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Should NICE lower blood pressure thresholds for hypertension?

Dr John Aschroft and Dr David Spitzer go head to head on proposals to introduce lower blood pressure thresholds for diagnosis and management of hypertension

dr john aschroft

YES. It will benefit both patients and the NHS

US and European guidelines recently introduced lower blood pressure thresholds for management of hypertension,1,2 and I believe NICE should do the same when it updates its guideline next year.

The main evidence behind this change comes from the Systolic Blood Pressure Intervention Trial, or SPRINT.3 It included more than 9,000 adults and was meticulously run. It was stopped early by the independent monitoring board because ‘it became clear that treating systolic blood pressure to a target of less than 120mmHg significantly reduced rates of cardiovascular events and death’.

The relative reduction in overall risk of death was big, at 27%; as the average age of patients at baseline was 68, this represents a big health gain. The risk of cardiovascular events was reduced by 25%.

Adverse events were no worse than for usual care

As with the US and European guidance, I would like to see more people diagnosed with hypertension and given advice on lifestyle changes. Those with other cardiovascular risk factors should be treated to lower targets, with earlier addition of medications where needed. Targets for older patients may see the biggest changes, from <150/90mmHg now to <130/80mmHg as in the US guidelines, or 130-139/80mmHg in the European guidelines.

Treating often older patients to lower targets will no doubt raise concerns about side-effects; I know this was the concern from my partners. But adverse events linked to more intensive treatment in SPRINT were mainly ‘electrolyte abnormalities’, which are reversible; worrisome adverse events such as ‘falls with injury’ and orthostatic hypotension were no more frequent in the intensive treatment than usual treatment group.

Of course, there are implications for GPs’ workload. The average number of medications patients took in SPRINT to reach lower targets was 2.8, compared with 1.8 in the usual treatment group, and patients would need close monitoring of biochemical abnormalities.

But with hypertensive treatments cheap and typically cost saving, the gains for patients and the NHS of treating to lower targets could be large. With more money promised to the NHS, and the health secretary prioritising prevention, the extra work should be met by increased funding, logically through the QOF.

Dr John Ashcroft is a GPSI in cardiology in Derbyshire

 

Dr David Spitzer square large

NO. It will cause more problems than it solves

At first glance, reducing blood pressure thresholds for hypertension seems a good idea. More people diagnosed and treated surely means less disease.

But consider the bigger picture. A large number of well people become ‘hypertensive’ overnight, even though they won’t need any treatment. If we aim to improve health, should we really be making so many more people ‘unwell’? The paradox is clear. If there is one thing I hate, it’s patients leaving my consulting room more unwell than when they arrived.

Good practice dictates that we should not carry out investigations that make no difference to management. Currently, at lower risk levels, with no end-organ damage, treatment is aimed at modifying lifestyle factors – advice everyone should ideally be following. So what exactly is the point of diagnosing hypertension? Is it to scare people into change? There is a strong whiff of paternalism here.

The focus should be on those we know are at higher risk

Inevitably, many more people will be medicated. A recent large study showed little benefit from taking medication in people with low-risk hypertension.4 Even for those at higher risk, the absolute risk reductions are very small and the numbers needed to treat large. And medicating so many people increases the risk of iatrogenic harm. Morbidity will rise due to side-effects, whether common, like dizziness and falls in the elderly, or rare, more serious adverse events.

There are other downsides too – time spent on consultations, the burdens of taking medication, the rise in health and travel insurance premiums and the psychological impact of the diagnosis.

The crux of the matter is the age-old conflict between the health of the population and that of the individual. On a population basis, changing the thresholds may save some lives. But at what cost to each individual?

Which brings us to the opportunity costs. Hypertension is rightly no longer diagnosed via a couple of measurements, with NICE now advising ambulatory or home monitoring. With resources tight and demand sky high, who is going to diagnose all these patients? Who will counsel them and follow them up? And what will we choose not to do instead?

Instead of making more people into patients, the focus should be on those we already know are at higher risk, and on promoting resources for better shared decision making with patients.

Dr David Spitzer is a GP in London and vice-chair of the RCGP’s standing group on overdiagnosis

References

1 Whelton P et al. 2017. J Am Coll Cardiol 2018;71:e127-e248.

2 Williams B et al. 2018. Eur Heart J, 2018;39:3021–3104

3 The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

4 Sheppard J et al. JAMA Intern Med 2018; published online 29 October

 

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Readers' comments (10)

  • I realise Dr Ashcroft's "brief" is to present one side of the argument, but whenever anyone tells me a relative risk reduction as a basis for a change of practice without telling me the NNT,I find it hard to trust their argument...

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  • As in most of these hypertension studies they don't even reach their own target BP. The mean systolic achieved was 121.4 mm Hg. So I assume 50% had a higher BP than this, yet guidelines will use 120 as a blanket policy.

    2284 were excluded from the study for taking too many medications or had a systolic BP that was out of range ! Inclusion criteria below.

    * SBP (mmHg) in a range:
    * 130-180 on ≤1 medication
    * 130-170 on ≤2 medications
    * 130-160 on ≤3 medications
    * 130-150 on ≤4 medications

    All the exclusion criteria are here. https://www.wikijournalclub.org/wiki/SPRINT#Exclusion_Criteria

    Good luck to you if you have any patients at all that would fit into this group.

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  • Big-Pharma Zillions - GP Zilch

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  • I smell Big pharma. I smell a Big Con.
    Will ALL the results of ALL BP trials ever done be available to NICE when they try to arrive at their decision with this latest possitive result?
    Was this the 'all cause' death rate? Why no NNT value? Who are on the 'independent' monitoring board that stopped the trial?- at the end of the day this trial was incomplete?
    And even at the end of the day the evidence does stack up, how are we going to implement it with our neagtive health resources?

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  • Yep, I'm all for lowering the systolic BP target to a level where people live for longer and those workshy nursing home and social care providers get to learn what real work is.(/s)

    And I'm pleased to confirm, to our GP colleagues in Derbyshire, that Dr Ashcroft, GPwSI in Cardiology/Immortality will gladly see all your patients who are failing to reach a systolic BP of 120, and who have expressed the wish to be dead in preference to having more side effects from the multitude of pills given to achieve a number, rather than actual patient "care".

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  • AlanAlmond

    of cause! BP should be as low as the patinet can tolerate. we need to move to an individualized model where BP meds are titrate to sitting/standing BP - such that the patinet can maintain consciousness on standing from a sitting position. Wan then work toward a world inwhich we spend most of our time supine, and ajust BP targets accordingly. Anything that takes the pressure off the cardiac muscle is good in my book, and if that includes medication...all the better!!

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  • Angus, Angus (GP Partner/Principal07 Dec 2018 4:23pm) how could you? Those altruistic, benevolent organisations are only trying to help patients by offering them, from cradle to grave, life-saving statins, psychotropics, antihypertensive etc . Ah yes, I forgot, and women the pill followed by HRT, covering most of their life span with hormones.

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  • And more money for the Big Pharma. I am very sceptical about the strong sponsorship of all this trials, pretty much like the statins, none of them could be branded independent! All staff and researchers salaries are payed by Pharmaceutical “grants” How non biased this is ?!

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  • Ivan Benett

    sceptic | GP Partner/Principal08 Dec 2018 11:02am Nikolova | Locum GP08 Dec 2018 12:23pm and others - The SPRINT trial was funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01206062.). No Pharma involvement.
    Among nearly 10,000 patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group.
    NB same was not shown in the ACCORD trial of a similar population but with diabetes.
    You can't just discount the SPRINT study because you don't like it. However, I would suggest waiting for a holistic assessment from NICE before changing UK targets.
    PS Statin trial trials also show benefit

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  • The study looked at over 50s but only 28% of total patients were over the age of 75 - despite this thresholds for over 80s are suggested to be decreased significantly.

    On top of this, I'm afraid UK GP does not have the resources to do more diagnosis and follow up - the proposed QOF suggestion will not materialise

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