NEW YEAR, NEW GUIDELINES

BY JAMES S. BURKHARDT, D.O.

Recently, new guidelines have emerged for both cholesterol reduction and blood pressure control.  The Eighth Joint National Committee (JNC8) has released guidelines on the management of high blood pressure.  In November, the American Heart Association (AHA) and the American College of Cardiology announced new guidelines for treating cholesterol.

            Both hypertension (elevated blood pressure) and high levels of cholesterol are associated with increased risk of heart attack and stroke.  The other major risk factors are family history, diabetes mellitus, and smoking.  And by family history, I am specifically referring to a first-degree relative; mother, father, sister or brother.  If one of them had a heart attack or stroke, then you are at increased risk.

            Let’s take blood pressure first.  The 14-page, JNC 8 guidelines formed nine recommendations which are discussed in detail.  The authors also published over 300 pages of supplemental evidence in outlining their review process. 

            There are nine recommendations, some of which are new and some are modifications.  Among the recommendations:

            -In patients 60 years or over, start treatment in blood pressure over 150 mm Hg     systolic or over 90 mm Hg diastolic and treat to under those thresholds.

-In patients under 60 years, treatment initiation and goals should be 140/90 mm Hg, the same threshold used in patients over 18 years with either chronic kidney disease (CKD) or diabetes. 

            -In nonblack patients with hypertension, initial treatment can be a thiazide-type diuretic, Calcium Channel Blocker ( CCB), angiotensin converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB), while in the general black population, initial therapy should be a thiazide-type diuretic or calcium channel blocker.

            -In patients over 18 years with chronic kidney disease (CKD), initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

            The medication recommendations for black patients and for diabetic patients is not exactly new.  The loosening of blood pressure goal for those over 60 is new, however.  This is also not to say that if your blood pressure is well controlled at 130/80, that you can stop your medicine. 

            While the blood pressure recommendations are new, we are still treating to a target number.  The new cholesterol guidelines are somewhat muddier.

            The guidelines include new weight and lifestyle measures to lower the risk of having a heart attack and stroke.  The guidelines also recommend that doctors focus on overall risks to the heart and less on cholesterol numbers. 

            To determine that risk, doctors use a calculator that figures out the chances of having heart problems in the next 10 years.  It is also available online. (You must know your cholesterol numbers and blood pressure to use it.) 

            The calculator takes into account cholesterol numbers, age, blood pressure, smoking habits, and use of blood pressure medicines.  All of these things affect your chance of having heart problems.

            Initially it appears that more people will be taking cholesterol lowering drugs, usually in the form a family of medicines called statins. 

            Just as in the past, people diagnosed with heart disease will start taking a statin.

New to the guidelines: People with extremely high LDL, or “bad” cholesterol, and all middle-aged people with type 2 diabetes will be advised to take a statin.  

Also, men and women 40-75 who have an estimated 10-year risk of heart or blood vessel problems of 7.5% or higher will be recommended a statin. 

            Living a healthy lifestyle is still most important.  These things include diet, exercise and not smoking.  Many people make resolutions at this time of year.  While these New Year resolutions often involve healthy lifestyle changes, I encourage you to continue with healthy living. 

            As always, consult your family doctor regarding blood pressure or cholesterol questions.