Connect
MJA
MJA

Relieving the pressure: new Australian hypertension guideline

Garry LR Jennings
Med J Aust 2016; 205 (2): 63-64. || doi: 10.5694/mja16.00475
Published online: 18 July 2016

The National Heart Foundation guideline has been updated to reflect recent evidence and Australian conditions

Some might think there are too many guidelines on hypertension.1-4 However, given that hypertension is a major risk factor for premature death and disability from cardiovascular disease in Australia and globally,5,6 practitioners need a practical, contemporary and localised guide to best practice. Most countries and their hypertension societies publish their own guidelines. However, these differ for a number of reasons. The data available at the particular time of publication vary. Experts interpret these data differently. To varying extents, guideline development is subject to vested interests, such as governments and other funders wishing to keep down costs, or industry wishing to make treatments available to the widest groups possible.7 The scope of the review can vary from people with uncomplicated hypertension to those with a broad range of complications and comorbidities.

In Australia, we are fortunate that the National Heart Foundation has produced an excellent new guideline (http://heartfoundation.org.au/for-professionals/clinical-information/hypertension) adapted for Australian conditions at a time when knowledge of the field has been moving rapidly.8

One of the first questions concerns who is at risk from hypertension and who warrants active treatment. For some time now, Australian recommendations have followed an absolute risk approach, rather than determining risk on blood pressure alone. The recommended way of assessing this is according to the national guideline on absolute risk developed by the National Vascular Disease Prevention Alliance.9 This predicts risk of a major cardiovascular event or death in the next 5 years based on a modified Framingham equation. Unless blood pressure is very high, it is a better way of identifying someone who will benefit from treatment than blood pressure alone as a single risk factor. It also helps deal with the well known epidemiological paradox that most people who have heart attacks or strokes caused by elevated blood pressure do not meet the conventional definition of hypertension. Systolic blood pressure in the high normal range (130/85–139/89 mmHg) carries risk and this includes a substantial proportion of the population. This applies equally to other risk factors such as blood glucose or lipids. Levels below arbitrary cut-points capture only some of the relevant risk.

However, risk assessed this way is very much influenced by age and is not applicable in young adults (aged under 45 years, or under 35 years in Indigenous Australians) or older adults (aged over 74 years).9

Recent hypertension trials and other guidelines have used several methods of assessing risk, including the presence or absence of target organ damage, clinical indicators such as abdominal girth, tobacco use, low levels of high density lipoprotein.10 What can be concluded is that there are many ways of assessing risk and, if risk is high, people benefit from modification of standard risk factors including blood pressure.

The 2016 guideline offers advice on new areas including out-of-clinic blood pressure measurement using ambulatory or home procedures, white coat hypertension and blood pressure variability. It includes updated evidence on the management of hypertension with comorbidities including chronic kidney disease, diabetes and peripheral arterial disease. There are minor updates to recommendations on first-line and combination pharmacotherapies.

A key area of debate surrounds the revision of treatment targets based on new evidence for a target blood pressure of < 120 mmHg in patients at high risk for cardiovascular events but without diabetes.11 Where supported by evidence, a target of < 140 mmHg is recommended. In other groups where there is supporting evidence, the recommendation is to aim for < 120 mmHg but be cautious about adverse events, especially in older, frail people. The debate is fuelled by the lack of data in particular patient groups but increasingly the clinical trial data are aligning with the epidemiology, with lower blood pressure being associated with better outcomes across the spectrum.12

The holes in the evidence base and shifting ground as new evidence comes forward are not helpful to the individual clinician who wants advice on what to do for a particular patient on a particular day. Further, we know that despite the proliferation of guidelines, most people with hypertension do not achieve the goals of their therapy, irrespective of what country they live in and what guideline is being followed. In future, we need to move the emphasis from large tomes written by expert groups to providing decision support individualised to the patient.

The new guideline also covers emerging evidence on diagnostic and therapeutic aspects of hypertension, including the uncertain role of renal denervation. It will guide management of hypertension in Australia for the immediate future. I commend it to readers of the MJA and thank all those who contributed to its preparation.


Provenance: Commissioned; externally peer reviewed.

  • Garry LR Jennings1,2

  • 1 Baker IDI Heart and Diabetes Institute, Melbourne, VIC
  • 2 National Heart Foundation of Australia, Melbourne, VIC


Acknowledgements: 

I am a principal investigator on a National Health and Medical Research Council program grant.

Competing interests:

No relevant disclosures.

  • 1. Ritchie LD, Campbell NC, Murchie P. New NICE guidelines for hypertension. BMJ 2011; 343: d5644.
  • 2. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC practice guidelines for the management of arterial hypertension. Blood Press 2014; 23: 3-16.
  • 3. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014; 32: 3-15.
  • 4. Armstrong C. JNC8 guidelines for the management of hypertension in adults. Am Fam Physician 2014; 90: 503-504.
  • 5. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011 (AIHW Cat. No. BOD 4; Australian Burden of Disease Study Series No. 3). Canberra: AIHW, 2016.
  • 6. Mendis S, Puska P, Norrving B, editors. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization, 2011. http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en (accessed May 2016).
  • 7. Jennings GL, Touyz RM. Hypertension guidelines: more challenges highlighted by Europe. Hypertension 2013; 62: 660-665.
  • 8. Gabb GM, Mangoni A, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults — 2016. Med J Aust 2016; 205: 85-89.
  • 9. Usherwood T. National guidelines for the management of absolute cardiovascular disease risk. Med J Aust 2013; 199: 243-244. <MJA full text>
  • 10. Yusuf S, Lonn E, Pais P, et al. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med 2016; 374: 2032-2043.
  • 11. SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373: 2103-2116.
  • 12. Perkovic V, Rodgers A. Redefining blood-pressure targets–SPRINT starts the marathon. N Engl J Med 2015; 373: 2175-2178.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

access_time 01:02, 18 July 2016
James A Dickinson

In his introduction to the hypertension guidelines, Professor Jennings states that “guideline development is subject to vested interests, such as governments and other funders wishing to keep down costs, or industry wishing to make treatments available to the widest groups possible.” The self-reference he cites (7) makes the same accusation, stating that government-run health systems are interested in reducing costs, but he gives no reference.

I have been involved in writing prevention guidelines in Australia, Hong Kong and Canada. In each setting, the committees were often funded by government, but scrupulously separated to ensure that government did not influence the recommendations, nor even be perceived as doing so. The only pressure was to focus on greatest benefit and least harm to the population. After all, politicians and public servants know that they themselves will likely become patients at some time. Nonetheless, when recommendations to decrease screening are likely to reduce costs, guideline committee members are often accused of being tools of government, only interested in saving money. Such accusations mainly appear to come from professional groups and segments of industry that fear reduction in their income. On the other hand, when recommendations are made that might increase costs, such accusations are missing, and I have heard no push-back from government, nor individuals, though we are all taxpayers, and guidelines that increase cost affect all our pockets.

Consequently, I ask Professor Jennings to identify any occasions when he has experienced or knows of government interference in guideline development that is comparable with the documented pressures from industry to write guidelines that sell their products.

Competing Interests: No relevant disclosures

Dr James A Dickinson
University of Calgary

Responses are now closed for this article.