#NephMadness 2019: Chang’s Commentary on Hypertension Guidelines

Posted on March 30, 2019 by AJKDblog in NephMadness // 0 Comments

Alex Chang @alexchangmd

Alex Chang is an Assistant Professor of Medicine at Geisinger Commonwealth School of Medicine. His research focuses on the role of obesity and nutrition in hypertension and chronic kidney disease.

Competitors for the Hypertension Region

EU Guidelines vs US Guidelines

Hyperaldo Diagnosis vs Hyperaldo Treatment

The nephrologist often serves as the “go-to” at our hospitals for patients with challenging hypertension. This year’s Hypertension Region has two exciting matchups, and @hswapnil packs in great nuggets of hypertension wisdom in his breakdown of the region. In this blog post, I will focus on a few key differences between the US Guidelines and the EU Guidelines.

The EU Guidelines retained the ≥ 140/90 mm Hg hypertension definition whereas the US Guideline controversially redefined hypertension as ≥ 130/80 mm Hg. Lifestyle modifications are recommended for low-risk CVD patients with 130-139/80-89 mm Hg in both guidelines, rather than medications. While some thought leaders have bemoaned the medicalization of American society (46% of adults in the US have hypertension according to the new AHA definition), I would argue that the patients who actually care about being reclassified as having hypertension are the “worried well,” and these individuals may actually be the most motivated to make lifestyle modifications to lower their BP and subsequent cardiovascular risk. Providing effective lifestyle modification in clinical care is not easy, and perhaps this redefining of hypertension will encourage us to figure out how we can better help patients make lasting lifestyle changes to lower BP and CVD risk.

Both EU and US guidelines emphasize BP measurement technique and the important role of home BP measurement. The EU Guidelines expressed skepticism about how automated office BP was measured in SPRINT (often unattended) and how this translates to clinical practice. Imagine a patient running into a busy clinic from a parking lot ½ a mile away after being stuck in traffic, then having their BP measured while being asked a mandatory EPIC nursing questionnaire. Clearly, many factors will influence office BP measurement, and the relatively minor issue of whether the automated BP measurement in SPRINT was attended vs. unattended is exaggerated.

In terms of BP targets for chronic kidney disease (CKD), the EU Guidelines recommend SBP 130-139 mm Hg whereas the US Guideline recommends < 130/80 mm Hg. The lower BP target of < 130/80 mm Hg is backed by the pre-specified CKD subgroup analysis of 2,646 patients in SPRINT as well as long-term follow-up data from the AASK and MDRD trials (please see our recent review on this topic). Thus, I remain firmly in the US Guideline camp (full disclosure: I am a fellow of the AHA). Further, the EU Guidelines writing committee included a grand total of 0 nephrologists whereas the US Guideline included prominent nephrologists/hypertension experts Jackson Wright, Sandra Taler, and Paul Whelton, who served as the chair.

In the end, both guidelines are excellent scholarly works and share much more similarities than differences in covering the classification, measurement, causes, and strategies to improve hypertension control. The target BP guideline debate seems to boil down to whether you are a SPRINT-believer or a SPRINT-skeptic, and how well you feel you can trust your BP measurements. In the end, guidelines are just guidelines rather than mandates, and we need to use shared decision-making, incorporating patients’ preferences when choosing treatment goals.

– Guest Post written by Alex Chang @alexchangmd

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.