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Latest news from around the cardiology network

Updated Hypertension guidelines (Ann Intern Med, Published January 17, 2017.)

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have released a joint practice guideline on systolic blood pressure targets for people aged 60 years and older with hypertension.

The guidance calls for physicians to start treatment for patients who have persistent systolic blood pressure at or above 150 mm Hg to achieve a target of less than 150 mm Hg to reduce risk for stroke, cardiac events, and death. The recommendation was rated strong, with high-quality evidence.

“The evidence showed that any additional benefit from aggressive blood pressure control is small, with a lower magnitude of benefit and inconsistent results across outcomes,” ACP’s President Nitin S. Damle, MD, said in a news release.

However, in some cases, a lower systolic target should be considered, according to the guidelines.

If patients have a history of stroke or transient ischemic attack or have high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve systolic blood pressure of less than 140 mm Hg to reduce risk for stroke and cardiac events. The authors note, however, that this recommendation was rated weak, with moderate-quality evidence.

High cardiovascular risk generally includes patients with diabetes, vascular disease, metabolic syndrome, or chronic kidney disease, as well as older adults.

The guidelines also emphasize that cost burden for patients should be considered in any treatment discussions. “When prescribing drug therapy, clinicians should select generic formulations over brand-name drugs, which have similar efficacy, reduced cost, and therefore better adherence,” they write.

In addition, the guidelines stress that clinicians should periodically discuss the potential benefits and harms of specific blood pressure targets with the patient.

The full guidelines, written by Amir Qaseem, MD, PhD, head of the ACP guidelines committee, and colleagues, were published online January 17 in the Annals of Internal Medicine. A guideline summary will be published in the March/April 2017 issue of the Annals of Family Medicine.

Lower Targets Also Have Risks

In a supporting evidence review, Jessica Weiss, MD, MCR, from the Portland Veterans Affairs Medical Center in Oregon, and colleagues warn that the benefits of a lower threshold (less than 140/90) should be weighed against risk.

“Tighter control may prevent, on average, roughly 10 to 20 events for every 1000 high-risk patients treated over 5 years across a population,” they write. But the trade-off may be higher costs and greater risk for hypotension and syncope.

“On the other hand, we found that lower targets are unlikely to increase the risk for dementia, fractures, and falls or reduce quality of life,” Dr Weiss and colleagues write.

Most of the support for treatment targets below 140 mm Hg come from a single trial that had a target of less than 120 mm Hg, the reviewers note. The Systolic Blood Pressure Intervention Trial (SPRINT), as previously reported by heartwirefrom Medscape, compared benefit of a systolic target of less than 120 mm Hg vs less than 140 mm Hg and found substantial reductions in cardiac events and deaths with tighter control.

However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which tested the same targets, did not show similar benefits.

When you remove SPRINT data from the analysis, the effects on mortality were reduced and the effects on cardiovascular events were no longer significant, Dr Weiss and colleagues write.

The guidelines mention “white coat” syndrome, which can skew blood pressure readings. Before changing any treatment plan, the authors urge physicians to ensure they are getting the most accurate numbers over time.

ACP and AAFP did not have enough evidence to make recommendations regarding diastolic blood pressure targets.

Substantial Improvements in Morbidity Possible

In an accompanying editorial, Michael Pignone, MD, MPH, from the Department of Medicine, University of Texas Dell Medical School in Austin, and Anthony J. Viera MD, MPH, from the Department of Family Medicine, University of North Carolina in Chapel Hill, write that improving blood pressure control in this patient group has the potential to substantially reduce morbidity and mortality.

They note that 65% of US adults aged 60 years and older have hypertension, and only about half (52.5%) have controlled blood pressure levels (defined as less than 140/90 mm Hg). “Over 15% of persons with hypertension are unaware of their condition,” they write.

With the publication of the new ACP/AAFP guidelines, they say physicians who want to implement high-value prevention programs should take the following steps:

  • offer accurate blood pressure measurement taken by a well-trained staff and offer training in home or ambulatory monitoring;
  • routinely assess CVD risk in patients older than 40 years and in some younger patients with prominent risk factors;
  • train providers in shared decision making for the treatment of high blood pressure;
  • create a registry to track hypertensive patients; and
  • use additional nonvisit follow-up measures for patients with moderate to severe hypertension.

“Such programs, when implemented, have been associated with large improvements in blood pressure control and have the potential to significantly reduce hypertension-related morbidity and mortality, particularly in older adults,” the editorialists write.

Funding for the evidence review was provided by the US Department of Veterans Affairs. The authors and editorialists have disclosed no relevant financial relationships.

Ann Intern Med, Published online January 17, 2017.

Anticoagulation in AF (Heartone Aug 2016)

The issue of suboptimal anticoagulation management in patients with nonvalvular atrial fibrillation (NVAF) has been highlighted in recent years, although the true impact upon patient outcomes has not been fully quantified.

A retrospective cohort study by Chan et al in this month’s Heart Rhythym used a population-wide database managed by the Hong Kong Hospital Authority. Patients newly diagnosed with NVAF during 2010–2013 were included in the analysis. A Cox proportional hazards regression model with 1:1 propensity score matching was used to compare the risk of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between patients receiving antiplatelet drugs and those receiving warfarin stratified by level of international normalized ratio (INR) control.

Of the 35,551 patients with NVAF, 30,294 (85.2%) had a CHA 2 DS 2 -VASc score of ≥2 (target group for anticoagulation). Of these, only 7029 (23.2%) received oral anticoagulants and 18,508 (61.1%) received antiplatelet drugs alone. There were 1541 (67.7%) of warfarin users who had poor INR control (time in therapeutic range [2.0–3.0] <60%). Patients receiving warfarin had comparable risks of intracranial hemorrhage (hazard ratio [HR] 1.24; 95% confidence interval [CI] 0.65–2.34) and gastrointestinal bleeding (HR 1.23; 95% CI 0.84–1.81) and lower risk of ischemic stroke (HR 0.40; 95% CI 0.28–0.57) and all-cause mortality (HR 0.45; 95% CI 0.36–0.57) than did patients receiving antiplatelet drugs alone. Good INR control was associated with a reduced risk of ischemic stroke (HR 0.48; 95% CI 0.27–0.86) as compared with poor INR control. Modeling analyses suggested that ~40,000 stroke cases could be potentially prevented per year in the Chinese population if patients were optimally treated.

The authors concluded that three-quarters of high-risk patients among this Chinese population with NVAF were not anticoagulated or had poor INR control. This study illustrates the continued need to improve the optimization of anticoagulation for stroke prevention in patients with atrial fibrillation.