The latest medical controversy: Blood pressure goals

Another medical guideline. Another controversy.

This time, a group of experts wants to redefine high blood pressure - it's now OK for some of us to be a little higher, they say - and other doctors are resisting the change.

Raymond Townsend, a kidney specialist at the University of Pennsylvania who helped write the new guidelines, said the group's work is based on the best available evidence from high-quality clinical trials. Published last week in the Journal of the American Medical Association (JAMA), the recommendations allow people over 60 and those with diabetes and kidney disease to have slightly higher blood pressure than current standards, a change that could mean having to take fewer pills.

"It certainly created a little bit of stir," he said, referring to immediate criticism from the American Heart Association, which supports the old rules.

"If you want to practice medicine in an evidence-based era, we looked at the evidence."

Mariell Jessup, another Penn doctor who is president of the American Heart Association, said she worries about public reaction. "I just get anxious when people hear that they don't need as much medicine and they can allow their blood pressure to drift up," said Jessup, medical director of the Penn Heart and Vascular Center.

According to JAMA, nearly 78 million adults in the United States had high blood pressure in 2010; only about half controlled it adequately. High blood pressure is a risk factor for heart disease, stroke, and kidney disease.

"One in three people in this country has hypertension, and it's a silent killer," Jessup said, "and I don't think this is the time, when we have rising levels of diabetes and obesity, to be less vigilant about blood pressure."

Last month, Jessup was in Townsend's position, defending controversial new guidelines from the heart association and the American College of Cardiology calling for more people to take statins, a type of cholesterol-lowering drug, to prevent heart disease, heart attacks, or stroke. Those guidelines also eliminated specific numeric targets for LDL, or bad cholesterol. The two organizations plan to develop their own blood pressure standards, Jessup said.

JAMA editors pointed out that Lyme disease standards from the Infectious Diseases Society of America and mammography screening recommendations from the U.S. Preventive Services Task Force also drew criticism.

"Producing guidelines in the United States has become increasingly more complicated and contentious," they wrote.

The stakes are higher because guidelines now are used more often to evaluate the quality of care, and may even affect payment.

Both sides agree that a large study is needed to establish treatment goals for different age groups.

"There's a whole lot of work we have to do in the field of hypertension," Jessup said.

The group that produced the new guidelines was impaneled in 2008 by the National Heart, Lung and Blood Institute (NHLBI) as the Eighth Joint National Committee (JNC8), Reynolds said. Its mission was to create evidence-based recommendations.

Last summer, though, the NHLBI announced it was getting out of the clinical guidelines business, and shifting responsibility to the heart association and college of cardiology. Other guidelines committees accepted the change, but the JNC8 refused.

Townsend, who directs Penn's hypertension program, said the group wanted to focus on guidelines that community doctors could use easily in the short time they have with patients. "The JNC8 report was written for primary care," he said. "It was not written for cardiologists and specialists."

In an unusual move, they sought publication in JAMA as an independent group.

Blood pressure is expressed as systolic (the pressure in arteries when the heart beats) over diastolic (the pressure in arteries between heart beats). Under 120/80 is considered normal; high blood pressure has been defined as 140/90 or greater.

Under the new guidelines, the goal for people over 60 is to get the top number under 150 instead of 140. "Below that is the target, and that means mid-140s most of the time," Townsend said.

Current guidelines call for people with diabetes or kidney disease to shoot for 130/80. The new rules say 140/90 is fine for them.

Townsend said the evidence is strong for keeping diastolic pressure under 90. There was not enough evidence that older people benefit from reducing systolic pressure from 150 to 140, and no evidence that people with diabetes or kidney disease need to be at 130.

His group never intended for doctors to take people off blood pressure medicines that are working without problem, he said. However, this might keep doctors from writing more prescriptions for patients already taking multiple drugs.

"We don't have evidence to support a lower [blood pressure] goal," Townsend said, "but we also want to reduce the pill burden as much as possible."

120/80

Normal blood pressure

140/90

High blood pressure

130/80

Goal for people with diabetes or kidney disease

150

New top number recommended for people older than 60

140/90

New goal for those with diabetes or kidney diseaseEndText