Year 2013 was very eventful for practicing cardiologist. Numbers of guidelines were published and amount of impact these guidelines have made on our practice is significant. These new guidelines came up with remarkable change compared to previous versions, and equally few new guidelines created controversies too.
It is very unfortunate that in India we have few guidelines and for the most, we have to depend on western literature. These western Guidelines are based on western subjects, who are much different both genetically and also by life styles. It is high time for us to form guidelines for our own subcontinent. At the same time guidelines formed in the west are not free from conflicts of interest, many panelist in guideline making body are taking or taken huge sum of fees from pharmaceutical companies. All the guidelines recommendation are not from random control trial or systemic reviews but some are form expert opinion. Same data by different group of panelist gives different recommendations some times, for example hypertensive guidelines by JNC 8 and ASH/ISH gave different set of recommendations which were published within one two days apart. This difference is because guidelines makers have to use their judgment too.
Honestly it is very difficult to discuss details of guidelines in this article. I will try discussing in brief
Of the all the guidelines in cardiology, guideline of lipid management also called ATP4 by ACC/AHA came up with sea change. This ATP4 unlike its precursor ATP3 published almost a decade age removed targets of lipids namely LDL and Non-HDL cholesterol. This ATP4 and other 3 guidelines namely Obesity management, assessment of cardiovascular risk and life style management were published in mid November 2013 all together. ATP4 guidelines have focused on events i.e. atherosclerotic cardiovascular diseases (ASCVD) rather than surrogates like LDL and non-HDL etc, which is more meaningful.
ATP 4 has created four groups namely,
- Group one those with already established Coronary Artery or Cerebro–Vascular or peripheral vascular disease.
- Group two is subjects excluding group one but with LDL cholesterol more than 190mg/dl.
- Group three is subjects excluding group one and two but having diabetes with age more than 40 and less than 75 years.
- Group four is subjects excluding group one, two and three (primary prevention) but with 10 years ASCVD risk more than 7.5% and age between 40 to 75 years.
Unlike in the past for 10 year risk calculation Framingham risk score was used but in these new guidelines new risk calculator i.e. from pooled cohort equations is available. This new calculator is freely downloadable from official site but it is in excel format. Smart phone versions are available from Google play I think it costs Rs 55.
In this new guideline statins are the only preferred drugs and other non statins drugs like fenofibrate, niacin and Omega three fatty acids are not recommended. Statins recommendation has been divided in to high intensity moderate intensity and low intensity. High intensity means LDL reduction to less than 50% of previous value, moderate intensity means LDL reduction to 30 to 50% of previous value. In high intensity group only atorvastatin and rosuvastatin are recommended. The dose recommended for atorvastatin is 40 to 80 mg and for rosuvastatin it is 20 to 40 mg. in moderate intensity group apart from atorvastatin and rosuvastatin other statins like simvastatin pravastatin are included. Dose recommended are less for atorvastatin and rosuvastatin i.e. 10 to 20 and 5 to 10 mg respectively.
For the first and second groups high intensity statin therapy is advised and for third and fourth group moderate intensity statin therapy is advised. However there caveats for example if the age is more than 75 years, more aggressive treatment might not be a choice. For third group high intensity statin might also be used, if the calculated risk is more than 7.5%. In subject in group four if calculated risk value very much more than 7.5% than one may choose high intensity statins also.
In subjects with secondary hyperlipidemia like hypothyroidism, nephritic syndrome, biliary obstruction and drugs (steroids, amiodarone and diuretics) primary disease has to be treated first. In patient with severe hypertriglycidemia i.e. more 500 mg, fenofibrate may be used. In pregnancy and lactation statins are contraindicated.
In the year 2013 we receive at least four sets of hypertensive guidelines, first from our country IGH3, ESH/ESC guidelines, and JNC 8 and ISH/ASH guidelines.
Of all most controversial guidelines was JNC 8. This JNC 8 which was proposed by 18 panelist (not endorsed by any is federal agency of USA) is actually meant for practicing front line American primary care physicians. JNC 8 according to some experts not truly a guideline. In JNC 8 instead of going in detail on definition classification and treatment of resistant hypertension etc, it has only addressed three questions i.e. when to start treatment, what are the goals of treatment and third was what drugs to use. These three questions are very important from primary care physician point of view.
Instead ISH/ASH is more elaborate guideline with definition, classification, BP recording and dealing in special situations. In this guideline there is recommendation for developing and under developed countries too.
ESC/ESH guidelines were issued in mid 2013.
General summery from all Hypertensive guidelines
- In previous guidelines in patients with Diabetes , Cardiovascular and renal disease BP target was less than 130/80 but all new set of guidelines this target is increased to less than 140/90mmhg.
- Both ESH/ESC and ISH/ASH have relaxed BP target of control to less than 150/90 in age group of more than 80 years. But in case of JNC 8 this relaxation starts from age group more than 60 years.
- Unlike previous guidelines diuretics are not very preferred drug in any age groups. Ca channel blockers, ACE/ARB or diuretics are considered equal good. Beta blockers are the last preferred drugs unless there is compelling indication like IHD or heart failure.
- In age group above 60 years Ca channel blockers or diuretics may be considered in younger individuals ACE/ ARB maybe preferred.
- Combinations of ACE/ARB with Ca channel blockers and or diuretics are preferred if needed. Combinations of ACE with ARB are contraindicated. Ca channel blocker (Dihydropyredines and also Nondihydropyredines ) with beta clocker is not very preferred combination.
- In patients with stage 2 hypertension i.e. BP more than 160/100mmhg recommendation of drug treatment is very strong. But in patient of Stage 1 (140 to 159/ 90-99 mmhg) hypertension drug treatment is less well established but how ever still recommended along with life style modification. In stage 1 hypertension strength of drug in treatment increases if there are associated risk f actors like Diabetes cardiovascular disease and stroke even if ambulatory blood pressure monitoring (ABPM) confirms hypertension then strength of drug treatment in stage 1 hypertension increases.
- ESH/ESC advises to use ABPM more frequently, Cardiovascular vascular risk more strongly correlated with ABPM then with office blood pressure measurement. ABPM can also be used to rule out white coat hypertension.
- J curve hypothesis is more appreciated in these set of guide lines from cardio vascular point of view at least. Lower the BP pressure is not better.
- Blood pressure not reaching the targets even with 3 different classes of drugs of which one is diuretic and even if BP is controlled with more than three drugs, it is called resistant hypertension. In such cases advice is to use Spironolactone for purpose controlling hypertension.
- IGH3 recommends Chlorthalidone over hydrochlorothiazide for better control of blood pressure and reduction of cardiac events, but ESC/ESH guide lines say, evidence in fever of Chlorthalidone is not very robust, so guidelines do not differentiate between these drugs.
- IGH3 recommends if target BP reduction is more than 20/10mmhg than combination therapy is advised
Some links I would suggest to