The New Controversy Over Cholesterol and Blood Pressure Guidelines

As much as I’d love to blog about UFC or great medical movies again, let’s take a break from the fun stuff and discuss something that is really important — the new hypertension (blood pressure) and cholesterol guidelines that your doctor is probably already using whether you realize it or not. Your doctor determines your goal cholesterol and blood pressure based on the medical opinion of internationally recognized panels of experts, namely the Joint National Committee for blood pressure and the American Heart Association and the American College of Cardiology consensus statement for cholesterol. In this edition of The Health and Medical Blog with a Personality we’re going to examine the new blood pressure guidelines and next time we’ll delve into the controversy over the new cholesterol targets.

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Talking about doctors fighting over blood pressure guidelines isn’t quite as exciting as watching these guys go at it, but it’s a hell of a lot more important…

“For every 20-mmHg increase in SBP beginning at 115 mmHg, or 10-mmHg increase in DBP beginning at 75 mmHg, mortality from ischemic heart disease and stroke are doubled” [Reference #1. Note: SBP = the top number and DBP = the bottom number. More on that later]. The problem with hypertension is that you don’t feel sick, even though you really are, and by the time that you DO feel sick you have a serious problem on your hands — if you’re lucky enough to still be alive, that is. The good news is that dangerously high blood pressures are easy to detect via simple screening in your doctor’s office and that hypertension is usually pretty easy to treat. Fully 1/3 of all Americans have high blood pressure (2/3 if your older than age 60) and the cost to our society of the preventable heart attacks and strokes that these people needlessly suffer every year is greater than $100 billion dollars!

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A right-sided hemorrhagic (bleeding) cerebral vascular accident (stroke) with midline shift of the brain (not good) seen on a CT scan. Strokes come in two forms: hemorrhagic and ischemic. Hemorrhagic strokes occur when a blood vessel in the brain “pops” open, often because of uncontrolled high blood pressure. Ischemic strokes occur when a clot blocks an artery in the brain. Uncontrolled hypertension substantially increases your risk for both types of stroke.

Physicians have known for at least the past few centuries that walking around with a sky high blood pressure was really bad for you. Even before we had blood pressure cuffs, doctors realized that people with abnormally strong pulses had a habit of keeling over prematurely. The problem until the late 1950s was that we didn’t have very many effective ways to treat hypertension. Yes, there was the salt-restrictive diet, that worked (and still does work) wonders in a minority of hypertensives, and we had some really nasty drugs like phenobarbital (commonly used to anesthetize lab animals prior to execution and dissection these days), but there weren’t any good choices to treat the average High Blood Pressure Joe without causing side-effects that were arguably worse than the disease. This all changed in the ’50s with the introduction of thiazide diuretics, an effective class of medications for high blood pressure with relatively few side-effects. Over the next few decades a plethora of effective classes of antihypertensives entered the market and medicine was changed forever (now the problem is getting patients to take their damn medications…).

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Another potential catastrophic sequelae (side-effect) of untreated hypertension is aortic dissection. Essentially the unravelling of the largest artery in your body (the aorta) by untreated high blood pressures. The weakened aorta then ruptures and rapidly spills the majority of the body’s blood into the chest cavity, resulting in sudden death. 

The Joint National Committee (JNC) was established in the mid-1970’s to provide physicians with guidance over how and when to use our new armamentarium of antihypertensive drugs. Every 5-10 years JNC releases a report that most doctors use as their guide regarding how and when to treat your high blood pressure. JNC is a group of experts in the treatment of high blood pressure, the best-of-the-best, who get together and mull over the results of clinical trials (really big and expensive scientific studies) and then determine what your goal blood pressure should be and what treatments your doctor should use to get it there based on these scientific studies. Until a few weeks ago the results of the 7th JNC meeting, JNC-7 (released in 2003), was the final word on the treatment of hypertension and, whether you knew it or not, was almost certainly the source of the blood pressure goals and treatment guidelines that your doctor was preaching to you every time you went in for a checkup. That changed on the 18th of December 2013 with the much anticipated release of JNC-8 in the Journal of the American Medical Association.

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Another nice artist’s rendition from the Wiki of the cardiovascular (“heart and blood vessel”) complications (“bad stuff that happens”) due to uncontrolled hypertension.

The biggest difference between JNC-7 and JNC-8 is that the JNC-8 commission only looked at the results of Randomized Controlled Clinical Trials, the highest quality scientific studies, whereas all of the prior JNC groups (including JNC-7) also considered the results of lower quality clinical evidence, including “expert opinions (the ‘two-cents’ of certain medical big shots),” when they formulated their guidelines. Let’s look at what’s changed and then we’ll argue about it!

 

 

JNC-7

JNC-8

 

 

 

Blood Pressure Goal

<140/90

Age >60 : <150/90

Age <60 : Only treat if Diastolic Blood Pressure (the bottom number) is >90. If treated, the goal is <140/90.

 

   

Blood Pressure Goal if Diabetic or Chronic Kidney Disease

<130/80

<140/90

 

   

1st Drug Choice if Medication is Required

Hydrochlorothiazide

Black Patients : Hydrochlorothiazide or Calcium Channel Blockers

 

Nonblack Patients: ACE Inhibitors/ARBs, Calcium Channel Blockers, or   Hydrochlorothiazide.

Note: Black patients tend to response less to the ACE Inhibitor/ARBs class of blood pressure medications than other populations of people do.

 

   

Other Acceptable Drug Choices

ACE Inhibitors/ARBs, Beta Blockers, Calcium Channel Blockers

Same as Above (Beta Blockers are no Longer Recommended as 1st or 2nd   Line Treatments For Hypertension by JNC-8)

 

   

The most surprising difference in JNC-7 vs. JNC-8 is the new recommendation NOT to begin treatment for people older than age 60 unless their blood pressure is >150/90 (instead of the old guideline of >140/90). The JNC-8 panel only looked at the very best clinical trials and they found evidence that 150/90 was the point where the benefits of treating folks with medications outweighed the side-effects of those medications. With that said, JNC-8 used very high criteria to define what a “good” study is. To add fuel to the debate, virtually all of the studies out there looking at blood pressure weren’t actually designed to help answer the questions JNC-8 was asking, questions like “when should we treat high blood pressure” or “what kind of drugs should we use to treat high blood pressure.” Rather, even the best of these clinical trials were generally drug company sponsored studies that were evaluating whatever particular drug the sponsoring company was trying to sell.

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Drug companies fill a vital role in modern medicine, designing the life-saving medications, vaccinations, and medical devices that have revolutionized the human experience in the past century. However, they also do a lot of ethically “questionable” things, like hiring former cheerleaders to market drugs to male doctors, bribing doctors with “continuing medical education” cruises and golf outings, using indigent people in piss-poor countries as their research subjects (and sometimes “doctoring” the results of these studies), and promoting drugs for “off-label” uses of questionable value (and etc., etc.). Studies that are funded by drug companies are important because who the heck else is going to fund this stuff (!), but remember to take them with a grain of salt.

There was a vocal minority in the JNC-8 commission (see their dissenting paper listed in the “References” section below) that argues that there is a clear decline in heart disease and stroke when  <140/90 is used as the blood pressure goal and that the side-effects of treating people to this goal, especially increased falls, don’t really become a significant problem in most patients until they are older than age 80. This minority of experts argues that <140/90 is a more appropriate goal for patients who are younger than age 80. The take home message is that this is still very much a topic of debate and that you should have a discussion with your doctor regarding your personal blood pressure goal since your physician knows you better than the experts who wrote the general guidelines (e.g. Are you at high risk for falls? Then maybe your personal blood pressure goal should be >150/90. Have you had a hemorrhagic stroke in the past but aren’t a particularly high fall risk? Then maybe your personal blood pressure goal should be lower.).

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A large hematoma (essentially a huge bruise caused by a deep collection of blood) after a hip fracture. Untreated hypertension is a leading cause of disability and death due to preventable strokes, heart attacks, kidney failure, and aortic dissections (etc.). However, overtreated hypertension can also be dangerous due to increased risk of falls.

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A fractured (broken) hip on X-ray. Falls are a common cause of hip fracture in the elderly, and hip fractures are a common cause of permanent disability and even death in this population. On the other hand, strokes and heart attacks are also a rather common cause of disability and death in the elderly, and untreated (or undertreated) hypertension substantially increases your risk of having both. As with most things in medicine, the treatment of hypertension is a balancing act that should be managed by an experienced physician — and sometimes there isn’t a right answer, just the least wrong one.

The other major changes were the higher (<140/90 instead of <130/80) blood pressure goal for diabetics and persons with chronic kidney disease, the consensus not to treat people younger than 60 unless their diastolic blood pressure (the bottom number) was >90, and the removal of beta blockers from the recommended 1st or 2nd line blood pressure medication treatment options. The higher blood pressure goal for diabetics and in chronic kidney disease were based on an expert consensus statement because high quality evidence is limited (i.e. there isn’t a lot of it out there) — the expert consensus of the JNC-8 panel is at odds with the expert consensus statements of several prominent diabetes and kidney organizations, so again, speak with your doctor to determine what you personal goals should be based on your unique medical situation because this is still a gray area issue.

The blood pressure goal for folks younger than age 60 also suffered from a paucity of quality evidence. In my personal opinion a blood pressure goal of <140/90 is reasonable for most folks who are younger than 60 (you’re not likely to be a high fall risk at this age), but you should be aware that the best clinical evidence only supports treating hypertension in this age group if the diastolic (bottom number) blood pressure is higher than 90. The final major change in JNC-8 was regarding beta blockers for the treatment of hypertension. Beta blockers are good drugs for protecting the heart when someone has heart disease. However, they tend to be wimpy drugs when used soley for the treatment of hypertension, which is why they aren’t recommended by JNC-8 as a 1st or 2nd line drug for folks with high blood pressure anymore. With that said, a lot of patients with high blood pressure have another medical condition like heart disease for which beta blockers are indicated, so don’t be surprised if your doctor prescribes one of these medications if this describes you.

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This is the chemical structure of carvedilol, aka: Coreg, a type of beta blocker medication. The beta blockers studied by JNC-8 (the ones that don’t work well for high blood pressure) were “cardioselective” beta blockers. Carvedilol, on the other hand, is a “broad spectrum” beta blocker that additionally blocks alpha receptors, another important drug target in the treatment of hypertension. In my clinical experience, drugs like carvedilol are substantially more effective in the treatment of hypertension than the cardioselective beta blockers that  the JNC-8 panel studied. Unfortunately, JNC-8 didn’t address this category of drugs.

In a nutshell, as with most major guidelines in medicine, JNC-8 begged two questions for every one that it answered. Remember that guidelines are an important part of medicine, but also remember that you are a unique person, with a unique constellation of health attributes and health problems, and that you should always discuss your treatment options and goals with your personal physician to make certain that you are both on the same page when it comes to your health!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your e-reader at http://www.smashwords.com/books/view/215272. Thanks for reading!

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 20-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES:

Jackson, James H. et al. Blood Pressure Control and Pharmacotherapy Patterns in the United States Before and After the Release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment. J Am Board Fam Med. 2008;21(6):512-521. http://www.medscape.com/viewarticle/583572

Basile, J and Ventura, H. A Historical Look at Hypertension: Celebrating 100 Years with the Southern Medical Association. Southern Medical Journal:  December 2006 – Volume 99 – Issue 12 – pp 1412-1413. http://journals.lww.com/smajournalonline/fulltext/2006/12000/a_historical_look_at_hypertension__celebrating_100.36.aspx

James, Paul A. 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). Journal of the American Medical Association. doi: 10.1001/jama.2013.284427. Published online December 18, 2013.

Wright, Jackson T. et al. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View. Annals of Internal Medicine. 2014 American College of Physicians.

Brett, Allan S. JNC 8 Has Finally Arrived. NEJM Journal Watch. January 15, 2014. Vol. 34 No. 2.

CT of Hemorrhagic Stroke. http://en.wikipedia.org/wiki/Stroke
Haggstrom, Mikael (Wikipedia/Wikimedia Commons). High Blood Pressure Complications Graphic. http://en.wikipedia.org/wiki/File:Main_complications_of_persistent_high_blood_pressure.svg