Volume 206 - Issue 3
Guideline for the diagnosis and management of hypertension in adults — 2016
Authors: Anthony Rodgers, Clara K Chow, Rodney T Jackson, Anushka Patel and Tim Usherwood
Med J Aust 2017; 206 (3): 141. || doi: 10.5694/mja16.01057
Published online: 20 February 2017
Published online: 20 February 2017
n/a
To the Editor:
We write to raise concern that the focus on diagnosis and treatment of “hypertension” (an arbitrary construct) in the 2016 National Heart Foundation guideline1 creates confusion with the 2012 Guidelines for the management of absolute cardiovascular disease risk,2 and may lead to undertreatment of high risk patients.
First, we question restricting lifestyle advice and treatment to patients with hypertension “confirmed” by ambulatory and/or home monitoring. Trials clearly demonstrate benefits in high risk patients with office blood pressure (BP) < 140/90 mmHg,3,4 and most such patients are likely to have had ambulatory BP < 130/80 mmHg and home BP < 135/85 mmHg had such measurements been taken.5 Not treating those who would benefit will of course increase cardiovascular burden,6 and this is a considerable missed opportunity, as so many cardiovascular events in a population occur among high risk individuals with moderate elevations of BP.
Second, the statement that “while combination therapy is more effective in lowering blood pressure than monotherapy, direct evidence of its effect on cardiovascular outcomes is less clear”7 contradicts the trial evidence on combination therapy.8 This stems from the paradigm clash between hypertension and risk management. In a world where the only consideration was hypertension treatment, some patients would only need monotherapy. But if the focus is prevention of BP-related cardiovascular events, long term use of monotherapy should be regarded in the same way as the lowest doses of fluvastatin or lovastatin — difficult to justify when there are alternatives that provide twice as much risk factor reduction and much more cardiovascular event reduction for little or no extra cost or side effects.
Of the 2.3 million Australians with established vascular disease or equivalent risk, 39% do not receive any BP-lowering therapy9 and many of those treated only receive monotherapy. We hope that future National Heart Foundation guidelines will focus on reducing this treatment gap and emphasise multifactorial interventions targeted to those with most to gain.2
Competing interests
George Health Enterprises, the social enterprise arm of The George Institute for Global Health, has received investment to develop aspirin–statin–BP combinations.
Acknowledgements
We thank John Chalmers, Bruce Neal and Emily Atkins of The George Institute for Global Health for their assistance in preparing this letter.
References
- Gabb GM, Mangoni AA, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults – 2016. Med J Aust 2016; 205: 85-89.
- National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation, 2012.
- Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016; 387: 957-967.
- Xie X, Atkins E, Lv J, Rodgers A. Intensive blood pressure lowering–Authors' reply. Lancet. 2016; 387: 2291.
- Mancia G, Sega R, Bravi C, De Vito G, et al. Ambulatory blood pressure normality: results from the PAMELA study. J Hypertens 1995; 13: 1377-1390.
- Lovibond K, Jowett S, Barton P, et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet 2011; 378: 1219-1230.
- National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults 2016. Melbourne: NHF, 2016.
- Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338: b1665.
- Banks E, Crouch SR, Korda RJ, et al. Absolute risk of cardiovascular disease events, and blood pressure-and lipid-lowering therapy in Australia. Med J Aust 2016; 204: 320.