The American Academy of Family Physicians (AAFP) announced this week that it will not endorse new hypertension guidelines backed by the American Heart Association (AHA), the American College of Cardiology (ACC), and nine other organizations, citing concerns with methodology and perceived conflicts of interest.

The new guidelines call for lowering the threshold for treating hypertension with lifestyle changes and medication as necessary to 130/80 mm Hg instead of the previous commonly accepted mark of 140/90 mm Hg. Under the new guidelines, 46% of the US adult population would be considered to have high blood pressure (BP), as opposed to the 32% under the 140/90 guidelines.

Instead, the AAFP said it will continue to endorse the 2014 guidelines developed by the Eighth Joint National Committee.

Those guidelines state that in the general population, for people aged 60 years and older, treatment should begin at 150/90 mm Hg, and at age younger than 60 years, treatment should start at 140/90 mm Hg.

AAFP President Michael Munger, MD, said in a statement: "The American Academy of Family Physicians formally reviewed the AHA/ACC hypertension guideline but it did not meet the criteria for endorsement nor affirmation of value. The AAFP was not involved in the development of the new guidelines and continues to endorse the 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults.

"In addition, in January 2017, the AAFP and ACP published the clinical practice guideline Hypertension in Adults Over 60. Family physicians approach hypertension treatment on an individualized basis, taking into account patients' histories, risk factors, preferences and resources. We will maintain making informed decisions with patients while considering potential benefits and harm," Dr Munger said.

Reasons for Rejecting Guidelines

David O'Gurek, MD, chair of the Commission on Health of the Public and Science (CHPS), said in an AAFP News article there were several reasons for declining to endorse the new AHA/ACC guidelines. Among them, he said, was that "the bulk of the guideline wasn't based on a systematic evidence review."

As an example, commission members stated that the new guideline gave a strong recommendation for using the unvalidated atherosclerotic cardiovascular disease risk assessment tool, which was developed by the AHA and ACC to help gauge whether medications were necessary for BP control.

"However, this recommendation wasn't based on evidence that using the tool in this way improves outcomes," the commission stated.

The CHPS also said too much weight was given to the Systolic Blood Pressure Intervention Trial (SPRINT), and other trials were minimized. Although the commission said SPRINT was important, it "needs to be considered in the context of the totality of the evidence."

The commission added that it sees some conflicts of interest.

"In the case of the AHA/ACC guideline, the guideline panel commissioned the principal investigator of the SPRINT trial to chair its work, when, notably, the SPRINT trial served as the foundation for the guideline panel's recommendations to change BP treatment targets," the commission said, adding that, "[S]everal other AHA/ACC guideline panel members had intellectual conflicts of interest, which were not considered in the guideline's preparation."

A Path for Primary Care Physicians

Michael Blaha, MD, director of clinical research for the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins School of Medicine in Baltimore, Maryland, told Medscape Medical News that conflict-of-interest issues can always be debated, but the core issue is that organizations and global regions will continue to have different ideas about aggressiveness of BP control.

He acknowledged patients and physicians may be confused by the evolving numbers, but said that changing numbers are something both groups have come to expect, as seen with varying opinions on cholesterol guidance, for example.

He said what should not change is that conversations for care plans should be individualized because guidelines are simply that: guidelines.

Dr Blaha says the evidence-based AHA/ACC guidelines are thought of as more optimistic, something to strive for, but include targets many adults will not reach. The general message is good, he said — that patients should work to lower their numbers as close to 130 as possible to do safely — and that's something primary care physicians can easily explain to their patients.

The AHA/ACC guidelines do not say that those newly classified as in stage 1 hypertension (130 - 139 mm Hg) necessarily need medication, Dr Blaha emphasized.

"Lifestyle is still front and center and I think that's something the American Academy of Family Practitioners would agree with."

Dr Blaha has disclosed no relevant financial relationships.

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