Questions

O'Gurek said it's important for family physicians to understand the differences between and within the currently available hypertension guidelines -- not simply with the recommendations, but with the science behind the recommendations -- because this is what truly affects the patients with hypertension for whom they provide care.

"With the media attention to this new (AHA/ACC) guideline, patients will undoubtedly have questions about their treatment, as well as their goal blood pressures," he said. "Furthermore, family physicians should engage patients in discussion to assess what they have heard from media outlets, friends, family and other physicians."

O'Gurek said that although patients should understand the benefits of potentially lower BP targets, family physicians should also address associated risks, which weren't clearly discussed in the studies supporting the AHA/ACC guideline.

"With competing guidelines and recommendations, family physicians, as bold champions of science, have an opportunity to be a guiding light in the darkness of confusion to deliver quality care that's grounded in science and is patient-centered," O'Gurek concluded.

Related AAFP News Coverage
Neighborhood Socioeconomic Position Key to Predicting CVD Risk
(9/1/2017)

Extended In-office BP Monitoring Could Reduce Hypertension Overtreatment
Family Physician Calls for New BP Monitoring Standards, Protocols
(3/22/2017)

Joint Hypertension Guideline Released
AAFP, ACP: Lower Older Adults' SBP to Below 150 mm Hg
(1/18/2017)

More From AAFP
Clinical Preventive Service Recommendation: Hypertension

Clinical Practice Guideline: Hypertension in Adults Over 60