Study finds ACC AHA BP guidelines not representative of patient population

Lindsey Diaz-MacInnis (BIDMC Communications) 617-667-7372,

MARCH 16, 2020

Underrepresentation in clinical trials leaves evidence gaps for younger adults with low cardiovascular risk and in older adults with multiple health conditions

In a new study published today in JAMA Internal Medicine, a team of researchers led by Timothy Anderson, MD, a primary care physician at Beth Israel Deaconess Medical Center (BIDMC), found that patients enrolled in two national trials used by the American College of Cardiology / American Heart Association (ACC/AHA) to develop blood pressure (BP) management guideline were not representative of the U.S. adult population with high blood pressure. Given the large evidence gap, the authors recommend a patient-centered approach to treating individuals who fall outside of those covered by the guidelines.

Although the 2017 ACC/AHA guideline substantially expanded the number of adults defined as having hypertension and recommended medication treatment, the clinical trials underlying these recommendations are only representative of less than one-third of the guideline target population. The two trials – the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial – were most representative of adults between ages 50 and 69 years, indicating large evidence gaps on the effectiveness of intensive BP treatment in younger adults with low cardiovascular risk and in older adults with multimorbidity and limited life expectancy.

The authors conclude clinicians should be aware that the risk-benefit profile of intensive BP targets in low-risk individuals and younger adults is unknown and that the ACC/AHA guidelines are based on findings from higher risk populations. Additionally, older adults with multiple health conditions, who were largely excluded from trials, may see less benefit from the intensive BP management the ACC/AHA guidelines suggest, due to the competing risks of non-cardiovascular death and a potential increased risk of adverse events related to taking multiple medications.

“For the majority of individuals addressed in the guidelines and not represented by trials, a patient-centered approach tailoring recommendations by degree of blood pressure elevation, competing risks, and time to benefit is likely preferable to unwavering adoption of strict treatment targets,” said Anderson, who is also a researcher in BIDMC’s Division of General Medicine and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

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About Beth Israel Deaconess Medical Center

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School and consistently ranks as a national leader among independent hospitals in National Institutes of Health funding. BIDMC is the official hospital of the Boston Red Sox.

Beth Israel Deaconess Medical Center is a part of Beth Israel Lahey Health, a health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,800 physicians and 36,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.