The rise of the medical home along with the publication of large clinical trials will likely influence updated Joint National Committee guidelines for the management of hypertension, according to several experts at the annual meeting of the American Society of Hypertension.

Team@CMHF

• Updated guidelines may and should address home and ambulatory monitoring of blood pressure, greater reliance on global risk assessment, a revision of target blood pressures in high-risk groups, greater use of individualization in setting pressure targets, greater clarity on when to start drug therapy, earlier use of fixed-dose combination antihypertensive therapy, revocation of beta-blockers as frontline therapy, and specific recommendations on how to overcome therapeutic inertia.
• The panel of experts explored how hypertension management has evolved since the Seventh Report of the Joint National Committee was published in 2003.
• The so-called medical home – where a patient stays within a care system with a primary care physician coordinating care – is causing a “paradigm shift,” according to Dr. Jan Basile, professor of medicine at the Medical University of South Carolina in Charleston.
• We’ve always been paid for face-to-face interactions, and we really need to be paid for energy and effort.
• Why aren’t we incentivized to use novel means of tracking blood pressure at home through telemonitoring and other techniques?”
• The reorganization of primary care and the publication of JNC 8 may create significant opportunities to involve nurses, pharmacists, and dieticians, in controlling blood pressure
• Dr. Angela Brown, assistant professor of medicine at Washington University, St. Louis, noted that hypertensive patients in her clinic already receive 6 months of dietician counseling.
• Ambulatory blood pressure is most likely going to be recommended for everyone who has documented nuanced hypertension, and the reasons for that include blood pressure variability, the dramatic increase in the appreciation of masked hypertension, and the dipping and non dipping phenomenon, all of which contribute to higher mortality
• Personalized follow-up is also important to make sure patients get their medications and take them as directed
• Dr. Brown suggested that routine screening for albuminuria should become part of the global assessment for the hypertensive patient in the primary care setting.
• Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed that when systolic blood pressures reached 120 mm Hg, microalbuminuria “melted away.”
• The target blood pressure should be 140/90 mm Hg or less for most patients except for those with advanced kidney disease who have proteinuria.
• In patients aged 80 years and older, the target pressure may be less than 150/80 mm Hg, according to Dr. Basile.
• Latest American Diabetes Association guidelines set the target for diabetics at 130/80 mm Hg, and that treatment should be tailored to the individual.
• Individualization is going to be a very important word because perhaps, as in ACCORD, if your patient has had a stroke or is stroke prone, you might want to drive the blood pressure lower, but if the patient is not [stroke prone] one may not want to be as aggressive.
• JNC 7 recommends initial combination therapy when systolic blood pressure is more than 20 mm Hg above goal.
• Although some of the newer beta-blockers may be better tolerated and have other potential advantages over some older drugs in that class, recommending those drugs as first line therapy will be more difficult in the absence of new end-point trials as the JNC 8 panel strives to make the guidelines more evidenced based.

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