Abstract
This editorial refers to ‘Association of hypertension cut-off values with 10-year cardiovascular mortality and clinical consequences: a real-world perspective from the prospective MONICA/KORA Study’†, by S. Atasoy et al., on page .
The publication of the new 2017 American College of Cardiology/American Heart Association Guideline has generated significant controversy around the world, particularly because of the novel definition of hypertension.1 The new definition establishes that individuals have elevated blood pressure (BP) if their systolic BP is 120–129 mmHg, that they are hypertensive (stage 1) if their BP is ≥130/80 mmHg, and that they have stage 2 hypertension if their BP is ≥140/90 mmHg. The new definition of hypertension inevitably results in an increased prevalence of hypertension, as already pointed out by Muntner et al.,2 who analysed data from the 2011–2014 National Health and Nutrition Examination Survey (n = 9623). According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the prevalence of hypertension among US adults was then 31.9%, and with the 2017 ACC/AHA guidelines it rose to 45.6%. Thus, prevalence rose by ∼13.7% or an additional 31.1 million adults nationally compared with the JNC 7 guideline, although most of these would probably receive lifestyle modification recommendations according to their risk level, and not antihypertensive agents. The number of newly identified hypertensives requiring drug treatment would increase by 1.9% or 4.2 million individuals. However, drug therapy will need to be intensified in an additional 14.4% (7.9 million) of adults already receiving antihypertensive agents according to the new thresholds for initiating drug therapy for hypertension. Greater emphasis on lifestyle modification would also be necessary in order to reduce the number of patients requiring drug treatment for hypertension.
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In this issue of the European Heart Journal, Atasoy et al.3 report follow-up of community-dwelling individuals in the Prospective MONICA/KORA Study over a 10-year period (70 148 person-years) in whom they evaluated the impact of the traditional and the new stage 1 definition of hypertension from the ACC/AHA Guideline. The authors assessed hypertension prevalence and associated cardiovascular disease (CVD) events in a sample of 11 603 participants (52% men, 48% women; mean age 47.6 years). Implementing the new hypertension definition increased the prevalence of hypertension from 34% to 63%. In this cohort, only 24% of stage 2 hypertensive subjects were treated for hypertension. Stage 2 hypertensive subjects had more adverse risk factors compared with stage 1 hypertensive subjects and those with elevated or normal BP, and were more likely to be obese and physically inactive, and have hypercholesterolaemia and type 2 diabetes. Within the 10-year follow-up, Cox proportional regression models were significant for the association of stage 2 hypertension and CVD mortality, which was not the case for stage 1 hypertension. Furthermore, among stage 2 hypertensive individuals, there was significantly higher prevalence of depressed mood in treated patients (47%) in comparison with non-treated patients (33%) (P < 0.0001). The authors conclude that the new definition of hypertension with a lower BP cut-off significantly increased hypertension prevalence, but included a population with lower CVD mortality. Thus, in this study, the traditional cut-off of ≥140/90 mmHg was superior in terms of absolute and relative CVD mortality risk. In addition, subjects treated with drugs for hypertension were more likely to have a depressed mood compared with those not treated, suggesting that labelling leads to mood disorders, particularly depression (Take home figure).
Specifically looking at the cohort reported by Atasoy et al.3 in this issue, the 95% confidence intervals of the hazard ratios for stage 1 hypertension of the ACC/AHA Guideline were very wide, ranging from 0.61 to 1.44. Accordingly, the authors cannot unambiguously exclude the possibility that stage 1 hypertension from the ACC/AHA Guideline is associated with increased mortality in their cohort. It is true that unnecessary labelling of healthy subjects as ‘hypertensive’ should be avoided,11 , 12 but the data of Atosoy et al.3 are not robust enough to counter previous studies showing that individuals with systolic BP of 130–139 mmHg or diastolic BP of 80–89 mmHg have increased CVD mortality risk. In addition, the authors indicate that ‘participants under treatment were more likely to have depressed mood in comparison to non-treated participants, which might reflect a negative labelling effect.’ However, it should be noted that subjects with 130–139 mmHg systolic or 80–89 mmHg diastolic BP were not labelled as ‘hypertensive’ at the time of the study, rendering difficult the interpretation that their mood status was a response to labelling. Furthermore, some antihypertensive medications have actions on the brain that can trigger depressive mood and even frank depression.13 This may be particularly true for some beta-blockers and antiadrenergic agents, and may be worsened by the need to use multiple antihypertensive drugs, especially in patients not adherent to treatment. Indeed, in their study, Atasoy et al.3 remark that adherence to antihypertensive medication in this cohort of subjects was very low: 76% of stage 2 patients according to the ACC/AHA Guideline were untreated, and among those receiving antihypertensive agents, only 13% had successfully lowered BP at baseline. BP control to 14 These subjects also followed the unhealthiest lifestyle and had the highest CVD risk. According to the authors ‘this also implies that classifying as hypertensive does not lead to a decrease in unhealthy lifestyle factors, and a lower hypertension classification may not have relevance to initiating lifestyle interventions.’ In fact, this is a failure of the healthcare providers’ intervention and the implementation of guidelines, not a failure of the guidelines. The statement that the 2013 European Society of Cardiology/European Society of Hypertension (ESC/ESH) ‘guideline did not lead to higher medical treatment or a healthier lifestyle’ is correct with respect to the cohort examined from the Prospective MONICA/KORA Study but, as mentioned, it indicates failure of physicians and other healthcare professionals who took care of these patients, and does not justify the phrase that ‘it is doubtful whether a new guideline would lead to higher compliance with BP lowering initiatives.’ The 2017 ACC/AHA Guideline1 and other recent national15 and international recommendations16 have specific approaches to address lack of adherence to treatment and physician inertia to make sure that treatment to goal is achieved if outcomes are to be improved for hypertensive subjects.
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This study underlines the difficulties in achieving the new goals proposed in the 2017ACC/AHA Guideline1 as well as other guidelines15 , 16 in which intensified treatment is recommended, while at the same time drawing attention to SAEs of treatment, including the potential for depressive mood disorders in treated individuals. However, we can also draw the conclusion that it stresses the need for adequate implementation of hypertension management recommendations if these intensified goals are to be reached in the patients that qualify for treatment intensification due to their enhanced cardiovascular risk. This does not necessarily weaken the rationale for the novel definition of hypertension in the 2017ACC/AHA Guideline1 that now finds a basis in previous trials and recent meta-analyses, as already proposed by us at the time of publication of the SPRINT trial.17
Conflict of interest: none declared.
