New High Blood Pressure Guidelines

Blood pressure 4The guidelines for treating high blood pressure (hypertension) were recently revised. In brief, the authors raised the acceptable limit for systolic blood pressure for individuals 60 years and older. Additionally, they questioned the previous recommendation of aiming for lower blood pressures for patients with diabetes and kidney disease. As was the case with cholesterol, the conclusions were challenged by many experts, particularly challenging the choice of studies that produced the conclusions.

The previous blood pressure treatment goal of less than 140/90 mm Hg for individuals 60 years or older has been raised by the new guidelines to 150/90 mm Hg. The former goal was based on studies showing an increased cardiovascular risk in individuals with blood pressure over 140/90 mm Hg and risk improvement when the blood pressure was lowered. For instance, lowering blood pressure by 10 mm Hg in patients with hypertension reduces the risk of cardiovascular and stroke death by 25% to 40%.

However, the studies documenting results such as the above often had a goal of less than 160 mmHg and often did not examine the subset of patients 60 years and older. Two recent relatively short-duration studies comparing a goal of less than 140 mm Hg with less than 150 mm Hg in patients over 65 years showed no outcome difference. Using a review of many studies, the guideline authors did not find sufficient evidence that the more aggressive treatment goal of 140/90 mm Hg vs. 150/90 mm Hg benefits older adults.

The obvious question is: What is the harm of a more aggressive goal since so many studies, however imperfect, document improvement with lower blood pressure? Medication side effects are the worry. Too many times physicians become cemented on a number and push medications to the point where an individual experiences dizziness (the most common antihypertensive medication side effect.) The risk from falls can exceed the more remote risk from hypertension. Therefore, on balance the guideline authors suggest flexibility when treating patients 60 years and older.

That said, if an older hypertensive individual tolerates a goal of 140/90 without side effects there is no reason to decrease or stop medication allowing an increase in blood pressure to 150/90. Furthermore, many think that there is reason to believe that the lower goal, absent the concern of medication side effects, probably is more beneficial.

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New Statin Guidlines

Cholesterol

New guidelines from the American Heart Association and the American College of Cardiology have changed both the indications for taking statins and, in some cases, have suggested a lower dose. Also, the use of additional medications to assist in lowering cholesterol values has been called into question.

 

The new statin dose guidelines require in most cases a calculation of cardiovascular risk over the next ten years. This calculation includes age, sex, race, systolic blood pressure, blood pressure medication history, history of diabetes, smoking history, total cholesterol and HDL cholesterol values. The risk calculation does not include family history. Your risk can be calculated by using the formula included in the following link:

 

http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx

 

Within days of the announcement experts criticized the cardiovascular calculator as outdated and, as a result, overstating the risk of cardiovascular disease by up to 100%. All cardiovascular calculators rely on historical data which don’t adequately reflect the very significant decrease in cardiovascular risk in more recent years and this one is no exception.

 

The guidelines recommend abandoning the former goals of reducing LDL, or bad cholesterol, to below 100 or below 70 for people at high risk. The authors of the guidelines stated that those goals resulted in undertreatment of some patients and overtreatment of others.

 

Instead they suggest individualizing treatment based on risk. For an individual younger than 75 years and over 21 years with known cardiovascular disease high-intensity dosing of statin medication is prescribed with a goal of reducing LDL cholesterol by 50% or more not tied to a specific number. For an individual over 75 years with known cardiovascular disease the goal is an LDL reduction of between 30-50% (moderate-intensity dosing.).

 

High-intensity statin dosing with a goal of a 50% or more reduction in LDL is also suggested for people between the ages of 40 and 75 years with type 1 or type 2 diabetes, LDL cholesterol between 70 and 189 and a risk of cardiovascular disease that exceeds 7.5% over the next ten years. For people with diabetes between the ages of 40 and 75 years with LDL cholesterol between 70-189 and a less than 7.5% ten year risk for cardiovascular disease moderate-intensity statin dosing is suggested (an LDL reduction of between 30-50%.)

 

Moderate-to high-intensity statin dosing is indicated for those people between the ages of 40 and 75 years, LDL cholesterol between 70 and 189 and a 7.5% or more risk of cardiovascular disease in the next ten years.

 

Only individuals with LDL cholesterol values of 190 or more are designated to receive statin therapy in the absence of known cardiovascular disease, history of diabetes or a 7.5% or more risk of cardiovascular disease over the next ten years. In these situations high-dose statin therapy is suggested.

 

An example: A 45 year old woman with an LDL cholesterol of 150 and a less than 7.5% risk of cardiovascular disease over the next ten years would not require statin treatment.

 

Notes:

 

Cardiovascular disease is defined as acute coronary syndromes, or a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

 

The authors of the guidelines do not recommend adding additional medications (such as Zetia) to achieve LDL cholesterol goals.