AAFP Issues New Clinical Practice Guideline on Hypertension

Recommendations and Key Points

The hypertension clinical practice guideline contains 2 recommendations.

First, the AAFP recommends that clinicians treat adults with hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risk of all-cause mortality and cardiovascular mortality. This is a strong recommendation based on high-quality evidence. While treating to a lower blood pressure target of less than 135/85 mm Hg may be considered based on patient preferences and values, the lower target does not provide additional benefit at preventing mortality.

The systematic review found no significant differences in total serious adverse events between the lower and standard target groups but did note a significant increase in all other adverse events (such as syncope and hypotension) when treating to a lower systolic target. Overall, the lower target group had an absolute risk increase of 3% for all other serious adverse events compared with the standard target group.

Second, the AAFP recommends that clinicians consider treating adults with hypertension to a lower blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction (MI). This is considered a weak recommendation and is based on moderate-quality evidence. Although treating to a standard blood pressure target of less than 140/90 mm Hg reduced the risk of MI, there was a small additional benefit observed with a lower blood pressure target; however, there was no observed additional benefit in preventing stroke.

Coles, who served as the guideline panel chair, noted several key takeaways for family physicians to consider when implementing the recommendations.

“High-quality evidence shows that treating adults with hypertension to a target blood pressure of less than 140/90 mm Hg reduces the risk of all-cause and cardiovascular mortality,” she said. “Treating a lower blood pressure target does not provide any additional benefit to mortality or stroke risk. This holds true for adults with and without preexisting cardiovascular disease.

“Treating to a target of less than 135/85 can further reduce the risk of MI by about 4 fewer MIs per 1,000 patients. However, treating to a lower blood pressure target does come with harms. People treated to a lower blood pressure target increased rates of adverse events, including syncope and hypotension, with a number needed to harm of 33 over 3.7 years. On average, each patient would need to take 1 additional medication to get to the lower target. This could increase cost, medication adverse effects, and drug-drug interactions.

“Because the potential benefit is small and there are increased risks, family physicians should use shared decision making when considering treating to a lower blood pressure goal to reduce MIs. These discussions should include a patient’s risk of MI, potential for increased harms for lower targets, costs, and patient values and preferences.”

Guideline Development

To create the new guideline, the AAFP’s Commission on Health of the Public and Science appointed a development group that analyzed the evidence from a 2020 Cochrane systematic review and conducted a target literature search of additional trials. The primary objective was to determine whether lower blood pressure targets were associated with lower morbidity and mortality compared with standard blood pressure targets.

In constructing the guideline, the development group focused on patient-centered clinical outcomes such as total mortality, cardiovascular-related mortality, cardiovascular events such as stroke and myocardial infarction, and adverse events. The group also used a modified version of the Grading of Recommendations Assessment, Development and Evaluation system to rate the quality of evidence for each outcome and the overall strength of each recommendation.

Future Research

The authors and the guideline development group noted several gaps in the existing research. They called for additional studies that would, among other things,

• Evaluate longer-term outcomes

• Examine whether certain patient populations would benefit from lower blood pressure targets

• Evaluate blood pressure targets in younger individuals at low risk

• Examine the social determinants of health that contribute to health care disparities

Since all AAFP clinical practice guidelines are scheduled for review 5 years after completion (or earlier if new evidence is available), the authors said any new research into these and other areas will provide important information for future guidelines.