New recommendations about Arterial Hypertension

It seems that the entries in this health blog persistently revolve around pathologies related to cardiovascular risk and particularly high blood pressure, but the recent publication on the management of lipids in 2013 and earlier this year the recommendations of the Joint National Committee (JNC) on hypertension justify the interest created.

The JNC's recommendations on the diagnosis and management of high blood pressure began in 1976 and are updated every 4 years, the latest (JNC7) dating back to 2004. These JNC7 recommendations consider that elderly patients, mainly those over 65 years of age, present isolated systolic hypertension, tripling cardiovascular risk, setting control objectives at figures below 140/90 mm Hg, and achieving these objectives in only 20% of cases. In the presence of diabetes mellitus or chronic renal disease the targets to be achieved would be <130/80 mm Hg. In a meta-analysis of 4-year control follow-up, it was found that the presence of ischemic cardiopathy was reduced by 23%, stroke by 30%, cardiovascular mortality by 18% and total mortality by 13%, with a greater benefit in those over 70 years of age, depending more on the percentages of blood pressure reduction than the different medicines used. A relevant aspect in the elderly is the presence of orthostatic hypotension, being more frequent in older people, concomitant presence of diabetes, treatment with venodilators, diuretics or nitrites, being related to an increase in mortality, falls and fractures.

The JNC8* recommendations have been developed using evidence-based medicine methodology, establishing the quality of the available evidence and the strength of the different recommendations based on the available clinical trials and systematic reviews.

The new recommendations establish that in people with ≥ 60 years of age the targets to be achieved should be lower than 150/90 mm Hg of blood pressure (Grade A recommendation), as it seems that there are no major additional benefits comparing lower levels of 140, with ranges of 140-160 or 140-149 mm Hg of systolic blood pressure. In case of well-tolerated levels below 140 mm Hg, which do not modify the patient's quality of life, they can be maintained. In people under 60, the target remains below 140/90, including people with diabetes or chronic kidney disease.

First-line treatments are considered to be ACEi, ARAII, thiazides and calcium-antagonists, however beta-blockers and alpha-adrenergic drugs in some studies increase cardiovascular mortality, risk of AMI or stroke compared to ARA II or diuretics. In the presence of chronic renal disease it would be indicated to start preventive treatment with ACEi or ARA II. The concomitant use of both is not indicated, due to the high risk of hyperkalemia and scarce benefit.

It should be noted that in an increasingly older world, the age of consideration for geriatric patients is decreasing from 65 to 60 years, with the same objectives at 61 as at 90 years of age. Relevant aspects such as life expectancy, present co-morbidities, functional capacity are not taken into consideration, and therefore emphasis is placed on aspects of cardiovascular risk, predetermining a life expectancy of more than 10 years. It is paradoxical that the group of patients who are going to be treated the most is the one with the least information available due to the low inclusion in clinical trials.

"Every day we know more and understand less. (G. Bernard Saw)

* James P, Oparil S, Carter B et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults JAMA 2014;E1-E14.