Canadian blood pressure authority skeptical of new U.S.

guidelines
New U.S. guidelines that suggest treatment goals for people over 60 should be set at 150 over 90 mm Hg are expected to help lower the number of medications taken by baby boomers. But Hypertension Canada says the new U.S. guidelines dont prioritize risk status.

Laura Kane (via The Star) Dec 19th 2013

The Canadian hypertension authority is criticizing new American guidelines that lower blood pressure goals for people over 60, suggesting they could lead to more strokes and cardiovascular disease. But some experts are calling the U.S. recommendations more realistic for baby boomers and calling on the authority to take a closer look. Dr. Raj Padwal of Hypertension Canada, which sets blood pressure goals used widely by doctors, questioned new guidelines published online Wednesday in the Journal of the American Medical Association. He said the guidelines dont prioritize risk status for example, whether the patient has prior cardiovascular disease or organ damage. The result is that many high-risk patients over 60 wont be treated aggressively and, as a consequence, stroke rates and cardiovascular and kidney disease rates will probably rise, he said. The U.S. guidelines suggest treatment goals for people over 60 should be set at 150 over 90 mm Hg, based on studies showing these patients fare just as well over time at this higher level. The goal for other groups is 140 over 90.

These guidelines are expected to help lower the number of medications taken by baby boomers, as they wont need to be treated as aggressively for high blood pressure. Padwal said most of the recommendations are reasonable and Hypertension Canada will consider them in its next annual set of guidelines. The 2014 guidelines are already written and will not include an age-based recommendation for people over 60 when they are published in January. The 2013 guidelines set the treatment goals for Canadians over the age of 80 at 150 over 90. For the rest of the population, the guidelines are based on risk level. The goal for highrisk people is 140 over 90, while the goal for low-risk people is 160 over 100. In Canada, the goal for people with diabetes is 130 over 90, while the new U.S. guidelines change that goal to 140 over 90 if the patient is under 60. Dr. Peter Liu, scientific director of the University of Ottawa Heart Institute, said the new U.S. guidelines were more realistic for baby boomers and that the Canadian goals should evolve in the same direction. As we get older, our blood pressure naturally gets higher, said Liu. Its not realistic when you have folks that are much older, starting out with a much higher blood pressure, to have to load them with a lot of medications with side-effects. Dr. Jacob Udell, a cardiologist and spokesperson for the Heart and Stroke Foundation, agreed there was little evidence to show that more aggressive treatment was effective over age 60. He was supportive of the current Canadian guidelines, but said experts should take a good look at the data supporting the new U.S. recommendations. If we get too aggressive with blood pressure when were over an advanced age . . . sometimes we can do more harm than good, because low blood pressure can have side-effects too. Hypertension increases the risk of heart disease, the leading cause of death worldwide. While the changes probably wont reduce how many people are treated for hypertension, the new goals may trim the number and types of pills taken, U.S. doctors have said. The authors of the U.S. guidelines focused on people ages 60 and older because they are a unique population and we are concerned about the number of medications that may be required, said lead author Dr. Paul James of the University of Iowa. There are side effects from each and every medication and there may be drug -drug interactions. Padwal agreed medication burden is a concern, but said thats why its important to start medications only when the benefits outweigh the risks.

In people who are over 60 and high risk, the benefits outweigh the risks. So, the age is only one factor that we consider, and its probably not even the most important factor to consider. The risk status . . . is more important. These guidelines are the second in two months to be published in the U.S. The panel of 17 academics began its work under the banner of the National Heart, Lung and Blood Institute, but when it was nearly done, the institute withdrew and handed the task over to the American College of Cardiology and the American Heart Association. The blood pressure panel decided to publish on its own, but the cardiology college and the heart association beat the panel to it, publishing their own guidelines last month. Dr. Ross Feldman of Hypertension Canada called the fiasco the paradigm for dysfunctional U.S. management of their public health. The Americans have written the book on how not to do evidence-based recommendations, he said. We take a very inclusive approach and are very careful in terms of our messaging. A recent study showed that Canada has a blood pressure control rate of about 65 per cent, compared with the U.S. rate of 50 per cent. While Canadas universal health-care model likely plays a role, Feldman said that this shows that Canada has been more successful in implementing blood pressure guidelines. Are (the U.S. guidelines) relevant for Canadian health-care providers? Probably not. Do we have a lot to learn from the American process? No.