Primary Care/Internal Medicine

The group of experts who had constituted the JNC 8 panel, a team assembled in 2008 by the National Heart, Lung, and Blood Institute to update official U.S. hypertension management guidelines, set the target blood pressure for the general population aged 60 years or older to less than 150/90 mm Hg, a major break from long-standing practice to treat such patients to a target systolic pressure of less than 140 mm Hg.

This decision, which the panel contends was driven by lack of clear evidence for extra benefit from the below–140 mm Hg target, will surely prove controversial, along with the panel’s relaxing of target blood pressures for patients with diabetes or chronic kidney disease to less than 140/90 mm Hg (increased from 130/80 mm Hg in the prior, JNC 7 guidelines). That controversy would be a fitting final curtain for the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), a project that courted controversy by running years longer than anticipated and then generating several plot twists during the final months leading up to Dec. 18, when the former JNC 8 panel published its hypertension-management guideline (JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284427]).

©Dr. Heinz Linke/iStockphoto.com

The new target of a systolic pressure of less than 150 mm Hg for hypertensive patients aged 60 or older without diabetes or chronic kidney disease "is definitely controversial," said Dr. Paul A. James, cochairman of the panel and professor of family medicine at the University of Iowa in Iowa City. "There is A-level evidence that getting blood pressure below 150 mm Hg results in improved outcomes that really matter, but we have no evidence at this time to support going lower," to less than 140 mm Hg. "The good news is that the panel is comfortable that we don’t do harm," by treating patients to less than 140 mm Hg. "But why put patients at increased risk for medication adverse events when we don’t have strong evidence of benefit?" he said in an interview.

He stressed that his group released their conclusions and guideline on their own, identifying themselves as "the panel members appointed to the Eighth Joint National Committee (JNC 8)." Leaders from the National Heart, Lung, and Blood Institute announced last June that the agency was pulling out of the business of issuing cardiovascular-disease management guidelines, and would instead fund evidence reviews and partner with other organizations to issue guidelines. The NHLBI arranged for its cholesterol, obesity, and lifestyle guidelines to be released through the American Heart Association and American College of Cardiology, but no similar arrangement worked out for the JNC 8 panel, which became the former panel when the NHLBI officially dissolved it by late summer.

The former JNC 8 panel applied "a very narrow interpretation" of the clinical evidence where the evidence is very incomplete, commented Dr. Michael A. Weber, professor of medicine at State University of New York, Brooklyn. "The purpose of guidelines is for a group of experts to be guided as far as they can by the evidence, and then use their judgment and experience to make recommendations that in the best interests of patients." He cited findings from the ACCOMPLISH, INVEST, and VALUE trials that show benefits from treating patients older than 60 years to a systolic pressure of less than 140 mm Hg, though he admitted that in each of these studies the findings did not come from primary, prespecified analyses.

Dr. Weber led a panel organized by the American Society of Hypertension and International Society of Hypertension that released its own set of hypertension diagnosis and management guidelines a day earlier, on Dec. 17 (J. Clin. Hypertension 2013 [doi:10.1111/ch.1223]). Where they overlap, the guidelines from ASH/ISH and from the former JNC 8 panel are mostly the same, with the systolic target for the general population aged 60-79 years being the main area of contention, Dr. Weber said. The ASH/ISH guideline set a systolic target of less than 150 mm Hg for the general hypertensive population aged 80 years or older.

The former-JNC 8 panel also qualified their 150 mm Hg–target by adding that if general population patients aged 60 years or older are on stable, well-tolerated antihypertensive treatment and have a systolic pressure of less than 140 mm Hg, changing treatment and aiming for a higher systolic pressure is not recommended.

The target of less than 150 mm Hg for these patients also had defenders. "They made a reasonable recommendation for the elderly based on the evidence," said Dr. John M. Flack, professor and chief of medicine at Wayne State University in Detroit. But he took the JNC 8 panel to task for relaxing the systolic and diastolic pressure targets for patients with either diabetes or chronic kidney disease from the prior target of less than 130/80 mm Hg to new targets of less than 140/90 mm Hg. "Relaxing blood pressure targets in high-risk groups when so much progress has been made over the last decade is going to be very controversial," he said in an interview. The new ASH-ISH hypertension guideline also set a blood pressure target of less than 140/90 mm Hg for patients with diabetes or chronic kidney disease.

The guideline from the former JNC 8 panel "will produce a lot of discussion, and the main target will be whether the 150 mm Hg target is right or not," commented Dr. Eric D. Peterson, professor of medicine at Duke University in Durham, N.C. In an editorial that accompanied the published guideline, Dr. Peterson and his associates also noted that the hypertension goals specified in authoritative guidelines had a magnified importance these days because they often are incorporated into "performance measures" to which physicians can be often held rigidly accountable.(JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284430]).

"I chair the ACC/AHA Task Force on Performance Measures, and we will be in a bind because the current performance measures call for a blood pressure target of less than 140/90 mm Hg," he said in an interview. The ACC/AHA task force is one of the main contributors of performance measures for cardiovascular disease to the U.S. clearing house for performance measures, the National Quality Forum. "The Task Force will need to respond to this guideline in some way," he said, but the Task Force takes into account the range of current guidelines that exist and their backup evidence, so how it will decide on this issue remains uncertain.

"My concern is not so much with the number they came up with as with how it will be used by physicians in the community," Dr. Peterson said. On one hand, you don’t want physicians to get carried away and feel they need to treat all their patients to below some magical number." As he pointed out in his editorial, the counterbalancing problem is that there is always a gap between the hypertension treatment goals and what is often achieved in practice. If that relationship remains and the accepted goal for patients aged 60-79 years becomes less than 150 mm Hg, then many U.S. patients in this group may end up treated but with systolic pressures above 150 mm Hg.

Dr. James and Dr. Peterson said that they had no disclosures. Dr. Weber said that he has been a consultant to Novartis, Takeda, and Forest. Dr. Flack said that he has been a consultant to Novartis, Medtronic, and Back Beat Hypertension and received funding from Novartis and Medtronic.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

The group of experts who had constituted the JNC 8 panel, a team assembled in 2008 by the National Heart, Lung, and Blood Institute to update official U.S. hypertension management guidelines, set the target blood pressure for the general population aged 60 years or older to less than 150/90 mm Hg, a major break from long-standing practice to treat such patients to a target systolic pressure of less than 140 mm Hg.

This decision, which the panel contends was driven by lack of clear evidence for extra benefit from the below–140 mm Hg target, will surely prove controversial, along with the panel’s relaxing of target blood pressures for patients with diabetes or chronic kidney disease to less than 140/90 mm Hg (increased from 130/80 mm Hg in the prior, JNC 7 guidelines). That controversy would be a fitting final curtain for the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), a project that courted controversy by running years longer than anticipated and then generating several plot twists during the final months leading up to Dec. 18, when the former JNC 8 panel published its hypertension-management guideline (JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284427]).

©Dr. Heinz Linke/iStockphoto.com

The new target of a systolic pressure of less than 150 mm Hg for hypertensive patients aged 60 or older without diabetes or chronic kidney disease "is definitely controversial," said Dr. Paul A. James, cochairman of the panel and professor of family medicine at the University of Iowa in Iowa City. "There is A-level evidence that getting blood pressure below 150 mm Hg results in improved outcomes that really matter, but we have no evidence at this time to support going lower," to less than 140 mm Hg. "The good news is that the panel is comfortable that we don’t do harm," by treating patients to less than 140 mm Hg. "But why put patients at increased risk for medication adverse events when we don’t have strong evidence of benefit?" he said in an interview.

He stressed that his group released their conclusions and guideline on their own, identifying themselves as "the panel members appointed to the Eighth Joint National Committee (JNC 8)." Leaders from the National Heart, Lung, and Blood Institute announced last June that the agency was pulling out of the business of issuing cardiovascular-disease management guidelines, and would instead fund evidence reviews and partner with other organizations to issue guidelines. The NHLBI arranged for its cholesterol, obesity, and lifestyle guidelines to be released through the American Heart Association and American College of Cardiology, but no similar arrangement worked out for the JNC 8 panel, which became the former panel when the NHLBI officially dissolved it by late summer.

The former JNC 8 panel applied "a very narrow interpretation" of the clinical evidence where the evidence is very incomplete, commented Dr. Michael A. Weber, professor of medicine at State University of New York, Brooklyn. "The purpose of guidelines is for a group of experts to be guided as far as they can by the evidence, and then use their judgment and experience to make recommendations that in the best interests of patients." He cited findings from the ACCOMPLISH, INVEST, and VALUE trials that show benefits from treating patients older than 60 years to a systolic pressure of less than 140 mm Hg, though he admitted that in each of these studies the findings did not come from primary, prespecified analyses.

Dr. Weber led a panel organized by the American Society of Hypertension and International Society of Hypertension that released its own set of hypertension diagnosis and management guidelines a day earlier, on Dec. 17 (J. Clin. Hypertension 2013 [doi:10.1111/ch.1223]). Where they overlap, the guidelines from ASH/ISH and from the former JNC 8 panel are mostly the same, with the systolic target for the general population aged 60-79 years being the main area of contention, Dr. Weber said. The ASH/ISH guideline set a systolic target of less than 150 mm Hg for the general hypertensive population aged 80 years or older.

The former-JNC 8 panel also qualified their 150 mm Hg–target by adding that if general population patients aged 60 years or older are on stable, well-tolerated antihypertensive treatment and have a systolic pressure of less than 140 mm Hg, changing treatment and aiming for a higher systolic pressure is not recommended.

The target of less than 150 mm Hg for these patients also had defenders. "They made a reasonable recommendation for the elderly based on the evidence," said Dr. John M. Flack, professor and chief of medicine at Wayne State University in Detroit. But he took the JNC 8 panel to task for relaxing the systolic and diastolic pressure targets for patients with either diabetes or chronic kidney disease from the prior target of less than 130/80 mm Hg to new targets of less than 140/90 mm Hg. "Relaxing blood pressure targets in high-risk groups when so much progress has been made over the last decade is going to be very controversial," he said in an interview. The new ASH-ISH hypertension guideline also set a blood pressure target of less than 140/90 mm Hg for patients with diabetes or chronic kidney disease.

The guideline from the former JNC 8 panel "will produce a lot of discussion, and the main target will be whether the 150 mm Hg target is right or not," commented Dr. Eric D. Peterson, professor of medicine at Duke University in Durham, N.C. In an editorial that accompanied the published guideline, Dr. Peterson and his associates also noted that the hypertension goals specified in authoritative guidelines had a magnified importance these days because they often are incorporated into "performance measures" to which physicians can be often held rigidly accountable.(JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284430]).

"I chair the ACC/AHA Task Force on Performance Measures, and we will be in a bind because the current performance measures call for a blood pressure target of less than 140/90 mm Hg," he said in an interview. The ACC/AHA task force is one of the main contributors of performance measures for cardiovascular disease to the U.S. clearing house for performance measures, the National Quality Forum. "The Task Force will need to respond to this guideline in some way," he said, but the Task Force takes into account the range of current guidelines that exist and their backup evidence, so how it will decide on this issue remains uncertain.

"My concern is not so much with the number they came up with as with how it will be used by physicians in the community," Dr. Peterson said. On one hand, you don’t want physicians to get carried away and feel they need to treat all their patients to below some magical number." As he pointed out in his editorial, the counterbalancing problem is that there is always a gap between the hypertension treatment goals and what is often achieved in practice. If that relationship remains and the accepted goal for patients aged 60-79 years becomes less than 150 mm Hg, then many U.S. patients in this group may end up treated but with systolic pressures above 150 mm Hg.

Dr. James and Dr. Peterson said that they had no disclosures. Dr. Weber said that he has been a consultant to Novartis, Takeda, and Forest. Dr. Flack said that he has been a consultant to Novartis, Medtronic, and Back Beat Hypertension and received funding from Novartis and Medtronic.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

The group of experts who had constituted the JNC 8 panel, a team assembled in 2008 by the National Heart, Lung, and Blood Institute to update official U.S. hypertension management guidelines, set the target blood pressure for the general population aged 60 years or older to less than 150/90 mm Hg, a major break from long-standing practice to treat such patients to a target systolic pressure of less than 140 mm Hg.

This decision, which the panel contends was driven by lack of clear evidence for extra benefit from the below–140 mm Hg target, will surely prove controversial, along with the panel’s relaxing of target blood pressures for patients with diabetes or chronic kidney disease to less than 140/90 mm Hg (increased from 130/80 mm Hg in the prior, JNC 7 guidelines). That controversy would be a fitting final curtain for the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), a project that courted controversy by running years longer than anticipated and then generating several plot twists during the final months leading up to Dec. 18, when the former JNC 8 panel published its hypertension-management guideline (JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284427]).

©Dr. Heinz Linke/iStockphoto.com

The new target of a systolic pressure of less than 150 mm Hg for hypertensive patients aged 60 or older without diabetes or chronic kidney disease "is definitely controversial," said Dr. Paul A. James, cochairman of the panel and professor of family medicine at the University of Iowa in Iowa City. "There is A-level evidence that getting blood pressure below 150 mm Hg results in improved outcomes that really matter, but we have no evidence at this time to support going lower," to less than 140 mm Hg. "The good news is that the panel is comfortable that we don’t do harm," by treating patients to less than 140 mm Hg. "But why put patients at increased risk for medication adverse events when we don’t have strong evidence of benefit?" he said in an interview.

He stressed that his group released their conclusions and guideline on their own, identifying themselves as "the panel members appointed to the Eighth Joint National Committee (JNC 8)." Leaders from the National Heart, Lung, and Blood Institute announced last June that the agency was pulling out of the business of issuing cardiovascular-disease management guidelines, and would instead fund evidence reviews and partner with other organizations to issue guidelines. The NHLBI arranged for its cholesterol, obesity, and lifestyle guidelines to be released through the American Heart Association and American College of Cardiology, but no similar arrangement worked out for the JNC 8 panel, which became the former panel when the NHLBI officially dissolved it by late summer.

The former JNC 8 panel applied "a very narrow interpretation" of the clinical evidence where the evidence is very incomplete, commented Dr. Michael A. Weber, professor of medicine at State University of New York, Brooklyn. "The purpose of guidelines is for a group of experts to be guided as far as they can by the evidence, and then use their judgment and experience to make recommendations that in the best interests of patients." He cited findings from the ACCOMPLISH, INVEST, and VALUE trials that show benefits from treating patients older than 60 years to a systolic pressure of less than 140 mm Hg, though he admitted that in each of these studies the findings did not come from primary, prespecified analyses.

Dr. Weber led a panel organized by the American Society of Hypertension and International Society of Hypertension that released its own set of hypertension diagnosis and management guidelines a day earlier, on Dec. 17 (J. Clin. Hypertension 2013 [doi:10.1111/ch.1223]). Where they overlap, the guidelines from ASH/ISH and from the former JNC 8 panel are mostly the same, with the systolic target for the general population aged 60-79 years being the main area of contention, Dr. Weber said. The ASH/ISH guideline set a systolic target of less than 150 mm Hg for the general hypertensive population aged 80 years or older.

The former-JNC 8 panel also qualified their 150 mm Hg–target by adding that if general population patients aged 60 years or older are on stable, well-tolerated antihypertensive treatment and have a systolic pressure of less than 140 mm Hg, changing treatment and aiming for a higher systolic pressure is not recommended.

The target of less than 150 mm Hg for these patients also had defenders. "They made a reasonable recommendation for the elderly based on the evidence," said Dr. John M. Flack, professor and chief of medicine at Wayne State University in Detroit. But he took the JNC 8 panel to task for relaxing the systolic and diastolic pressure targets for patients with either diabetes or chronic kidney disease from the prior target of less than 130/80 mm Hg to new targets of less than 140/90 mm Hg. "Relaxing blood pressure targets in high-risk groups when so much progress has been made over the last decade is going to be very controversial," he said in an interview. The new ASH-ISH hypertension guideline also set a blood pressure target of less than 140/90 mm Hg for patients with diabetes or chronic kidney disease.

The guideline from the former JNC 8 panel "will produce a lot of discussion, and the main target will be whether the 150 mm Hg target is right or not," commented Dr. Eric D. Peterson, professor of medicine at Duke University in Durham, N.C. In an editorial that accompanied the published guideline, Dr. Peterson and his associates also noted that the hypertension goals specified in authoritative guidelines had a magnified importance these days because they often are incorporated into "performance measures" to which physicians can be often held rigidly accountable.(JAMA 2013 Dec. 18 [doi:10.1001/jama.2013.284430]).

"I chair the ACC/AHA Task Force on Performance Measures, and we will be in a bind because the current performance measures call for a blood pressure target of less than 140/90 mm Hg," he said in an interview. The ACC/AHA task force is one of the main contributors of performance measures for cardiovascular disease to the U.S. clearing house for performance measures, the National Quality Forum. "The Task Force will need to respond to this guideline in some way," he said, but the Task Force takes into account the range of current guidelines that exist and their backup evidence, so how it will decide on this issue remains uncertain.

"My concern is not so much with the number they came up with as with how it will be used by physicians in the community," Dr. Peterson said. On one hand, you don’t want physicians to get carried away and feel they need to treat all their patients to below some magical number." As he pointed out in his editorial, the counterbalancing problem is that there is always a gap between the hypertension treatment goals and what is often achieved in practice. If that relationship remains and the accepted goal for patients aged 60-79 years becomes less than 150 mm Hg, then many U.S. patients in this group may end up treated but with systolic pressures above 150 mm Hg.

Dr. James and Dr. Peterson said that they had no disclosures. Dr. Weber said that he has been a consultant to Novartis, Takeda, and Forest. Dr. Flack said that he has been a consultant to Novartis, Medtronic, and Back Beat Hypertension and received funding from Novartis and Medtronic.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

The two U.S. groups most active in issuing guidelines and recommendations for cardiovascular disease diagnosis and management, the American College of Cardiology and American Heart Association, received a surprise in June when the National Heart, Lung, and Blood Institute suddenly announced that it would shift to these and other "partner organizations" primary responsibility for the next updates of U.S. hypertension guidelines, national cholesterol-management guidelines, and the other cardiovascular disease–related management recommendations that the institute has had in the works.

The NHLBI launched "a collaborative relationship with the ACC, AHA, and other organizations because they said they are not in a position to endorse guidelines, they must be endorsed by other organizations," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill. Dr. Smith is a member of the panel that’s been writing the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), and has been active for a long time in the ACC and AHA guidelines-development process.

On June 19, Dr. Gary H. Gibbons, NHLBI director, and his associates announced that effective immediately the institute was getting out of the guidelines-issuing business (Circulation 2013; doi: 10.1161/CIRCULATIONAHA.113.004587).

"Just over the past couple of months we began to look at how this will be done. Everyone wants the process to move quickly. How quickly can these organizations put it together? That’s the limiting factor right now," Dr. Smith said in an interview in early September.

While the ACC and AHA have on record some 20 sets of practice guidelines that cover most facets of cardiology, their list omits areas that the NHLBI covered in the past, notably hypertension and hypercholesterolemia assessment and management.

"The ACC and AHA guideline process is very expensive, and we wouldn’t dream of duplicating something when people you trust were commissioned by someone else [NHLBI] to do the work," 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. He serves as vice-president of the ACC. "We have all been under the impression that JNC 8 was being put together and getting published soon," he said in an interview.

Dr. Williams stressed that he and other ACC officials have pledged not to talk about the JNC 8 process until transition from the NHLBI works itself out, but he offered this succinct observation: The ACC "has made a commitment to go forward with the JNC process. There will be a publication from that panel, although it may not have that name."

Dr. Smith and Dr. Williams said that they had no relevant disclosures.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

The two U.S. groups most active in issuing guidelines and recommendations for cardiovascular disease diagnosis and management, the American College of Cardiology and American Heart Association, received a surprise in June when the National Heart, Lung, and Blood Institute suddenly announced that it would shift to these and other "partner organizations" primary responsibility for the next updates of U.S. hypertension guidelines, national cholesterol-management guidelines, and the other cardiovascular disease–related management recommendations that the institute has had in the works.

The NHLBI launched "a collaborative relationship with the ACC, AHA, and other organizations because they said they are not in a position to endorse guidelines, they must be endorsed by other organizations," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill. Dr. Smith is a member of the panel that’s been writing the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), and has been active for a long time in the ACC and AHA guidelines-development process.

On June 19, Dr. Gary H. Gibbons, NHLBI director, and his associates announced that effective immediately the institute was getting out of the guidelines-issuing business (Circulation 2013; doi: 10.1161/CIRCULATIONAHA.113.004587).

"Just over the past couple of months we began to look at how this will be done. Everyone wants the process to move quickly. How quickly can these organizations put it together? That’s the limiting factor right now," Dr. Smith said in an interview in early September.

While the ACC and AHA have on record some 20 sets of practice guidelines that cover most facets of cardiology, their list omits areas that the NHLBI covered in the past, notably hypertension and hypercholesterolemia assessment and management.

"The ACC and AHA guideline process is very expensive, and we wouldn’t dream of duplicating something when people you trust were commissioned by someone else [NHLBI] to do the work," 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. He serves as vice-president of the ACC. "We have all been under the impression that JNC 8 was being put together and getting published soon," he said in an interview.

Dr. Williams stressed that he and other ACC officials have pledged not to talk about the JNC 8 process until transition from the NHLBI works itself out, but he offered this succinct observation: The ACC "has made a commitment to go forward with the JNC process. There will be a publication from that panel, although it may not have that name."

Dr. Smith and Dr. Williams said that they had no relevant disclosures.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

The two U.S. groups most active in issuing guidelines and recommendations for cardiovascular disease diagnosis and management, the American College of Cardiology and American Heart Association, received a surprise in June when the National Heart, Lung, and Blood Institute suddenly announced that it would shift to these and other "partner organizations" primary responsibility for the next updates of U.S. hypertension guidelines, national cholesterol-management guidelines, and the other cardiovascular disease–related management recommendations that the institute has had in the works.

The NHLBI launched "a collaborative relationship with the ACC, AHA, and other organizations because they said they are not in a position to endorse guidelines, they must be endorsed by other organizations," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill. Dr. Smith is a member of the panel that’s been writing the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), and has been active for a long time in the ACC and AHA guidelines-development process.

On June 19, Dr. Gary H. Gibbons, NHLBI director, and his associates announced that effective immediately the institute was getting out of the guidelines-issuing business (Circulation 2013; doi: 10.1161/CIRCULATIONAHA.113.004587).

"Just over the past couple of months we began to look at how this will be done. Everyone wants the process to move quickly. How quickly can these organizations put it together? That’s the limiting factor right now," Dr. Smith said in an interview in early September.

While the ACC and AHA have on record some 20 sets of practice guidelines that cover most facets of cardiology, their list omits areas that the NHLBI covered in the past, notably hypertension and hypercholesterolemia assessment and management.

"The ACC and AHA guideline process is very expensive, and we wouldn’t dream of duplicating something when people you trust were commissioned by someone else [NHLBI] to do the work," 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. He serves as vice-president of the ACC. "We have all been under the impression that JNC 8 was being put together and getting published soon," he said in an interview.

Dr. Williams stressed that he and other ACC officials have pledged not to talk about the JNC 8 process until transition from the NHLBI works itself out, but he offered this succinct observation: The ACC "has made a commitment to go forward with the JNC process. There will be a publication from that panel, although it may not have that name."

Dr. Smith and Dr. Williams said that they had no relevant disclosures.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

aotto@frontlinemedcom.com

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

aotto@frontlinemedcom.com

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

aotto@frontlinemedcom.com

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m² with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m² with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m² with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com