Understanding the 2017 Hypertension Guidelines

Understanding the 2017 Hypertension Guidelines

November 1, 2019 9 By Jose Scott


Hello, I’m Dr. John
Warner, president of the American Heart Association. I’m here today with Paul
Whelton, whose the chair of the writing group
for the new hypertension clinical practice guidelines,
who were just released today at Scientific Sessions. Congratulations on such
an impactful publication– Thank you John.
And for your work and the rest of the writing groups work on this important publication. Thank you very much. It’s been awhile since
we’ve had an updated the hypertension guidelines,
since 2003, maybe you can give us a little context
around them, the need for the guidelines, an overall view
of why they were put forward. Certainly, you’re correct,
the last comprehensive guidelines we’re 2003, and
of course, National Heart, Lung and Blood Institute,
sponsored these guidelines for many years, and did a great job. In 2013, they got elected
to pass that responsibility over to American Heart
Association, and American College of Cardiology, and then
they assembled a number of partner organizations during
that year, and assembled our group, the writing group, in 2014. 21 member, multi-disciplinary
group, two lay members, all of them, very, very
engaged and active, and then we spent about
two to three years, we reviewed about a thousand studies, it was a very intense process,
but we’re very happy now to have the guideline
out, and hopefully it’ll be helpful to clinician’s and to the adults in the US population. I think they certainly will be, tell us a little bit about
some of the big changes in the guidelines, things
that you think will change practice based on their publication. Well, certainly a big
change is classification. And the last time we had
a new classification blood pressure was 1993, so maybe its time. And you know, we have new
information now, that at a lower level, then we would
classify hypertension before, that is asystolic of 130
to 139, or diastolic of 80 to 89, that’s already
high risk and we call that stage 1 hypertension, and
we have a lot of trials that show this benefit
from reducing below those levels of blood pressure,
so that’s a big change. And in addition to that,
we take those who are above 140 systolic and above 90
diastolic and label them a stage 2 hypertension,
so that’s a big change. Normal is the same as before,
120 below 120 systolic, below 80 diastolic, and
then we have a group of elevated blood pressure,
between normal and stage 1, so its a new system, it’ll
take awhile to get used to it, but I think it’s the
right system, it’ll capture those at risk better
then our former system. Sure, that’s very clear,
so previously we would’ve called those people that were
elevated, pre-hypertension. Why is it important for us
to change that nomenclature so that people understand
the impact of looking at blood pressure a different way? Well you’re absolutely
right, the upper end of what was previously
pre-hypertension, or an earlier guidelines high normal blood
pressure, we didn’t like those terms because it suggests
that you’re still okay, you’re pre-hypertension,
you don’t have it yet, or you’re high normal, but you’re normal. And it was clear from the
information that’s available now that you’re not normal,
you’re in that stage 1 category at about twice the risk of
a heart attack as somebody with a normal blood pressure,
so that’s why we changed it. That and the knowledge that
lowering blood pressure in that category would be
helpful to individuals. What advice would you give
for clinician’s as they begin to use these new guidelines? Obviously there’d be a change
because their be particularly in that elevated category,
you know, those are the folks that will now give a
diagnosis of hypertension too, and what do you expect,
what’s your advice to the clinician’s so they can
give their advice to their patients about what to do next? Well of course the first
advice is accurate measurement of blood pressure, because
we as clinician’s don’t do such a good job, and in order
to really make decisions, to label somebody as
hypertensive, to help them to understand what treatments are
necessary, we need accurate measurements and we need to
get measurements on more than one occasion to get the
average estimate of what the body is seeing in terms of blood pressure. I think then, once we identify
the new group in stage 1 hypertension, it’s very
important to understand whether they are otherwise at
low risk for cardiovascular disease, or their at high risk,
either they’ve had an event, they’ve had a stroke or a
heart attack, which keeps them at high risk, or they haven’t
had that but on a calculation using the standard risk
factors, they’re at high risk, they have more than a 10%
chance of getting a major event in the next 10 years, so if
they’re otherwise at low risk, then non-drug, our lifestyle
changes should be very sufficient, important, but
very sufficient for that person, for the minority,
and it’s about 30% in that class one, or stage one hypertension, they will benefit, not
only from lifestyle change, but from an in-hypertensive drug as well. The one thing I like about
the text of the guidelines is they really embrace the
idea of involving patients in the management of their
own blood pressure and the lifestyle changes that
need to come along with changing their cardiovascular risk. What do you think your
advice would be for patients as they begin to sort of see
these new recommendations and how they might become more
engaged in their own health? Well you’re absolutely right,
I think, very important that it’s a team activity,
a lot of people are on the provision of care, and also
that patient is an important part of the care, and what
we realize now, increasingly is that office blood
pressures are very helpful, they are what all of our trials
are based on, as what most of us take, but we now know
that measurements outside the office, which the
patient can take, are really valuable, to confirm the
diagnosis of high blood pressure, to spot where so
called white code hypertension is occurring, their high in
the office, but their pressures are normal outside, those
sorts of people seem to have the same risk as normal
tensive’s, and the more insidious problem were the measurement
of blood pressure seems normal in the office, but
it’s quite high outside, so called masked hypertension,
where individuals have about the same risk as
sustained hypertension. So the patient is, I think,
really important at all aspects of diagnosis, understanding
the true exposure of the body to blood pressure, and then
of course in the therapy of those who have high blood pressure. I think that’s great advice
and you know, as I read these and think about them,
they’ll raise some new questions I think, for
clinician’s as well as patients, what do you think is next
for in terms of looking at risk and next frontiers in
terms of us and in terms of thinking about the next
step for clinical trials and questions that remain unanswered by the current literature? Well I have to say we
need to empower everybody and make it easy for everybody
so clinicians are being asked to do a lot or their
physicians, or nurses, or their pharmacists, we
need to try to make it easy for them, and I think
certainly in things like risk calculation, we out of be
able to get that into the electronic medical record and… I think as we go down the
pike we want to try to help as much as we can, and
one of the great things American Heart does for
patients as well as for clinicians is that they’ve
got a treasure trove of very useful information,
especially when it comes to things like lifestyle change,
for any patient, they have it within their power to
make those changes and American Heart is very
helpful in directing them how to make those changes. Well congratulations on a
great set of guidelines, I really think these are
incredibly well written, very clear and I think
they’ll clearly do a lot to educate not only clinician’s
but the public around the risk of hypertension as
it relates to cardiovascular disease and stroke, it really
offers a lot of information that I think will be dedicated
to improve lives of others. So congratulations–
Thank you. On a very significant
accomplishment and we look forward to hearing more
throughout the sessions about all the work that’s gone
on behind the scenes to translate these into clinical practice. Thank you Dr. Warner.