Over the past year and a half, leading cardiovascular disease researchers and clinicians serving on national panels have presented their findings on healthcare guidelines. The summary below, derived from the published reports of these groups, includes the updated recommendations and guidelines for the treatment of high blood pressure, cholesterol, and stroke.
High Blood Pressure
On May 14, 2003, the 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure was released by the National High Blood Pressure Education Program Coordinating Committee. This group represents a coalition of 39 major professional, public and voluntary organizations and seven federal agencies, including the National Institutes of Health. The revised guidelines in this report focus on early and aggressive treatment and outline the following basic strategies:
- Pay attention to blood pressure before it’s high.
The committee established a new classification of prehypertension: blood pressure readings between 120-139 mm Hg systolic or 80-89 mm Hg diastolic. The joint committee found “The evidence is now clear that those in the prehypertension range are at higher risk than those with lower blood pressures and are much more likely to move into the hypertension range where medication is required.”
The establishment of the new classification should serve to address the misleading nature of terms such as ‘high normal’ and ‘borderline’ and assist both clinicians and patients in identifying individual risk factors.
- In people over age 50, systolic pressure is more important than diastolic.
The guidelines state that systolic pressure of 140 mm Hg or greater in that age group should be treated regardless of the diastolic blood pressure level. Attention to this factor is considered significant in the short term and even more important as the person ages.
- Two (or more) drugs are better than one for most patients.
The committee stated that most hypertensive patients will require two or more antihypertensive medications to achieve goal blood pressure. The report notes that "Patients and physicians need to begin the drug treatment process with an open mind to using as much medication as necessary to achieve goal blood pressure".
As noted in previous reports, the use of a diuretic is recommended either singly or in combination with another drug class, as part of a treatment plan for most patients. The guidelines also include other drug classes that have been shown to be effective in reducing the complications of hypertension, and that might be considered for initial treatment:
- Angiotensin converting enzyme (ACE) inhibitors
- Angiotensin receptor blockers
- Calcium channel blockers
- Build trusting clinician/patient relationships that motivate patients to be healthy.
According to the report, a patient-centered strategy to achieve a treatment goal and an estimated time for reaching that goal are important. The report reiterates previous recommendations regarding limiting sodium intake, stopping smoking, losing excess weight, limiting consumption of alcohol, becoming physically active, and eating a heart healthy eating plan.
As in the Committee’s previous report in 1997, Americans are encouraged to follow the DASH (Dietary Approaches to Stop Hypertension) eating plan. This plan is rich in vegetables, fruit, and nonfat dairy products and clinical studies have established its usefulness in significantly lowering blood pressure. To learn more about the DASH Eating Plan, go to: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
To review the full Committee report, go to: http://hyper.ahajournals.org/cgi/content/full/41/6/1178
On July 13, 2004, with endorsements from the National Heart, Lung, and Blood Institute, the American College of Cardiology, and the American Heart Association, updated recommendations for cholesterol treatment were released by the National Cholesterol Education Program. The report, Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines, refined earlier findings and guidelines issued in 2001. The panel reviewed the findings of several key studies in cholesterol treatment and issued primary recommendations for persons identified as being at moderately high, high, and very high risk for cardiovascular disease.
- 'Very High Risk' is used to describe people who already have cardiovascular disease plus diabetes, persistent cigarette smoking, poorly controlled hypertension, or multiple risk factors of metabolic syndrome (high triglycerides, low level of HDL cholesterol, obesity), and immediately after a heart attack. For people considered to be in the Very High Risk category, the reviewing panel recommends an LDL goal of less than 70 mg/dL be set as a therapeutic option.
- 'High Risk' is identified in this report for people who have already had a heart attack or have other risk factors, and are considered to have more than a 20 percent estimated risk of heart attack or cardiac death within 10 years. This includes people with cardiac chest pain (angina), previous angioplasty or bypass surgery, obstructed blood vessels to the extremities or brain, or diabetes. The updated recommendations set forth in this report call for drug therapy in almost all patients considered at High Risk with LDL cholesterol measured at 100 mg/dL or higher. Previous guidelines had set 130 mg/dL as the recommended intervention point.
- 'Moderately High Risk' refers to people who have multiple risk factors and are estimated to have a 10 to 20 percent chance of heart attack or cardiac death within 10 years. The revised guidelines target treatment needs if a person’s LDL cholesterol levels are 130 mg/dL or higher and include optional considerations of drug therapy for people whose LDL level is between 100 and 129 mg/dL. Whether a person is considered to be at a moderately high or high risk, recommendations for drug therapy target a reduction of 30 to 40 percent in LDL cholesterol.
In addition to the recommendations noted above, the panel cited data from recent studies that supported the contention that it is never too late for older people to benefit from therapeutic intervention to lower their cholesterol levels.
To view the panel’s report in its entirety, go to: http://circ.ahajournals.org/cgi/content/full/110/2/227
Urgent care guidelines were targeted by the American Stroke Association when issuing Guidelines for the Early Management of Patients with Ischemic Stroke on April 4, 2003. The use of the clot-busting drug tPA (tissue plasminogen activator), the only U.S. Food and Drug Administration-approved treatment for ischemic stroke, was highlighted in the report. In addition, the association’s review panel set forth recommendations regarding the management of emergency medical and treatment services for people who have strokes. The public’s awareness of stroke symptoms and the critical need for fast action in seeking medical attention were duly noted.
The panel issuing the report noted the following:
- Because time is extremely crucial in acute stroke care (tPA is only effective if administered within 3 hours of the event), institutions should have diagnostic equipment and staff available 24/7 or consider transferring patients to facilities that are better equipped to deal with their immediate needs.
- Specialized services should be available to patients with strokes in comprehensive treatment facilities, rehabilitation settings, and other treatment centers.
- No other clot-busting agent has been established as a safe and effective alternative to tPA. Intra-arterial thrombolytic therapy (catheter-based treatment delivering a clot-dissolving drug to the target location of the brain blockage up to six hours after the onset of symptoms) was acknowledged by the panel as holding some promise, yet its effectiveness has not yet been established.
- Anticoagulants, e.g. heparin, were not indicated for use with most patients experiencing ischemic stroke. Earlier guidelines noted that there was insufficient data to make recommendations regarding anticoagulant use. In the current report, the panel notes that several trials testing the potential use of these drugs were conducted, yet none resulted in positive results.
- No medication with neuroprotective effects had been shown to be useful in treating patients having ischemic strokes.
- Aspirin may be administered within 48 hours of the onset of a stroke for most patients, but not within 24 hours of treatment with tPA. Aspirin was considered to have a modest benefit, yet should not be used as an alternative treatment to tPA for patients with acute illness.
- Prevention of additional strokes was regarded as very important, as was the role of rehabilitation plans in acute care.
To view the panel’s full report, go to: http://stroke.ahajournals.org/cgi/content/full/34/4/1056
The American Stroke Association has partnered with the National Institute of Neurological Disorders and Stroke and the American Academy of Neurology to offer training and testing on the NIH’s Stroke Scale for acute stroke assessment. Participants can access this no-cost program online and earn continuing education credits. The program is targeted primarily for emergency room physicians, neurologists, medical students, and nurses.
After completing the course, it is intended that participants will have the capacity to:
- identify and assess neurologic deficits in stroke patients.
- understand the measurement scale for quantifying neurologic deficits in stroke patients.
- consistently apply appropriate scores for neurologic deficits in stroke patients.
- use the scale to assess changes in neurologic deficits in stroke patients over time.
For more information, go to: http://asa.trainingcampus.net/uas/modules/trees/index.aspx