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Vol. 72. Issue 8.
Pages 677-679 (August 2019)
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Vol. 72. Issue 8.
Pages 677-679 (August 2019)
Scientific letter
DOI: 10.1016/j.rec.2018.08.005
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Impact of the ACC/AHA AHT Guidelines on the Frequency of Hypertension and the Need for Treatment. The RICARTO Study
Impacto de la guía de HTA del ACC/AHA en la frecuencia y la necesidad de tratamiento de la hipertensión arterial. Estudio RICARTO
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Luis Rodríguez-Padiala,
Corresponding author
lrodriguez@sescam.org

Corresponding author: Servicio de Cardiología, Complejo Hospitalario Universitario de Toledo. Avda. Barber 30, 45004 Toledo, Spain.
, Antonio Segura Fragosob, Francisco Javier Alonso Morenoc, Miguel A. Ariasa, Alejandro Villarín Castrod, Gustavo Cristóbal Rodríguez Rocae
a Servicio de Cardiología, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
b Unidad de Investigación, Instituto de Ciencias de la Salud, Talavera de la Reina, Toledo, Spain
c Medicina de Familia, Centro de Salud Sillería, Toledo, Spain
d Medicina de Familia, Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Toledo, Spain
e Medicina de Familia, Centro de Salud de La Puebla de Montalbán, Toledo, Spain
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Tables (2)
Table 1. Characteristics of the Individuals Studied
Table 2. Frequency of Hypertension According to the 2 Criteria Used, in Different Ages and Types of Patients
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To the Editor,

The new hypertension (HTN) guidelines of the American College of Cardiology/American Heart Association (ACC/AHA)1 use lower blood pressure (BP) values than in previous guidelines2,3 (≥ 130/80mmHg) to define HTN and therapeutic targets. In the United States population this means an increase of 13.7% in patients diagnosed with HTN and 1.9% in those requiring pharmacological treatment; in addition, 14.4% of hypertensive patients on treatment will require treatment intensification.4 Our aim was to evaluate the potential impact of the new ACC/AHA guidelines in the general population of Toledo.

RICARTO is an observational epidemiological study of a cohort undergoing follow-up for a minimum of 5 years.5 The target population consist of patients aged 18 years or older in the Toledo health care area (n=424 172). Cardiovascular risk was calculated with the ASCVD Pooled Cohort Risk Equations Risk Calculator. The protocol was approved by the Complejo Hospitalario de Toledo Ethics Committee. BP was taken as the mean of 3 readings measured with an Omron HEM-907.

The study included 1694 patients (59.2% were women; mean age, 49.35±15.73 years). The epidemiological data are shown in Table 1. Patients with systolic BP between 130 and 140mmHg were younger and had less obesity than those with BP ≥ 140mmHg (P <.001). A total of 21.4% of patients were receiving treatment with antihypertensives (10.9% angiotensin II receptor blockers; 9.1%, diuretics; 7.1%, angiotensin-converting enzyme inhibitors; 4.6%, calcium channel blockers; 3.9%, beta blockers; 1.2%, alpha blockers). The prevalence of HTN according to the 2 criteria is shown in Table 2. The overall frequency of HTN was 33.1% and 50.6% depending on the criteria used, a difference of 17.5% (P <.001), representing a 52.9% increase. The difference was 22.3% (54.6% increase) in men and 13.8% in women (51.1% increase) (P <.001).

Table 1.

Characteristics of the Individuals Studied

  Not hypertensive (< 130/80 mmHg)Hypertensive (≥ 140/90 mmHg)“New” hypertensive (≥ 130/80 but <140/90 mmHg)Total
Age
18-44 y  494 (59.0)    76 (13.6)    115 (38.7)    685 (40.4)   
45-64 y  302 (36.1)    242 (43.2)    146 (49.2)    690 (40.7)   
65-79 y  37 (4.4)    192 (34.3)    33 (11.1)    262 (15.5)   
≥ 80 y  4 (0.5)    50 (8.9)    3 (1.0)    57 (3.4)   
Sex
Female  563 (67.3)    257 (45.9)    131 (44.1)    951 (56.1)   
Male  274 (32.7)    303 (54.1)    166 (55.9)    743 (43.9)   
Setting
Urban  316 (37.8)    139 (24.8)    84 (28.3)    539 (31.8)   
Rural  521 (62.2)    421 (75.2)    213 (71.7)    1155 (68.2)   
Age, y  837  42.2±12.8  560  60.7±14.1  297  48.1±13.4  1694  49.3±15.7 
Weight, kg  837  69.3±13.2  558  80.9±16.7  297  79.47±15.6  1692  74.93±15.9 
Height, cm  837  165.4±8.97  558  163.9±9.82  297  167.5±10.1  1692  165.3±9.54 
Body mass index  837  25.3±4.24  558  30.1±5.38  297  28.2±4.56  1692  27.4±5.17 
Waist circumference, cm  837  85.6±11.4  560  101.0±12.8  297  94.8±12.4  1694  92.3±13.9 
SBP, mmHg  837  113.3±9.39  559  140.8±16.8  297  130.5±9.35  1693  125.4±17.5 
DBP, mmHg  837  67.3±6.88  559  81.0±11.4  297  79.6±6.21  1693  74.0±10.8 
Heart rate, bpm  837  72.9±10.6  559  76.3±12.7  297  74.1±10.9  1.693  74.2±11.4 
Fasting blood glucose, mg/dL  834  82.0±10.7  560  98.7±24.1  296  87.9±19.5  1.690  88.6±19.2 
Glycosylated hemoglobin, %  810  5.27±0.42  545  5.8±0.86  290  5.47±0.62  1.645  5.48±0.68 
Total cholesterol, mg/dL  832  190.0±34.6  559  194.0±37.0  296  202.0±34.9  1.687  194.0±35.7 
LDL-C, mg/dL  828  112.±31.7  557  115.0±33.0  295  123.0±31.6  1.680  115.±32.3 
HDL-C, mg/dL  828  59.7±15.3  559  53.7±16.5  295  56.4±15.4  1.682  57.1±16.0 
Triglycerides, mg/dL  832  93.1±53.2  559  130.0±81.1  295  118.0±96.0  1.686  109.±74.0 
Serum creatinine, mg/dL  833  0.78±0.15  560  0.8±0.25  296  0.85±0.18  1.689  0.82±0.20 
Microalbumin/creatinine ratio  521  6.84±16.1  351  29.6±128.  194  7.15±15.3  1.066  14.4±75.8 
CKD-EPI  837  101.0±14.9  560  85.7±18.1  297  94.7±15.7  1.694  94.8±17.5 

CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; DBP, diastolic blood pressure; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SBP, systolic blood pressure.

Values are expressed as No. (%) or mean±standard deviation.

Table 2.

Frequency of Hypertension According to the 2 Criteria Used, in Different Ages and Types of Patients

  Diagnosis of hypertension with mean BP from 3 measurements of 130/80 mmHgDiagnosis of hypertension with mean BP from 3 measurements of 140/90 mmHg
  Not hypertensive  Hypertensive (treatment or BP ≥ 130/80 mmHg)Not hypertensive  Hypertensive (treatment or BP ≥ 140/90 mmHg)
  No. (%)  No. (%)  95%CI  No. (%)  No. (%)  95%CI 
Age
18-44 y  494 (72.1)  191 (27.9)  24.55-31.36  609 (88.9)  76 (11.1)  8.841-13.66 
45-64 y  302 (43.8)  388 (56.2)  52.43-59.88  448 (64.9)  242 (35.1)  31.50-38.70 
65-79 y  37 (14.1)  225 (85.9)  81.06-89.56  70 (26.7)  192 (73.3)  67.48-78.27 
≥ 80 y  4 (7.0)  53 (93.0)  82.99-97.14  7 (12.3)  50 (87.7)  76.32-93.85 
Total  837 (49.4)  857 (50.6)  48.18-52.96  1134 (66.9)  560 (33.1)  30.81-35.33 
Sex
Female  563 (59.2)  388 (40.8)  37.65-43.95  694 (73.0)  257 (27.0)  24.22-29.93 
Male  274 (36.9)  469 (63.1)  59.53-66.51  440 (59.2)  303 (40.8)  37.22-44.35 
BMI
Normal (< 25)  438 (74.10)  153 (25.90)  22.40-29.57  509 (86.1)  82 (13.9)  11.18-16.89 
Overweight (25-29.99)  299 (45.20)  363 (54.80)  50.95-58.58  435 (65.7)  227 (34.3)  30.67-37.98 
Obese (≥ 30)  100 (22.80)  339 (77.20)  73.00-80.89  190 (43.3)  249 (56.7)  51.93-61.27 
Abdominal obesity*
No abdominal obesity  649 (63.60)  371 (36.40)  33.41-39.37  817 (80.1)  203 (19.9)  17.49-22.46 
Abdominal obesity  188 (27.90)  486 (72.10)  68.55-75.35  317 (47.0)  357 (53.0)  49.11-56.70 

95%CI, 95% confidence interval; BMI, body mass index; BP, blood pressure.

*

Abdominal obesity: waist> 102cm in men or> 88cm in women.

In absolute terms, the impact was higher in obese patients: the frequency of HTN rose from 56.7% to 77.2% (a 20.5% difference; 36.1% increase) in obese patients and from 24.7% to 41.2% (16.5% difference; 66.8% increase) in nonobese patients (P <.001 for all differences). In overweight individuals, a similar effect to obese patients was observed, and the prevalence rose from 34.3% to 54.8% (20.5% difference; 59.8% increase). In patients with abdominal obesity, HTN rose from 53.0% to 72.1% (19.1% difference; 36% increase), similar to the findings for obese patients; in contrast, in those without abdominal obesity, the frequency of HTN rose from 19.9% to 36.4% (16.5% difference; 82.9% increase) (P <.001 for all differences).

The estimated cardiovascular risk was ≥ 10% in 30.8% of the population (46.8% in hypertensive individuals and 7.1% in nonhypertensive individuals). In normotensive patients who would be hypertensive according to the new guidelines, 3.9% (2.2% of women and 6.1% of men) had a risk ≥ 10%. Furthermore, 54.8% of the 464 hypertensive patients who were well-controlled (BP <140/90mmHg) would become poorly-controlled with BP <130/80mmHg (P <.001).

This study demonstrates that the use of the ACC/AHA guidelines on HTN in this sample of the Spanish population would result in a significant 17.5% increase in the frequency of HTN, with this increase being higher in male patients (22.3%), and those who are obese (20.5%), overweight (20.5%) or have abdominal obesity (19.1%). Due to a high cardiovascular risk, 3.9% of the “new” hypertensive patients would require pharmacological treatment. More than half (55%) of patients currently controlled on treatment would require intensification of their antihypertensive treatment to be controlled according to the new guidelines.

The lower BP levels recommended by the new 2017 ACC/AHA guidelines are based on randomized and observational studies. The observational data demonstrated a gradual increase in mortality as BP increased beyond levels of> 115/75mmHg, and the studies carried out on treatment in hypertensive patients reported a reduction in morbidity and mortality at systolic BP levels <130mmHg. In the SPRINT study they demonstrated that in hypertensive patients with high risk, intensive treatment (BP 121/69mmHg) reduced morbidity and mortality vs standard treatment (BP 136/76mmHg).6

The ACC/AHA guidelines indicate a prevalence of BP between ≥ 130/80 and ≥ 140/90mmHg of 14%,1 very similar to the findings by Muntner et al.4 (13.7%) and our findings (17.5%). In the United States population, the proportion of hypertensive patients requiring treatment intensification to reach the new targets was 14.4%, somewhat different to the 55% found in this study. We consider these figures to be relevant, at a time when, as some authors have pointed out, hypertension may need to be redefined and its treatment improved.

FUNDING

The RICARTO study was funded from 2011 to 2013 by the government of Castile-La Mancha with a grant for Research in Biomedicine and Health Sciences (record no. PI-2010/043) from the Castile-La Mancha Social and Healthcare Foundation (FISCAM).

The Spanish Society of Primary Care Physicians (Fundación SERMERGEN) assisted in funding the RICARTO study from 2013 with an unconditional grant.

References
[1]
P.K. Whelton, R.M. Carey, W.S. Aronow, et al.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary.
Hypertension., 71 (2018), pp. 2199-2269
[2]
G. Mancia, R. Fagard, K. Narkiewicz, et al.
2013 ESH/ESC guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
Eur Heart J., 34 (2013), pp. 2159-2219
[3]
A.V. Chobanian, G.L. Bakris, H.R. Black, et al.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
JAMA., 289 (2003), pp. 2560-2572
[4]
P. Muntner, R.M. Carey, S. Gidding, et al.
Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline.
J Am Coll Cardiol., 71 (2018), pp. 109-118
[5]
G.C. Rodriguez-Roca, A. Segura-Fragoso, A. Villarin-Castro, et al.
[Characteristics and cardiovascular events in a general population included in the RICARTO (RIesgo CARdiovascular TOledo) study: Data from the first 1,500 individuals included in the study].
Semergen., 44 (2018), pp. 180-191
[6]
J.T. Wright Jr., J.D. Williamson, P.K. Whelton, The SPRINT Research Group, et al.
A randomized trial of intensive versus standard blood-pressure control.
N Engl J Med., 373 (2015), pp. 2103-2116
Copyright © 2018. Sociedad Española de Cardiología
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