AMSTERDAM – When the European Society of Cardiology in June reset its target systolic blood pressure for patients with diabetes, chronic kidney disease, or a history of cardiovascular disease to less than 140 mm Hg, it joined a small but growing cadre of medical societies that have looked at recent evidence and concluded that nothing currently justifies treating to a target systolic blood pressure below 130 mm Hg or to a diastolic pressure below 80 mm Hg.
The European Society of Cardiology’s new edition of hypertension management guidelines, produced in collaboration with the European Society of Hypertension, contrasts with the conspicuous void in U.S. practice that’s been widely acknowledged for a few years now: the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the prevailing version of U.S. hypertension-management guidelines, is a decade old and outdated.
Dr. Renata Cífková
The delay-plagued process to come out with the eighth JNC edition (JNC 8) took an unexpected turn last June, when the National Heart, Lung, and Blood Institute, the agency that shepherded the first seven editions of U.S. hypertension guidelines going back to 1976, announced that it was immediately turning responsibility for getting JNC 8 finalized and out to the public over to "partner organizations" such as the American College of Cardiology and American Heart Association.
With this new wrinkle, even with the ACC and AHA scrambling to deal with their new responsibility, it seems like JNC 8 – or whatever name it will have when it finally emerges – will not come out until 2014 at the soonest, making the ESC guidelines the only up-to-date hypertension recommendations from a cardiology-oriented medical group for at least several more months.
A U.S. view of the Euro guidelines
"U.S. physicians need to be aware of the evidence as it evolves," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill, and a member of the panel that’s been writing JNC 8.
"The American Diabetes Association came out with a similar recommendation" on the systolic blood pressure target for patients with diabetes. U.S. physicians should "see what the ADA says, see what the ESC says, and then decide what they should do. They need to read the recommendations and supporting evidence and see if it applies to their patients," Dr. Smith advised in an interview. "I think that patients and physicians will look at the current evidence and respond. You’ve got to go with what the evidence says and what seems best for the patient. No law says that you shall only do what is in the" JNC 7 guidelines.
A trickier situation may be settings in which physicians are assessed based on how many of their patients with diabetes reach a blood pressure target of less than 130/80, he said. "How do health care systems respond to evidence as it evolves? At what point should performance measures get changed?" Dr. Smith asked.
But because of its orientation to European populations, the new ESC hypertension guidelines can’t completely fill the U.S. vacuum.
"I’m sure JNC 8 will be nuanced differently than the European guidelines because we have a different population in the U.S., particularly African Americans and more patients with renal failure," said Dr. Kim Allan Williams Sr. of Wayne State University, Detroit. Dr. Williams will take the position of professor of medicine and chief of cardiovascular services at Rush University Medical Center in Chicago on Nov. 1. "As a practitioner, I would worry about using 140/90 mm Hg as the only target for the African American population that I deal with all the time. The stroke and renal failure rates are much higher in these patients" than in other patients with hypertension, he said in an interview. "The new European guidelines don’t deal with patients with African ancestry. JNC 7 had a section on blood pressure management in minority groups, which was very helpful."
Resetting the target for diabetics
The dialing up of the target systolic blood pressure for patients with diabetes or other high-risk factors, and the resulting damping down of antihypertensive treatment intensity, is the biggest change in the 2013 ESC hypertension recommendations, said Dr. Giuseppe Mancia, who chaired the task force that wrote the recommendations.
"We need to base the recommendations on the evidence. It’s been a consistent finding, in ONTARGET, ACCORD, and in other studies, that pushing the blood pressure of patients with diabetes below 130 mm Hg provided no additional benefit but was linked with more adverse events. If you set a lower target you need to be absolutely sure there is no harm associated with it, and at the moment we cannot say that.