Balancing guidelines with providing individualized patient care can be a challenge for pharmacists.
This article was co-written by Amanda McGehee, PharmD Candidate 2019, Andrew Yabusaki, PharmD, and Kimberly C. McKeirnan, PharmD, BCACP
Managing and monitoring blood pressure is not a new task for pharmacists. Treatment guidelines assist pharmacists and other health care professionals in assessing patients who may have hypertension and determining appropriate treatment.
A new challenge has become determining the risk vs. benefit when implementing new or updated guidelines into patient care. In 2017, new guidelines were provided by the American College of Cardiology (ACC) and the American Heart Association (AHA). The Joint National Committee (JNC) also offers guidelines for assessing hypertension. When multiple sets of guidelines are available, providers must consider which set of recommendations should be implemented to provide better outcomes for patients.
The JNC 8 guidelines, published in 2014, defined a blood pressure reading of 140/90 as stage I hypertension. The 2017 ACC/AHA guidelines have updated the definition of stage I hypertension as a blood pressure reading greater than or equal to 130/80 mmHg. Reducing blood pressure may reduce cardiovascular risk but can lead to additional medications for people who would not meet criteria for medication per on older guidelines.
According to the ACC/AHA guidelines, an increase of systolic blood pressure by 20 mmHg and a diastolic by 10 mmHg doubles the risk of mortality related to stroke and other cardiovascular diseases. However, according to the American Medical Association (AMA), the new classification of stage I hypertension will increase the number of hypertension patients in the United States to 46% compared to the 32% with the previous JNC8 recommendations.1-2
Medicating more patients for hypertension can lead to increased risk of drug interactions and adverse drug reactions. This may parallel the clinical approach of establishing blood glucose and hemoglobin A1C goals for diabetic patients.
If hypoglycemia and other adverse effects are being experienced at lower blood glucose levels, the provider and patient together may determine to increase the A1C target to improve quality of life. This approach can be similarly applied to patients with high blood pressure. It will be a key approach when determining which blood pressure goal will benefit an individual patient.
Dr Michael Lefevre stated the “benefits and harms in individual patient circumstances and respecting patient choice” should be incorporated into making a clinical decision.3 The ACC/AHA guidelines provide an approach to direct management of blood pressure and should not outweigh clinical judgment.4 According to the ACC/AHA guidelines and the American Academy of Family Physicians (AAFP), providers should weigh the risks and benefits for patients when contemplating whether to initiate pharmacologic treatment unless the level of blood pressure is higher than stage I hypertension.2
Meanwhile, the American Diabetes Association (ADA) has not applied the updated ACC/AHA blood pressure recommendations to all diabetes patients. In a prepared statement, the ADA said “blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences.”5 The ADA has retained the previous blood pressure goal of 140/90 mmHg because it is acceptable for most patients with diabetes as indicated in the ACCORD blood pressure results.3 The higher blood pressure goal will continue to be used for patients with lower cardiovascular risk with a 10 year ASCVD risk less than 15%.5 The ADA has recommended the lower blood pressure of 130/80 mmHg for patients who have a higher cardiovascular risk based on the 10-year ASCVD risk of greater than 15% and benefit from a lower blood pressure.3,5
The ACC/AHA guidelines address important nonpharmacologic approaches to improving patient health, and include lifestyle modification recommendations for patients diagnosed with stage I hypertension to decrease the likelihood of initiating medication therapy.1 The guidelines discuss weight loss and bariatric surgery for patients who do not achieve weight loss targets. The implementation of the DASH diet, decreasing sodium intake, increasing physical activity, and decreasing alcohol consumption are also discussed.4
The ACC/AHA guidelines provide more detailed information than the JNC 8 guidelines which list lifestyle modifications without expanding on the benefits to patients. The ACC/AHA guidelines not only include the various lifestyle modifications but also the impact of these changes. Each of these components individually provides positive outcomes and in combination will have an accumulative effect on lowering blood pressure and cardiovascular risk.4 Providers and pharmacists can encourage patients to implement these modifications as prevention or treatment of hypertension and decrease the possibility of other cardiovascular risks.
Determining how to apply new guidelines into practice can be challenging. Accurate diagnosing, patient self-monitoring, lifestyle modifications, and medication adherence all must be factored into decision-making. The implementation of these recommendations must be a collaborative effort between health care professionals and patients. Ultimately, the challenge of determining which blood pressure goal is based on clinical judgment of the health care provider and how a lower blood pressure goal may affect and benefit an individual patient.