Guideline Adjustments

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The diagnosis and treatment of many diseases, especially hypertension and diabetes, has been standardized across the country by the development and use of clinical practice guidelines (CPGs). In 1977, the first CPG for the treatment of hypertension was formulated by the first Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure. The members of the JNC1 were appointed by the National Heart, Lung, and Blood Institute (NHLBI) and included experts from major professional societies, the Veterans Administration, and the U.S. Public Health Service. JNC1 concentrated on diastolic blood pressure (DBP) and recommended a stepped-care approach for therapy in all adults with a DBP of 105 or greater. There were no specific recommendations for systolic blood pressure (SBP) because “if both systolic and diastolic blood pressures were used as guidelines, the recommendations would be far too complex.”

Since JNC1 in 1997, there have been six other JNCs. In 2003, JNC7 used a classification system in which adults with an average SBP of 140 or above and a DBP of 90 or above were designated as having hypertension and those with a SBP of 130 to 139 and a DBP of 80 to 89 were designated as having prehypertension. All of the JNCs recommended non-pharmacologic treatment measures such as weight loss, aerobic exercise, and smoking cessation, recommendations that are still used today. The goal of diagnosing and treating high blood pressure is to prevent heart disease. Recognizing this, in 2013 the NHLBI transferred the responsibility for development of heart disease prevention to the American Heart Association (AHA) and the American College of Cardiology (ACC). Last year, the AHA and ACC published their CPG for the diagnosis and treatment of hypertension and the prevention of heart disease. The new guideline uses a different classification system for blood pressure as compared to JNC7. Now adults with a SBP of 130 to 139 and a DBP of 80 to 89 are classified as having Stage 1 hypertension, not prehypertension. The new guideline takes into account a person’s risk for developing heart disease, which is why it is now recommended that anyone with diabetes or kidney disease and a blood pressure of 130/80 or greater should begin treatment.

For those without diabetes or heart or kidney disease treatment should begin at 140/90. In addition, the 2017 guideline recommends that anyone 65 or older with a SBP of 130 or greater should begin treatment. It is estimated that the 2017 guideline will increase the number of people classified as having hypertension by about 14 percent and will increase the number of those on antihypertensive medications by about 1.9 percent (4.2 million adults). The guideline also concludes that adults who warrant antihypertensive treatment will require at least two drugs. The actual treatment recommendations have not changed though and a diuretic (thiazide like HCTZ or chlorthalidone) should be used first with either an ARB (i.e. losartan), ACE inhibitor (i.e. lisinopril), or calcium channel blocker (i.e. diltiazem). Successful implementation of the new guideline should result in a substantial reduction in blood pressure with a commensurate decrease in the incidence of heart disease, in line with the mission of the organizations responsible for the new guideline.

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