Tuesday, August 11, 2020

Defining hypertension, personally and professionally

I recently started measuring my blood pressure at home at the recommendation of my new family physician in Salt Lake City, whom at a new patient visit had gotten readings that were somewhat higher than I'd had in the past. This finding was not completely unexpected: I'm in my mid-40s, have a family history of hypertension and cardiovascular disease, and my physical activity and dietary habits frequently fall short of optimal. On the other hand, he and I are well aware that out-of-office blood pressure readings are much better at predicting the risk of future hypertension-related events than those taken in the office; in a recent study of 90 family medicine patients with "uncontrolled" blood pressure in the office, nearly two-thirds had normal (defined as <140/90 mm Hg) readings at home.

Professionally, I struggle with hypertension too. As a former Clinical Practice Guideline subcommittee Chair and current scientific advisor for the American Academy of Family Physicians, I participated in the development of a 2017 guideline that suggested a target systolic blood pressure goal of <150 mm Hg for adults aged 60 years or older, and in the decision to not endorse a guideline from the American College of Cardiology / American Heart Association that set a blood pressure target of <130/80 mm Hg for adults of all ages, effectively redefining hypertension. Several publications have expressed concerns about the ACC/AHA hypertension guideline, including my Medscape commentary, an independent analysis of incremental benefits and harms, and a more recent research letter finding that "the clinical trials underlying new treatment thresholds are representative of less than one-third of the guideline target population."

Is it problematic that inconsistencies across recommendations in hypertension practice guidelines mean that family physicians and general internists may define high blood pressure differently than cardiologists? Yes and no. Although in an ideal world there would be a single (primary care-led, federally funded) hypertension guideline endorsed by all relevant stakeholders, including patient representatives, this is unlikely to be a national priority until the COVID-19 pandemic, which has caused the premature deaths of more than 163,000 Americans, is brought under some semblance of control. And just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.

I acknowledge that my training in family medicine and expertise in guideline development make me an atypical patient, better positioned than most to debate the pros and cons of blood pressure interpretation and treatment. At the same time, I have no interest in receiving "special treatment." I want my primary care physician to choose a hypertension guideline that makes sense given my individual circumstances and recommend a course of action supported by the best available evidence. Ultimately, that's what every patient deserves.