A guideline tsunami: Cholesterol and blood pressure targets

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com

Just when the initial buzz about the new cholesterol guidelines had died down, along came the new JNC 8 recommendations. The former did a remarkable job of aiming at the LDL target; the latter loosened blood pressure targets for specified subgroups. The times, they are a-changin’.

Still, the publishing of the cholesterol guidelines prompted a flurry of blogs and related commentaries, which upon a quick survey suggest the emergence of a type of "Red State–Blue State" divide. The most rigorous critiques focused on the use of a new global risk assessment tool developed from various observational cohorts to reconfigure the goals of therapy. From the clinician’s perspective, the messages were mixed, as noted in the mirror-image comments on one cardiology Internet site: "Very useful for my every day practice" and "This will make things more confusing in my approach to patients."

With JNC 8 the blood pressure targets are less strict for the older adult: controversial but plausibly more adaptable in a clinical setting.

So, taking a step back, it’s now more difficult to know how we should think about any and all therapeutic targets in the individual patient. We have been in a numbers era for a long time and, as a consequence, we are in a comfort zone where "treatment to goal" is the working paradigm. On the other hand, we should readily accept that a treatment goal is a convenience factor that often makes epidemiologic sense but not practical sense. Back in the "old days," an LDL of 71 mg/dL in a patient with CAD was good enough in my book. Personally, rather than convince the patient to work a bit harder on cholesterol lowering to achieve a level less than 70 mg/dL, I’d prefer to spend an extra minute or two on a discussion about exercise or work life or maybe even something more secular.

Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.

We can also rest assured that JNC 9, if it ever occurs, won’t be seen for at least a decade. The tsunami has passed; now it’s time to pick up the debris.

1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J. Am. Coll. Cardiol. 2013; doi:10.1016/j.jacc.2013.11.002.

2. James PA, Oparil S, Carter BL et al. 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; doi:10.1001/jama.2013.284427.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and likes to blog while staring out his office window at the Arch.

Write to Dr. Hauptman at cardnews@frontlinemedcom.com