(Note. This post originally published 1/23/2018 and updated 4/3/2023)
The skeptical cardiologist and many of his patients with hypertension have a decision to make: what should our BP goal be?
Given that we have data now on over 1 million patients one might think that the answer would be clear and that there would be a consensus amongst all the experts.
Messerli and Bangalore, writing in a recent special hypertension issue of JACC, however, clearly articulate the “blood pressure landscape schism” that currently exists.
This figure from their paper (subtitled “Schism Among Guidelines, Confusion Among Physicians, and Anxiety Among Patients”) shows the marked difference in BP goal and treatment recommendations for a 63-year-old woman with BP of 148/86 in different guidelines.
The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines—indicate that her BP should be <130/80 mm Hg .
The 2018 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelinesindicate that her BP should be <140/90 mm Hg
The 2017 American College of Physicians (ACP)/American Association of Family Physicians (AAFP) guidelines—indicate that her BP should be <150/90 mm Hg
Messerli and Bangalore use a second figure to graphically illustrate the potential consequences of the differing guidelines.
Cardiovascular death rates thus may vary three-fold depending on what BP goal we choose.
This marked variation in treatment recommendations highlights that they
are not only an evaluation and interpretation of evidence in question, but also a judgment weighted by personal, regulatory, and organizational preferences that can vary from physician to physician within a country and across geographical regions.
Physicians and patients (hopefully through shared decision-making) are going to have to do some thinking on their own.
Messerli and Bangalore quote Immanuel Kant in this regard:
Enlightenment is man’s emergence from his self-imposed nonage. Nonage is the inability to use one’s own understanding without another’s guidance. This nonage is self-imposed if its cause lies not in lack of understanding but in indecision and lack of courage to use one’s own mind without another’s guidance. Dare to know! (Sapere aude.) “Have the courage to use your own understanding,” is therefore the motto of the enlightenment.
As a 64 year old who has emerged from his nonage with hypertension, I have carefully examined the latest American hypertension guidelines especially in light of the SPRINT study and elected to add a third anti-hypertensive agent to get my average BP below 130/80.
It’s worked for me with minimal side effects but I carefully monitor my BP.
If I notice any symptoms (light-headed, fatigued) suggesting hypotension associated with systolic BP <120 mm Hg I tweak my medical regimen to allow a higher BP.
Like all of my patients I would prefer to be on fewer medications, not more but when it comes to enlightenment about the effects of hypertension, it is now clear that lower is better for most of us in our sixties down to at least 130/80*.
Sapere Audaciously Yours,
-ACP
*N.B. In the SPRINT study the BP was obtained using an automatic BP cuff after 5 minutes of rest with the patient unobserved and averaging 3 recordings one minute apart.
This “research grade BP” averages about 12 mm Hg less than a routine single clinic obtained BP (see here.)
–The BP Schism