Changing Guidelines for Hypertension and Hypercholesterolemia

Dr. David J. Holcombe
Dr. David J. Holcombe

For those who are interested in preventive care—which should be everyone—there has been some comfort and consistency in recognizing and achieving goals suggested by your physician.  These are not arbitrary goals, but the result of recommendations produced by expert panels from distinguished organizations (notably the American College of Cardiology, the American Heart Association and the National Heart, Lung, and Blood Institute).  Since 2003, the JNC (Joint National Committee, comprised of representatives of the above-mentioned groups) has made recommendations for blood pressure control.  Everyone—both patients and physicians—recognized that the upper acceptable limit for the systolic (top blood pressure) was 140 and the diastolic (lower blood pressure) was 90.


The latest JNC 8 recommendations raise the upper acceptable systolic pressure to 150 in non-diabetic, non-chronic kidney disease who are 60 years old or older.  There are also more specific recommendations about the initial choice of medications in white patients (thiazide diuretics, calcium channel blockers, ace-inhibitors or angio-tension blockers) vs. blacks patients (thiazide diuretics and calcium channel blockers).  If blood pressure is not achieved in one month, increased doses or additional medication are suggested.  If over three medications together are not successful in achieving blood pressure control, referral to a hypertension specialist is recommended.  Although all of this may seem rather academic, apparently 29% of the guideline writers dissented in promulgating these current recommendations.  Blood pressure, just as its treatment, may prove a somewhat moving target.


Similar issues have rocked the world of cholesterol guidelines.  For some time, the goal of a low density lipoprotein (LDL) or “bad cholesterol level” of 100 mg/dl or less was the standard recommendation.  After decades of statin use and a series of major medical studies, experts from some of the same organizations (American College of Cardiology and the American Heart Association) have abandoned use of this figure.  They have established four groups of primary and secondary prevention patients targeted for treatment with either high-intensity or moderate-intensity statins.


Group 1:  Includes patients with established atherosclerotic heart disease. Group 2:  Those with LDL-cholesterol levels of greater than or equal to 190 mg/dl.  Group 3: Diabetics between 40 and 75 years of age with LDL levels between 70 and 189 mg/dl with no evidence of vascular disease. Group 4: Those without diabetes or vascular disease with LDL levels between 70 and 189 mg/dl WITH a 10-year risk of atherosclerotic cardiovascular disease equal or exceeding 7.5%.


Specific LDL-cholesterol goals are not recommended, rather percentage decreases of 50% in Groups 1 and 2 (using high-intensity statins) and 30 to 49% in Groups 3 and 4 (using moderate-intensity or high-intensity statins, depending on the level of risk).  To determine 10-year risk, there is a global risk assessment tool developed by the panel and available at the American Heart Association website.


Why the changes?  The panel, using the aggregate of available scientific studies, hopes to achieve better outcomes in specific groups.  Achieving a fixed goal of 100 mg/dl LDL across the board was apparently over-treating some and under-treating others.  These changes are really an attempt to equilibrate risk and benefits, based on available research.


Making changes among physicians and patients alike is akin to changing the course of the Titanic.  There will be much resistance from both groups, especially when the new recommendations appear so much more complex than the older ones.  Do not be surprised, however, if your doctor mentions these changes and adjusts either your blood pressure treatment or statin doses accordingly.  This may include removing several drugs, including fibrates, niacin and ezetimibe (Zetia), thus simplifying your medication regimen.  Or perhaps re-adjusting or eliminating one of your blood pressure medications.  If your physician does not mention the changes, feel free to ask about them.