Potential Impact of 2017 American College of Cardiology/American Heart Association Hypertension Guideline on Contemporary Practice: A Cross-Sectional Analysis From NCDR PINNACLE Registry

Abstract

Background Clinical implications of change in the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the diagnosis and management of hypertension, compared with recommendations by 2014 expert panel and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), are not known. Methods and Results Using data from the NCDR (National Cardiovascular Data Registry) PINNACLE (Practice Innovation and Clinical Excellence) Registry (January 2013-Decemver 2016), we compared the proportion and clinical characteristics of patients seen in cardiology practices diagnosed with hypertension, recommended antihypertensive treatment, and achieving blood pressure (BP) goals per each guideline document. In addition, we evaluated the proportion of patients at the level of practices meeting BP targets defined by each guideline. Of 6 042 630 patients evaluated, 5 027 961 (83.2%) were diagnosed with hypertension per the 2017 ACC/AHA guideline, compared with 4 521 272 (74.8%) per the 2014 panel and 4 545 976 (75.2%) per JNC7. The largest increase in hypertension prevalence was seen in younger ages, women, and those with lower cardiovascular risk. Antihypertensive medication was recommended to 70.6% of patients per the ACC/AHA guideline compared with 61.8% and 65.9% per the 2014 panel and JNC7, respectively. Among those on antihypertensive agents, 41.2% achieved BP targets per the ACC/AHA guideline, compared with 79.4% per the 2014 panel and 64.3% per JNC7. Lower proportions of women, non-White (Black and "other") races, and those at higher cardiovascular risk achieved BP goals. Median practice-level proportion of patients meeting BP targets per the 2014 panel but not the ACC/AHA guideline was 37.8% (interquartile range, 34.8%-40.7%) and per JNC7 but not the ACC/AHA guideline was 22.9% (interquartile range, 19.8%-25.9%). Conclusions Following publication of the 2017 guideline, significantly more people, particularly younger people and those with lower cardiovascular risk, will be diagnosed with hypertension and need antihypertensive treatment compared with previous recommendations. Significant practice-level variation in BP control also exists. Efforts are needed to improve guideline-concordant hypertension management in an effort to improve outcomes.

Keywords: cardiovascular disease; guideline; hypertension; prevalence; prevention.

Figure 1. Flow diagram of PINNACLE (Practice Innovation and Clinical Excellence) Registry patients with hypertension.

ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; and JNC7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Figure 2. Proportion of patients enrolled in the PINNACLE (Practice Innovation and Clinical Excellence) Registry, seeking care in cardiology practices between January 2013 and December 2016 and meeting criteria for the definition of hypertension, recommendations for antihypertensive therapies, and targets for blood pressure based on American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, 2014 expert panel report, and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).

Compared with the 2014 expert panel report and JNC7, a higher proportion of patients are diagnosed with hypertension and meet recommendations for antihypertensive therapy. Moreover, as the blood pressure (BP) treatment goals set by the ACC/AHA guidelines are more intensive, a higher proportion of adults will not meet BP goals.

Figure 3. Proportion of patient enrolled in the PINNACLE (Practice Innovation and Clinical Excellence) Registry, between January 2013 and December 2016, meeting criteria for the definition of hypertension, recommendations for antihypertensive therapies, and targets for blood pressure based on the American Colleoge of Cardiology (ACC)/American Heart Association (AHA) guidelines, 2014 expert panel report, and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure (JNC7) across age categories (A), sex (B), race (C), ethnicity (D), 10 year atherosclerotic cardiovascular disease (ASCVD) risk categories (E), and presence of CVD (F).

CVD indicates cardiovascular disease.

Figure 4. Differences in the proportion of patients meeting blood pressure (BP) targets as per 2014 expert panel report but not as per American College of Cardiology (ACC)/American Heart Association (AHA) guideline across participating practices in the PINNACLE (Practice Innovation and Clinical Excellence) Registry.

The x axis shows random practice identifier; the y axis shows difference in the proportion of patients meeting BP target per 2014 expert panel report but not ACC/AHA guidelines. IQR indicates interquartile range; JNC8, Eighth Joint National Committee; Max, maximum; Min, minimum; Q1, quartile 1; and Q3, quartile 3.

Figure 5. Difference in the proportion of patients meeting blood pressure (BP) targets as per Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) but not as per American College of Cardiology (ACC)/American Heart Association (AHA) guideline across participating practices in the PINNACLE (Practice Innovation and Clinical Excellence) Registry.

The x axis shows random practice identifier; the y axis shows difference in the proportion of patients meeting BP target per JNC7 but not ACC/AHA guidelines. IQR indicates interquartile range; Max, maximum; Min, minimum; Q1, quartile 1; Q3, quartile 3.