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Controversial new blood pressure guidelines

When should 'high' blood pressure be regarded as 'hypertension'? When should we be looking at some kind of medication?

The American College of Cardiology (ACC) and the American Heart Association (AHA) think the current thresholds are too high, and they released new guideline recommendations for hypertension with lower blood pressure values defining elevated blood pressure, and lower treatment thresholds, than those recommended in current guidelines.

So, how many people would this affect, and at what cost?

Millions would be affected

A new study published by the BMJ today shows that adopting the new guidelines would dramatically increase the number of people labeled as having the condition and being recommended for drug treatment.  Millions more would be classified as having hypertension.

The findings show that, if the guidelines were introduced in the US and China, more than half of those aged 45-75 years in both countries would be considered hypertensive.

So, let's put that in perspective.  It would mean that the majority of people in that age range would be hypertensive!

Now, that is a lot of people! And it begs the question of what 'normal' pressures should be.  The impact of these new guidelines for health care would be huge.

Impact worldwide

While the impact of changes in guideline recommendations has been evaluated in the US, less is known about how they translate to other populations. China, in particular, has high levels of hypertension and the world’s largest population, so it is important to understand the impact of adopting these standards in China.

So, what would be the impact of the change in guidelines?

The team of researchers, led by Professor Harlan Krumholz at Yale School of Medicine,  set out to examine the effect of the guidelines on the prevalence of hypertension and eligibility for new and more intensive treatment in the US and China.

They analysed  representative data for adults aged 45 to 75 years from the US and China who would have a diagnosis of hypertension and be candidates for treatment under the proposed new guidelines, compared with current guidelines.

The results show that adoption of the  guidelines would dramatically increase the number of people with hypertension and those recommended for treatment.

In the US, the new guidelines would classify 70 million people in the 45-75 year age group as having hypertension.  That represents 63% of the population in this age group!  Is it really the case that such a large majority of people in the USA between those ages need treatment for hypertension?  

In China  it would lead to the classification of 267 million (55%) people in the same group as having hypertension.

This would represent a relative increase of 27% in the US and 45% in China compared with current recommendations.

Furthermore, they calculate that 7.5 million people in the US and 55 million people in China would be advised to start drug treatment, while 14 million in the US and 30 million in China would be advised to receive more intensive drug treatment.  Good for drug companies, but would it be good for patients?

Based on treatment patterns and current guidelines, 8 million Americans with hypertension are untreated, which would be expected to increase to almost 16 million after the implementation of the new guidelines.

In China, based on current treatment patterns, 75 million patients with hypertension are untreated, and this is likely to increase to 130 million under the new guidelines.

The researchers point out that the study focused only on those aged 45-75 years. Therefore, additional people aged under 45 and over 75 years of age in both the US and China may have hypertension and be candidates for treatment.

Good for patients?

The authors of the study point to several important public health implications, such as the psychological effects of a disease label, the potential harms of unnecessary treatment, and the extra infrastructure needed to manage the substantial increase in patient numbers.

They conclude: “If adopted, the 2017 ACC/AHA hypertension guidelines will markedly increase the number of people labeled as having hypertension and treated with drugs in both the US and China, leading to more than half of those aged 45-75 years in both countries being considered hypertensive.”

Controversy

Needless to say, not everyone agrees that the new guidelines should be adopted, including the AAFP (American Academy of Family Physicians).  They will not be adopting the new guidelines saying
The guidelines should be informed by an independent systematic review of the evidence, an assessment of the benefits and harms, and should follow a sound, transparent methodology with limited potential for financial and intellectual bias.
However, the problem remains that many cases of hypertension go undiagnosed and untreated.  

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