Tag: guidelines

Categories : Cardiovascular DiseaseTags :

AHA’s New Hypertension Guideline Emphasises Prevention, Early Treatment to Reduce CVD Risk

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Preventing and managing high blood pressure with healthy lifestyle behaviours combined with early treatment with medication to lower blood pressure if necessary are recommended to reduce the risk of heart attack, stroke, heart failure, kidney disease, cognitive decline and dementia, according to a new clinical guideline published in the American Heart Association’s peer-reviewed journals Circulation and Hypertension, and in JACC, the flagship journal of the American College of Cardiology.

The “2025 AHA / ACC / AANP / AAPA / ABC / ACCP / ACPM / AGS / AMA / ASPC / NMA / PCNA / SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults” replaces the 2017 guideline and includes new or updated recommendations for blood pressure management based on the latest scientific evidence to achieve the best health outcomes for patients.

The new guideline reflects several major changes since 2017, including use of the American Heart Association’s PREVENTTM (Predicting Risk of cardiovascular disease EVENTs) risk calculator to estimate cardiovascular disease risk. It also provides updated guidance on medication options, including the early treatment for high blood pressure to reduce the risk of cognitive decline and dementia; use of specific medications including the possible addition of newer therapies such as GLP-1 medications for some patients with high blood pressure and overweight or obesity, and recommendations for managing high blood pressure before, during and after pregnancy.

High blood pressure (including stage 1 or stage 2 hypertension) affects nearly half (46.7%) of all adults in the U.S., is the leading cause of death in the U.S. and around the world. The blood pressure criteria remain the same as the 2017 guideline:

  • normal blood pressure is less than 120/80 mm Hg;
  • elevated blood pressure is 120-129 mm Hg and <80 mm Hg;
  • stage 1 hypertension is 130-139 mm Hg or 80-89 mm Hg; and
  • stage 2 hypertension is ≥140 mm Hg or ≥90 mm Hg. 

“High blood pressure is the most common and most modifiable risk factor for heart disease,” said Chair of the guideline writing committee Daniel W. Jones, M.D., FAHA, dean and professor emeritus of the University of Mississippi School of Medicine in Jackson, Mississippi, and was a member of the writing committee for the 2017 high blood pressure guideline. “By addressing individual risks earlier and offering more tailored strategies across the lifespan, the 2025 guideline aims to aid clinicians in helping more people manage their blood pressure and reduce the toll of heart disease, kidney disease, Type 2 diabetes and dementia.”

“This updated guideline is designed to support health care professionals – from primary care teams to specialists, and to all clinicians across health systems – with the diagnosis and care of people with high blood pressure. It also empowers patients with practical tools that can support their individual health needs as they manage their blood pressure, whether through lifestyle changes, medications or both,” Jones said.

Importance of healthy lifestyle

The new guideline reaffirms the critical role healthy lifestyle behaviours play in preventing and managing high blood pressure, and it encourages health care professionals to work with patients to set realistic, achievable goals. Healthy behaviours such as those in Life’s Essential 8, the American Heart Association’s metrics for heart health, remain the first line of care for all adults.

Specific blood pressure-related guidance includes:

  • limiting sodium intake to less than 2,300 mg per day, moving toward an ideal limit of 1,500 mg per day by checking food labels (most adults in the U.S. get their sodium from eating packaged and restaurant foods, not the salt shaker);
  • ideally, consuming no alcohol or for those who choose to drink, consuming no more than two drinks per day for men and no more than one drink per day for women;
  • managing stress with exercise, as well as incorporating stress-reduction techniques like meditation, breathing control or yoga;
  • maintaining or achieving a healthy weight, with a goal of at least a 5% reduction in body weight in adults who have overweight or obesity;
  • following a heart healthy eating pattern, for example the DASH eating plan, which emphasizes reduced sodium intake and a diet high in vegetables, fruits, whole grains, legumes, nuts and seeds, and low-fat or nonfat dairy, and includes lean meats and poultry, fish and non-tropical oils;
  • increasing physical activity to at least 75-150 minutes each week including aerobic exercise (such as cardio) and/or resistance training (such as weight training); and
  • home blood pressure monitoring is recommended for patients to help confirm office diagnosis of high blood pressure and to monitor, track progress and tailor care as part of an integrated care plan.  

Addressing each of these lifestyle factors is especially important for people with high blood pressure and other major risk factors for cardiovascular disease because it may prevent, delay or treat elevated or high blood pressure.

New risk calculator and earlier intervention

The new guideline recommends that health care professionals use the PREVENTTM risk calculator to estimate a person’s risk of a heart attack, stroke or heart failure. Developed by the American Heart Association in 2023, PREVENTTM is a tool to estimate 10- and 30-year risk of cardiovascular disease in people ages 30-79 years. It includes variables such as age, sex, blood pressure, cholesterol levels and other health indicators, including zip code as a proxy for social drivers of health. It is the first risk calculator that combines measures of cardiovascular, kidney and metabolic health to estimate risk for cardiovascular disease. More precise risk estimates can help guide treatment decisions personalized for each individual.

In addition to the use of the PREVENTTM risk assessment tool, the new guideline recommends two important changes to laboratory testing for initial evaluation.

  • The ratio of urine albumin and creatinine (a test that assesses kidney health) is now recommended for all patients with high blood pressure. It was recommended as an optional test in the 2017 guideline.
  • The guideline also expands the indication for use of the plasma aldosterone-to-renin ratio test as a screening tool for primary aldosteronism in more patients including those with obstructive sleep apnea. (Primary aldosteronism is a condition that occurs when the adrenal glands make too much aldosterone, leading to high blood pressure and low potassium levels.)
  • Screening for primary aldosteronism may also be considered in adults with stage 2 hypertension to increase rates of detection, diagnosis and targeted treatment.

Association of high blood pressure with cognitive decline and dementia

While high blood pressure is a leading cause of heart attack and stroke, the new guideline highlights other serious risks. More recent research confirms that blood pressure affects brain health, including cognitive function and dementia. High blood pressure can damage small blood vessels in the brain, which is linked to memory problems and long-term cognitive decline. The guideline recommends early treatment for people diagnosed with high blood pressure with a goal of systolic blood pressure (top number) goal of <130 mm Hg for adults with high blood pressure to prevent cognitive impairment and dementia.

Tailored approaches to medication for high blood pressure

For many people with high blood pressure, especially those who have Type 2 diabetes, obesity or kidney disease, more than one medication may be needed to lower blood pressure to meet the <130/80 mm Hg criteria. The guideline highlights several types of blood pressure medications to initiate treatment, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), long-acting dihydropyridine calcium channel blockers and thiazide-type diuretics. If blood pressure remains high after one medication, clinicians may individualize treatment to either increase the dose or add a second medication from a different medication class.

The guideline maintains the recommendation to begin treatment with two medications at once – preferably in a single combination pill – for people with blood pressure levels 140/90 mm Hg or higher (stage 2 hypertension). The guideline also suggests possible addition of newer therapies such as GLP-1 medications for some patients with high blood pressure and overweight or obesity.

High blood pressure and pregnancy

High blood pressure during pregnancy can have lasting effects on the mother’s health, including an increased risk of future high blood pressure and cardiovascular conditions. Without treatment, high blood pressure during pregnancy can lead to serious complications, such as preeclampsia, eclampsia, stroke, kidney problems and/or premature delivery. Women with high blood pressure who are planning a pregnancy or are pregnant should be counselled about the potential benefits of low-dose aspirin (81 mg/day) to reduce the risk of preeclampsia.

For pregnant women with chronic hypertension (high blood pressure before pregnancy or diagnosed before 20 weeks of pregnancy), the new guideline recommends treatment with certain medications when systolic blood pressure reaches 140 mm Hg or higher and/or diastolic blood pressure reaches 90 mm Hg or higher. This change reflects growing evidence that tighter blood pressure control for some individuals during pregnancy may help to reduce the risk of serious complications.

In addition, postpartum care is especially important because high blood pressure can begin or persist after delivery. The guideline urges continued blood pressure monitoring and timely treatment during the postpartum period to help prevent complications. Patients with a history of pregnancy-associated high blood pressure are encouraged to have their blood pressure measured at least annually.

“It is important for people to be aware of the recommended blood pressure goals and understand how healthy lifestyle behaviours and appropriate medication use can help them achieve and maintain optimal blood pressure. Prevention, early detection and management of high blood pressure are critical to long-term heart and brain health, which means longer, healthier lives,” said Jones.

Source: American Heart Association

Categories : Environmental EffectsTags :

Solar Exposure Guidelines Could be Revised

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Photo by Amy Humphries on Unsplash

Previously published solar exposure guidelines for optimal vitamin D synthesis that were based on a study of skin samples may have to be revised. 

A study published in PNAS has tested the optimum ultraviolet radiation (UVR) wavelengths for human skin production of vitamin D in sunlight.

Though UVR from sunlight can cause sunburn and skin cancer, it is the most important source of vitamin D.

Public health advice on sunshine exposure balances its risk and benefit, which is not a simple task because the health outcomes from UVR exposure vary considerably with wavelength within the sun’s UVR spectrum. For example, the sun’s UVR contains less than 5% short wavelength UVB radiation but this is responsible for over 80% of the sunburn response. Each health outcome from solar exposure has its own unique wavelength dependency.

The link between specific UVB wavelengths and vitamin D production was determined more than thirty years ago in ex vivo skin samples. However, the finding is less well established, with doubts on its accuracy which compromise risk/benefit calculations for optimal solar exposure.

Researchers led by the Professor Antony Young from King’s College London measured blood vitamin D levels in 75 healthy young volunteers, before, during, and after partial or full body exposure to five different artificial UVR sources with different amounts of UVB radiation, to gauge the trade-off between solar exposure benefits, which include vitamin D synthesis, versus the risks of sunburn and skin cancer.

The results were compared against predictions from the old ex vivo vitamin D study, finding that it was not an accurate predictor of benefit from UVR exposure.

The authors’ recommendation is a systematic correction of the ex vivo wavelength dependency for vitamin D. The new study means that many risk benefit calculations for solar UVR exposure must be reviewed with a revised version of the wavelength dependency for vitamin D.

“Our study shows that risk versus benefit calculations from solar exposure may need to be re-evaluated. The results from the study are timely because the global technical committee, Commission internationale de l’éclairage, that sets UVR standards will be able to discuss the findings of this paper to re-evaluate the wavelength dependency of vitamin D. Further research from our group will determine the risk/benefit calculations.”

Professor Antony Young, King’s College London

Source: King’s College London

Categories : Cardiovascular DiseaseTags :

Cardiac Surgery Guidelines Updated with Emphasis on Patient Blood Management

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Photo by JAFAR AHMED on Unsplash

Newly updated multi-society cardiac surgery guidelines have shifted to a comprehensive blood management approach, with no longer simple recommendations on transfusion.

An update to the 2011 recommendations from the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists, now in collaboration with the American Society of ExtraCorporeal Technology, and the Society for the Advancement of Patient Blood Management (SABM), has been put out. It is available online in the Annals of Thoracic Surgery.

Since the last version, there has been so much new evidence that Pierre R. Tibi, MD, of Yavapai Regional Medical Center in Prescott, Arizona, and colleagues revised or added 23 recommendations and scrapped others.

Probably the biggest change is going from ‘blood conservation’ to the broader ‘patient blood management‘ (PBM) approach, Dr Tibi told MedPage Today.

“Basically we’re considering blood as another vital organ,” he said. “Why that is important is because now we look at a patient’s blood system as an organ that needs to be assessed and treated for the sake of that organ and not simply to decide when or when not to transfuse.”

Recommendations range from preoperative assessment of bleeding risk and anaemia to intraoperative perfusion and blood salvage practices to postoperative treatment with human albumin for volume replacement.

“Most hospitals around the U.S. are acutely aware of patient blood management and, to some degree or another, are implementing many of the things we are talking about,” noted Tibi, who is the most recent past president of SABM. Nationwide, the amount of blood transfused in cardiac surgery has dropped 45% in the past 10 to 15 years but still ranges widely across centres.

A broadly endorsed guideline like this emphasising the importance of a whole-patient strategy should hopefully standardize effective practices and move insurers to cover them, he suggested.

The guideline, for example, gives preoperative assessment of anaemia and its treatment with IV iron and erythropoietin-stimulating agents, if there is time, a class IIA endorsement. Anaemia is widespread, with possibly as many as 40% of patients having it, with one in 10 being under the 8 mg/dL haemoglobin threshold.

“There is a distinct correlation between preoperative anemia and worse clinical outcomes in most studies,” the guidelines note. “Usually, the greater the anemia, the more severe the complications.”

However, preoperative anaemia is “very, very underrecognised and undertested,” Dr Tibi said. While there isn’t always time to reverse anaemia that is found before cardiac surgery, he pointed out that “most of the factors in elective heart surgery have to do with insurance and Medicare. … Oftentimes the treatment for anaemia is not covered by various entities and is too expensive for patients to cover themselves.”

Other notable updates included a class IA recommendation for red blood cell salvage with centrifugation when patients are on cardiopulmonary bypass and the addition of recommendations for the assessment and treatment of patients on anticoagulants.

The guideline, for example, says to withdraw ticagrelor (Brilinta) at least 3 days, clopidogrel (Plavix) 5 days, and prasugrel (Effient) 7 days prior to elective cardiac surgery, while other non-vitamin K oral anticoagulants (NOACs) should be stopped at least 2 days in advance.

“Despite their advantages, NOACs present some periprocedural challenges for operations with a high-risk bleeding profile,” the document says. “Available measurement assays to assess anticoagulation for NOACs are imprecise, and the availability of reversal agents is limited.”

If point-of-care testing with thrombin clotting time is available for dabigatran (Pradaxa), or anti-factor Xa assays for apixaban (Eliquis) and rivaroxaban (Xarelto), in the case of emergent surgery, the guidelines recommend their use.

Source: MedPage Today

Journal information: Tibi P, et al “STS/SCA/AmSECT/SABM update to the clinical practice guidelines on patient blood management” Ann Thor Surg 2021; DOI: 10.1016/j.athoracsur.2021.03.033.