麻豆传媒

The American College of Physicians (ACP) came down hard on the new American College of Cardiology/American Heart Association blood pressure guideline that shifted the threshold and treatment target to 130/80 mm Hg.

"Are the harms, costs, and complexity of care associated with this new target justified by the presumed benefits of labeling nearly half the U.S. population as unwell and subjecting them to treatment? We think not and believe that many primary care providers and patients would agree," Amir Qaseem, MD, PhD, ACP vice president for clinical policy, and others on behalf of its Clinical Guidelines Committee wrote in an editorial accompanying a summary of the guidelines in the Annals of Internal Medicine.

The group stopped short of directing physicians to use its own blood pressure guideline, which "differs substantially," most notably in a diagnostic and treatment threshold below 150 mm Hg systolic for average- and lower-risk adults 60 and older.

The ACC/AHA guideline would recommend antihypertensive medication targeting below 130/80 mm Hg for nearly everyone ages 79 years or older based on history of cardiovascular disease or a 10-year risk for cardiovascular events of 10% or greater, Qaseem's group noted.

"We believe that initiation of pharmacologic therapy at or above a BP of 130/80 mm Hg and treatment to targets less than 130/80 mm Hg in a broad population of older adults are not supported by evidence and may result in low-value care for several reasons," they wrote.

The ACP complaints centered on risk-benefit tradeoffs, costs, and little empirical evidence for some recommendations as well as worries that performance measures wouldn't allow for individualization of a target that may be good for some but not necessarily so for most.

A in the New England Journal of Medicine by George Bakris, MD, and Matthew Sorrentino, MD, both of the University of Chicago, echoed some of the same concerns, arguing against a one-size-fits-all blood-pressure goal.

"Although the new guideline lowers the blood-pressure goal for people over 65, it suggests that 30-year-olds and 80-year-olds should have the same goal. Achieving that goal is impossible for many people, especially those with poor vascular compliance (i.e., pulse pressures above 80 to 90 mm Hg), who typically have dizziness and poor mentation as their systolic blood pressure approaches 140 mm Hg," Bakris and Sorrentino wrote.

The primary care physician workforce may be overburdened by this broad brush stroke, they added. "Proper blood-pressure measurement is critical but time consuming. The unintended consequence may be that many people, now labeled as patients with hypertension, receive pharmacologic therapy that's unlikely to provide benefit given their low absolute risk, and they may therefore experience unnecessary adverse events."

Bakris and Sorrentino concluded that, while a "target of less than 130/80 mm Hg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher."