Increase in Hypertensive Stroke Survivors After Implementation of New Hypertension Guidelines

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With the implementation of the 2017 ACC/AHA hypertension guidelines, there may be a significant increase in stroke survivors with hypertension.
With the implementation of the 2017 ACC/AHA hypertension guidelines, there may be a significant increase in stroke survivors with hypertension.

A greater proportion of people with hypertension who had a stroke and achieved blood pressure targets recommended in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines survived during 2003 to 2014 compared with patients who achieved blood pressure targets recommended in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) guidelines, according to a study published in the Journal of the American Heart Association.

In the JNC7 guidelines, the consensus committee recommends hypertension pharmacologic treatment for those who had a stroke and had systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. The JNC7 defined hypertension as SBP ≥140 mmHg or DBP ≥90 mmHg.

The updated 2017 ACC/AHA guidelines, however, lowered the blood pressure cutoff for hypertension in patients at risk for stroke to SBP ≥130 mmHg or DBP ≥80 mmHg. In addition, the 2017 ACC/AHA guidelines recommend initiating pharmacologic therapy for these individuals to achieve SBP/DBP target of <130/80 mmHg.

In this study, researchers enrolled people with hypertension who had a stroke and participated in the National Health and Nutrition Examination Surveys from 2003 to 2014. A history of stroke as well as the use of medications for hypertension were determined by self-report.

Under the new guidelines, hypertension prevalence increased by 66.7%. A greater proportion of those with hypertension who had a stroke were observed among those achieving the 2017 ACC/AHA blood pressure recommendations (49.8%; 95% CI, 45.4%-54.2%) vs patients achieving the JNC7 blood pressure recommendations (29.9%; 95% CI, 26.2%-33.7%) during 2003 to 2014. Per the 2017 ACC/AHA guidelines, approximately 56% (95% CI, 51.2%-60.6%) of those who survived a stroke were not at the recommended target blood pressure levels compared with 36.3% (95% CI, 31.6%-41.4%) of those who survived a stroke and achieved target levels per the JNC7 guidelines.

The morality rate for patients with SBP <130 mmHg or DBP <80 mmHg was 5.55% from 2003 to 2010. Meanwhile the mortality rate was 8.25% for those with SBP <140 mmHg or DBP <90 mmHg. These results correspond with a 32.7% relative mortality reduction.

A limitation of the analysis was the reliance on self-reported data for determining the incidence of stroke as well as the use of pharmacologic therapy for participants.

Findings from this review indicate that, while challenges may exist in implementing the new ACC/AHA hypertension guidelines, doing so may “result in significant increase in the proportion of stroke survivors with hypertension, recommended pharmacological treatment, and above blood pressure target.”

Reference

Lekoubou A, Bishu KG, Ovbiagele B. Nationwide impact of the 2017 American College of Cardiology/American Heart Association blood pressure guidelines on stroke survivors. J Am Heart Assoc. 2018;7(12).

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