Docs Debate 
New Blood Pressure Guidelines 

While a government panel accepted new guidelines for the treatment of high blood pressure without dissent, other specialists expressed problems with recommendations for treating the disease that potentially will affect 90 percent of people over the age of 55. 

"It's garbage," said Dr. Lawrence Resnick, professor of medicine at New York Presbyterian Hospital-Cornell University Medical Center. "Most doctors, I hope, will not take it seriously." 

The new guidelines -- formally known as the "Seventh Joint National Committee on Prevention, Detection and Treatment of High Blood Pressure," or JNC-7 -- call for treatment of high blood pressure with inexpensive diuretics, also known as water pills, as a first-line therapy, followed by use of other classifications of drugs including newer angiotensin-converting enzyme inhibitors and angiotensin receptor blockers which interfere with the mechanisms that cause increases in blood pressure. 

Use of diuretics for treatment -- a recommendation that has been prominent in the JNC reports since 1976 -- was met with criticism by doctors during a news briefing at the 18th annual meeting of the American Society of Hypertension. 

"While science has lept forward since the first JNC report, JNC-7 has lept nowhere," said Dr. John Laragh, editor-in-chief of the Journal of the American Society of Hypertension and a long-time leader in high blood pressure research. 

Laragh was distressed particularly by the "cookie cutter" approach to treatment. He and others said doctors should treat patients as individuals who have different forms of disease. Laragh has been a long-time advocate of treating individuals based on whether their high blood pressure is based on a sensitivity to salt -- about one-third of patients -- or not. He said the guideline committee failed to look at the appropriate literature on differences in the population of high
blood pressure patients. 

Ed Roccella, coordinator of the National High Blood Pressure Education Program, which commissioned the JNC-7 report, said the contentions of Laragh are not -- at present -- supported by clinical trial data. 

Laragh said he expects the medical profession will not accept the results of the new guidelines, basing that prediction on the fact many doctors did not accept the previous guidelines. He said the fact that barely a third of people with high blood pressure have the disease controlled attests to an overall lack of acceptance of the guidelines. 

"The only thing that had really new about JNC-7." said Resnick, "is the shrillness of the message. The JNC guidelines used to be suggestions and now they are getting coercive." 

Dr. Jay Meltzer, clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York, said the guidelines "are based on the assumption that physicians in general practice are not well-trained and need powerful guidance in treating patients with high blood pressure." 

About 24 percent of American adults have high blood pressure -- about 50 million people. At the news briefing, the doctors also attacked the concept of people with "pre-hypertension" -- an additional 45 million Americans. Being "pre-hypertensive" means a person in on the path toward developing hypertension, also known as high blood pressure, a major cause of heart attacks, stroke and kidney failure. 

Before JNC-7, most patients with blood pressure figures of 120-139 systolic, and 80-90 diastolic, were considered to have normal blood pressure. About 22 percent of American adults fall into this category, said Dr. Claude Lenfant, director of the National Heart, Lung and Blood Institute, a branch of the National Institutes of Health in Bethesda, Md.  He noted once a person's blood pressure climbs above 115 over 75, the risk of heart disease and stroke continue. He
added the risk doubles for every 20/10 points rise in blood pressure. 

Meltzer criticized the creating the category of "pre-hypertension" and millions of additional patients -- most of whom thought their blood pressure was under control -- without a way to treat them. The doctors said lifestyle changes advocated by the government panel were unrealistic. JNC-7 does not advocate pharmaceutical treatment of pre-hypertension. 

"The lifestyle change advice is correct," said Resnick, "but it doesn't work unless you are in a formal group. Practically speaking it doesn't work." 

"It's too hard to do and the reward is too tiny," Laragh added. 

The lifestyle changes advocated in JNC-7 for "pre-hypertensive" patients include eating a healthy diet, losing weight, quitting smoking, reducing salt in the diet and exercising. 

"Being pre-hypertensive represents an opportunity," Roccella said, "to change the progression towards high blood pressure. If you feel you don't have time for physical activity, you will have time for illness." 

Dr. William White, professor of medicine at the University of Connecticut, Farmington, told United Press International the JNC-7 guidelines "will be taken seriously by a lot of physicians." 

He said among the new emphasis on JNC-7 was treatment of systolic high blood pressure. Under the new guidelines, normal blood pressure is defined as being less than 120 millimeters of mercury (mm/Hg) systolic over less than 80 mm/Hg diastolic. New studies have indicated that control of systolic blood pressure, especially in the elderly, might be more important in preventing heart attacks and strokes. 

White also noted the new guidelines acknowledged that in patients with diabetes and kidney disease newer drugs such as the angiotensin receptor blockers were favored for use. 

"Inadequate control of blood pressure has become a  public health crisis. We are encouraged that new approaches recommended by JNC-7 will provide impetus for improvement," said Dr. Malcolm MacNab, vice president for US Clinical Development and Medical Affairs at Novartis Pharmaceuticals Corp. of East Hanover, N.J. 

Dr. Aram Chobanian, dean of the Boston University School of Medicine and chairman of the committee that wrote the JNC-7 recommendations, said the report was developed with the input of 39 institutions and organizations and seven government organizations. The final version was accepted without dissent by the steering committee of scientists who reviewed the document, he said, and the recommendations were based on more than 30 major studies that had been
published since 1997. 

Laragh said the guidelines appeared to be influenced by the recent publication of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) trial. ALLHAT indicated there was a treatment advantage for diuretic use in high blood pressure. 

However, Laragh argued ALLHAT was deeply flawed and reliance on it by the guideline committee was not appropriate. 

Lenfant, at a news briefing in Washington, D.C., earlier in the week, appeared to anticipate some of the arguments presented by Laragh and others. 

"We are not advocating cookbook medicine," he said. "Physicians will have to decide for themselves how to treat their patients." 

Said Roccella: "The new guidelines ask Americans to change how they think about high blood pressure. The risk for heart disease and stroke start to rise long before hypertension is established. Americans can't wait for that risk to overtake them. They need to start today to make the lifestyle changes that can protect them." 
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Copyright 2003 by United Press International. 
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