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The first update to U.S. guidelines for managing hypertension in adult patients with coronary artery disease in 8 years reset the target blood pressure for most of these patients to less than 140/90 mm Hg, and highlighted beta-blockers, renin-angiotensin-aldosterone system blockers, and thiazide diuretics as the mainstays of drug treatment for these patients.
The main messages in the new scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension, released on March 31 in an article published online (Hypertension 2015 [doi:10.116/HYP.0000000000000018]) are the blood pressure targets set for patients with coronary artery disease (CAD) and the designations of the preferred drugs to use to achieve the blood pressure goals when lifestyle measures alone prove inadequate, said Dr. Clive Rosendorff, chair of the panel that wrote the new statement.
But the statement also highlighted that a blood pressure target of less than 130/80 mm Hg “could be considered” and was reasonable for selected CAD patients whom physicians judge capable of achieving this lower blood pressure level safely and who are at especially high risk for cerebrovascular events.
“We felt the best evidence [to prevent future cardiovascular events] was to reduce pressure below 140/90 mm Hg, but a goal pressure of less than 130/80 mm Hg may be appropriate in some cases; we left it to the discretion of physicians to decide which blood pressure target to choose,” said Dr. Rosendorff, professor of medicine at Mount Sinai Hospital in New York.
The default blood pressure goal of less than 140/90 for most CAD patients represented an increase from the less than 130/80 mm Hg goal set by the prior edition of this guideline, issued in 2007 (Circulation 2007;115:2761-88). Current evidence for the lower blood pressure target of less than 130/80 mm Hg “was not as strong,” Dr. Rosendorff said in an interview. He suggested that physicians consider using the lower target for patients who are younger, reasonably healthy, able to tolerate a regimen that brings them to a lower blood pressure without an increase in angina or other significant effects caused by the drugs themselves, do not experience compromised renal function with reduced blood pressure, and have an increased risk for cerebrovascular events.
“These guidelines are not rigid, and should involve a discussion with the patient of the benefits and risks,” he said.
The new statement targets a blood pressure goal of less than 150/90 mm Hg for CAD patients who are more than 80 years old.
The new target for CAD patients represents something of a response to the blood pressure target of less than 150/90 mm Hg for people at least 60 years old recommended last year in recommendations made by the panel originally assembled as the Eighth Joint National Committee (JNC 8) (JAMA 2014;311:507-20). Although the JNC 8 recommendations aimed at the general population in a primary prevention setting, as opposed to CAD patients for whom secondary prevention is the goal, the target of less than 150/90 mm Hg became “highly controversial” and was a factor in composing the new recommendation, Dr. Rosendorff said. He also stressed that the AHA, ACC, and ASH have assembled a group that is formulating new recommendations for diagnosing and managing hypertension for the general population in a primary prevention setting that will come out sometime in the future.
The new hypertension guideline for CAD patients and the 2014 statement from the JNC 8 panel should be seen as distinct recommendations because they targeted different patient populations and because they were based on different ground rules for evidence, said Dr. Suzanne Oparil, one of three people who served on both writing groups. The JNC 8 group focused exclusively on findings from randomized, controlled trials that used hard cardiovascular disease endpoints. The writing committee for the new guidelines targeted specifically at CAD patients also considered evidence from epidemiologic studies. In addition, the new guidelines is targeted at primarily a cardiologist audience, while the 2014 JNC 8 guidelines were written primarily for primary care physicians, she said in an interview.
“I do not believe that the new CAD guidelines will change practice. They reflect what most cardiologists already do,” said Dr. Oparil, professor of medicine and director of the vascular biology and hypertension program at the University of Alabama, Birmingham.
Regarding antihypertensive drug selection the new statement endorses a focus on treating hypertensive patients with established CAD with a beta-blocker, a renin-angiotensin-aldosterone system blocker such as an ACE inhibitor or angiotensin-receptor blocker, and a thiazide or thiazide-like diuretic. Hypertensive patients with CAD should immediately start on all three drug classes, Dr. Rosendorff said.
“For patients with established CAD, a treatment with a beta-blocker moves from the limbo they are in for treating uncomplicated hypertension to center stage,” he said. The statement gives more detailed guidance on which specific drugs from the beta-blocker class have the best evidence for efficacy in various types of patients with CAD.
Dr. Rosendorff had no disclosures. Dr. Oparil has been a consultant to Bayer, Daiichi Sankyo, and Pfizer, and has received research grants from Medtronic, Merck, Novartis, and Takeda.
On Twitter @mitchelzoler
The new statement on treating hypertension in patients with established coronary artery disease clears up what had been a confusing situation for U.S. physicians during the past year.
In early 2014, the panel that had originally been assembled as the Eighth Joint National Committee (JNC 8) issued a statement that called for a blood pressure target of less than 150/90 mm Hg for people 60 years or older (JAMA 2014;311:507-20). People were very confused about that, and may have erroneously believed that this recommendation applied to patients with CAD. I and many of my colleagues believe that having a recommendation to treat to just less than 150/90 mm Hg potentially put millions of CAD patients at risk, especially at risk for stroke. The new statement highlights the high risk faced by CAD patients who need special attention to their blood pressure.
 |
| Mitchel L. Zoler/Fronbtline Medical News Dr. Elliott M. Antman |
The epidemiologic evidence clearly shows that increased blood pressure relates to an increased risk for cardiovascular events across a blood pressure range from 115/75 mm Hg to 185/115 mm Hg.
The new recommendations for CAD patients also say that a target blood pressure of less than 130/80 mm Hg may be preferred for selected patients, although the statement does not offer clear steps on how to identify these patients. Physicians must use their clinical judgment.
In my practice, I make sure not to drop a patient’s creatinine clearance to an unacceptably low level, and I would especially consider the lower target for patients with a history of heart failure or left ventricular dilatation or hypertrophy. I believe that in the past, physicians have been too conservative about blood pressure reduction in CAD patients, in part out of a concern about reducing perfusion pressure too much. I believe that if a CAD patient can tolerate a lower blood pressure and the treatment it takes to achieve it, then it is better to be more aggressive.
We also must always remember that the lifestyle modifications, including less dietary sodium, weight loss, and exercise, are the first steps to reducing blood pressure.
Dr. Elliott M. Antman is professor of medicine at Harvard University in Boston and president of the American Heart Association. He had no relevant disclosures. He made these comments in an interview.
The new statement on treating hypertension in patients with established coronary artery disease clears up what had been a confusing situation for U.S. physicians during the past year.
In early 2014, the panel that had originally been assembled as the Eighth Joint National Committee (JNC 8) issued a statement that called for a blood pressure target of less than 150/90 mm Hg for people 60 years or older (JAMA 2014;311:507-20). People were very confused about that, and may have erroneously believed that this recommendation applied to patients with CAD. I and many of my colleagues believe that having a recommendation to treat to just less than 150/90 mm Hg potentially put millions of CAD patients at risk, especially at risk for stroke. The new statement highlights the high risk faced by CAD patients who need special attention to their blood pressure.
|
| Mitchel L. Zoler/Fronbtline Medical News Dr. Elliott M. Antman |
The epidemiologic evidence clearly shows that increased blood pressure relates to an increased risk for cardiovascular events across a blood pressure range from 115/75 mm Hg to 185/115 mm Hg.
The new recommendations for CAD patients also say that a target blood pressure of less than 130/80 mm Hg may be preferred for selected patients, although the statement does not offer clear steps on how to identify these patients. Physicians must use their clinical judgment.
In my practice, I make sure not to drop a patient’s creatinine clearance to an unacceptably low level, and I would especially consider the lower target for patients with a history of heart failure or left ventricular dilatation or hypertrophy. I believe that in the past, physicians have been too conservative about blood pressure reduction in CAD patients, in part out of a concern about reducing perfusion pressure too much. I believe that if a CAD patient can tolerate a lower blood pressure and the treatment it takes to achieve it, then it is better to be more aggressive.
We also must always remember that the lifestyle modifications, including less dietary sodium, weight loss, and exercise, are the first steps to reducing blood pressure.
Dr. Elliott M. Antman is professor of medicine at Harvard University in Boston and president of the American Heart Association. He had no relevant disclosures. He made these comments in an interview.
The new statement on treating hypertension in patients with established coronary artery disease clears up what had been a confusing situation for U.S. physicians during the past year.
In early 2014, the panel that had originally been assembled as the Eighth Joint National Committee (JNC 8) issued a statement that called for a blood pressure target of less than 150/90 mm Hg for people 60 years or older (JAMA 2014;311:507-20). People were very confused about that, and may have erroneously believed that this recommendation applied to patients with CAD. I and many of my colleagues believe that having a recommendation to treat to just less than 150/90 mm Hg potentially put millions of CAD patients at risk, especially at risk for stroke. The new statement highlights the high risk faced by CAD patients who need special attention to their blood pressure.
|
| Mitchel L. Zoler/Fronbtline Medical News Dr. Elliott M. Antman |
The epidemiologic evidence clearly shows that increased blood pressure relates to an increased risk for cardiovascular events across a blood pressure range from 115/75 mm Hg to 185/115 mm Hg.
The new recommendations for CAD patients also say that a target blood pressure of less than 130/80 mm Hg may be preferred for selected patients, although the statement does not offer clear steps on how to identify these patients. Physicians must use their clinical judgment.
In my practice, I make sure not to drop a patient’s creatinine clearance to an unacceptably low level, and I would especially consider the lower target for patients with a history of heart failure or left ventricular dilatation or hypertrophy. I believe that in the past, physicians have been too conservative about blood pressure reduction in CAD patients, in part out of a concern about reducing perfusion pressure too much. I believe that if a CAD patient can tolerate a lower blood pressure and the treatment it takes to achieve it, then it is better to be more aggressive.
We also must always remember that the lifestyle modifications, including less dietary sodium, weight loss, and exercise, are the first steps to reducing blood pressure.
Dr. Elliott M. Antman is professor of medicine at Harvard University in Boston and president of the American Heart Association. He had no relevant disclosures. He made these comments in an interview.
The first update to U.S. guidelines for managing hypertension in adult patients with coronary artery disease in 8 years reset the target blood pressure for most of these patients to less than 140/90 mm Hg, and highlighted beta-blockers, renin-angiotensin-aldosterone system blockers, and thiazide diuretics as the mainstays of drug treatment for these patients.
The main messages in the new scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension, released on March 31 in an article published online (Hypertension 2015 [doi:10.116/HYP.0000000000000018]) are the blood pressure targets set for patients with coronary artery disease (CAD) and the designations of the preferred drugs to use to achieve the blood pressure goals when lifestyle measures alone prove inadequate, said Dr. Clive Rosendorff, chair of the panel that wrote the new statement.
But the statement also highlighted that a blood pressure target of less than 130/80 mm Hg “could be considered” and was reasonable for selected CAD patients whom physicians judge capable of achieving this lower blood pressure level safely and who are at especially high risk for cerebrovascular events.
“We felt the best evidence [to prevent future cardiovascular events] was to reduce pressure below 140/90 mm Hg, but a goal pressure of less than 130/80 mm Hg may be appropriate in some cases; we left it to the discretion of physicians to decide which blood pressure target to choose,” said Dr. Rosendorff, professor of medicine at Mount Sinai Hospital in New York.
The default blood pressure goal of less than 140/90 for most CAD patients represented an increase from the less than 130/80 mm Hg goal set by the prior edition of this guideline, issued in 2007 (Circulation 2007;115:2761-88). Current evidence for the lower blood pressure target of less than 130/80 mm Hg “was not as strong,” Dr. Rosendorff said in an interview. He suggested that physicians consider using the lower target for patients who are younger, reasonably healthy, able to tolerate a regimen that brings them to a lower blood pressure without an increase in angina or other significant effects caused by the drugs themselves, do not experience compromised renal function with reduced blood pressure, and have an increased risk for cerebrovascular events.
“These guidelines are not rigid, and should involve a discussion with the patient of the benefits and risks,” he said.
The new statement targets a blood pressure goal of less than 150/90 mm Hg for CAD patients who are more than 80 years old.
The new target for CAD patients represents something of a response to the blood pressure target of less than 150/90 mm Hg for people at least 60 years old recommended last year in recommendations made by the panel originally assembled as the Eighth Joint National Committee (JNC 8) (JAMA 2014;311:507-20). Although the JNC 8 recommendations aimed at the general population in a primary prevention setting, as opposed to CAD patients for whom secondary prevention is the goal, the target of less than 150/90 mm Hg became “highly controversial” and was a factor in composing the new recommendation, Dr. Rosendorff said. He also stressed that the AHA, ACC, and ASH have assembled a group that is formulating new recommendations for diagnosing and managing hypertension for the general population in a primary prevention setting that will come out sometime in the future.
The new hypertension guideline for CAD patients and the 2014 statement from the JNC 8 panel should be seen as distinct recommendations because they targeted different patient populations and because they were based on different ground rules for evidence, said Dr. Suzanne Oparil, one of three people who served on both writing groups. The JNC 8 group focused exclusively on findings from randomized, controlled trials that used hard cardiovascular disease endpoints. The writing committee for the new guidelines targeted specifically at CAD patients also considered evidence from epidemiologic studies. In addition, the new guidelines is targeted at primarily a cardiologist audience, while the 2014 JNC 8 guidelines were written primarily for primary care physicians, she said in an interview.
“I do not believe that the new CAD guidelines will change practice. They reflect what most cardiologists already do,” said Dr. Oparil, professor of medicine and director of the vascular biology and hypertension program at the University of Alabama, Birmingham.
Regarding antihypertensive drug selection the new statement endorses a focus on treating hypertensive patients with established CAD with a beta-blocker, a renin-angiotensin-aldosterone system blocker such as an ACE inhibitor or angiotensin-receptor blocker, and a thiazide or thiazide-like diuretic. Hypertensive patients with CAD should immediately start on all three drug classes, Dr. Rosendorff said.
“For patients with established CAD, a treatment with a beta-blocker moves from the limbo they are in for treating uncomplicated hypertension to center stage,” he said. The statement gives more detailed guidance on which specific drugs from the beta-blocker class have the best evidence for efficacy in various types of patients with CAD.
Dr. Rosendorff had no disclosures. Dr. Oparil has been a consultant to Bayer, Daiichi Sankyo, and Pfizer, and has received research grants from Medtronic, Merck, Novartis, and Takeda.
On Twitter @mitchelzoler
The first update to U.S. guidelines for managing hypertension in adult patients with coronary artery disease in 8 years reset the target blood pressure for most of these patients to less than 140/90 mm Hg, and highlighted beta-blockers, renin-angiotensin-aldosterone system blockers, and thiazide diuretics as the mainstays of drug treatment for these patients.
The main messages in the new scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension, released on March 31 in an article published online (Hypertension 2015 [doi:10.116/HYP.0000000000000018]) are the blood pressure targets set for patients with coronary artery disease (CAD) and the designations of the preferred drugs to use to achieve the blood pressure goals when lifestyle measures alone prove inadequate, said Dr. Clive Rosendorff, chair of the panel that wrote the new statement.
But the statement also highlighted that a blood pressure target of less than 130/80 mm Hg “could be considered” and was reasonable for selected CAD patients whom physicians judge capable of achieving this lower blood pressure level safely and who are at especially high risk for cerebrovascular events.
“We felt the best evidence [to prevent future cardiovascular events] was to reduce pressure below 140/90 mm Hg, but a goal pressure of less than 130/80 mm Hg may be appropriate in some cases; we left it to the discretion of physicians to decide which blood pressure target to choose,” said Dr. Rosendorff, professor of medicine at Mount Sinai Hospital in New York.
The default blood pressure goal of less than 140/90 for most CAD patients represented an increase from the less than 130/80 mm Hg goal set by the prior edition of this guideline, issued in 2007 (Circulation 2007;115:2761-88). Current evidence for the lower blood pressure target of less than 130/80 mm Hg “was not as strong,” Dr. Rosendorff said in an interview. He suggested that physicians consider using the lower target for patients who are younger, reasonably healthy, able to tolerate a regimen that brings them to a lower blood pressure without an increase in angina or other significant effects caused by the drugs themselves, do not experience compromised renal function with reduced blood pressure, and have an increased risk for cerebrovascular events.
“These guidelines are not rigid, and should involve a discussion with the patient of the benefits and risks,” he said.
The new statement targets a blood pressure goal of less than 150/90 mm Hg for CAD patients who are more than 80 years old.
The new target for CAD patients represents something of a response to the blood pressure target of less than 150/90 mm Hg for people at least 60 years old recommended last year in recommendations made by the panel originally assembled as the Eighth Joint National Committee (JNC 8) (JAMA 2014;311:507-20). Although the JNC 8 recommendations aimed at the general population in a primary prevention setting, as opposed to CAD patients for whom secondary prevention is the goal, the target of less than 150/90 mm Hg became “highly controversial” and was a factor in composing the new recommendation, Dr. Rosendorff said. He also stressed that the AHA, ACC, and ASH have assembled a group that is formulating new recommendations for diagnosing and managing hypertension for the general population in a primary prevention setting that will come out sometime in the future.
The new hypertension guideline for CAD patients and the 2014 statement from the JNC 8 panel should be seen as distinct recommendations because they targeted different patient populations and because they were based on different ground rules for evidence, said Dr. Suzanne Oparil, one of three people who served on both writing groups. The JNC 8 group focused exclusively on findings from randomized, controlled trials that used hard cardiovascular disease endpoints. The writing committee for the new guidelines targeted specifically at CAD patients also considered evidence from epidemiologic studies. In addition, the new guidelines is targeted at primarily a cardiologist audience, while the 2014 JNC 8 guidelines were written primarily for primary care physicians, she said in an interview.
“I do not believe that the new CAD guidelines will change practice. They reflect what most cardiologists already do,” said Dr. Oparil, professor of medicine and director of the vascular biology and hypertension program at the University of Alabama, Birmingham.
Regarding antihypertensive drug selection the new statement endorses a focus on treating hypertensive patients with established CAD with a beta-blocker, a renin-angiotensin-aldosterone system blocker such as an ACE inhibitor or angiotensin-receptor blocker, and a thiazide or thiazide-like diuretic. Hypertensive patients with CAD should immediately start on all three drug classes, Dr. Rosendorff said.
“For patients with established CAD, a treatment with a beta-blocker moves from the limbo they are in for treating uncomplicated hypertension to center stage,” he said. The statement gives more detailed guidance on which specific drugs from the beta-blocker class have the best evidence for efficacy in various types of patients with CAD.
Dr. Rosendorff had no disclosures. Dr. Oparil has been a consultant to Bayer, Daiichi Sankyo, and Pfizer, and has received research grants from Medtronic, Merck, Novartis, and Takeda.
On Twitter @mitchelzoler
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