Hypertension and Lipid Level Treatment Guidelines

High blood pressure, hypertension, and lipid level disorders, such as high cholesterol, are two of the most commonly treated diseases, with tens of millions of Americans using prescription medications to control these chronic conditions.  Numerous groups have issued guidelines, based on various clinical trials and the interpretation of the results of those trials, designed to help physicians identify who should be treated and how.  But studies and a commentary in the current Journal of the American Medical Association suggest the evidence may be more ambiguous than the guidelines would indicate.    (JAMA Issue)   In the last six months, prominent groups that promulgate guidelines in these areas issued new recommendations, which refined and in some cases lessened the number of people who should be treated.  Not everyone was thrilled; some questioned the underlying methods of measuring disease severity; some the insistence on strong evidence before recommending that certain blood pressure or lipid levels be treated.  Practicing physicians are probably left at least a little confused.  For cardiovascular disease related to high lipid levels, physicians are supposed to calculate a risk score and use that to guide treatment decisions.  But two studies in the Journal came to different conclusions about the accuracy of the risk calculation method and whether it appropriately identified those who should be treated or over-identified them.  Not exactly outcomes that give a high level of confidence in the new guidelines.

For hypertension, the primary issue is that the new guideline would remove a number of patients from the need to be treated, largely because there is insufficient evidence that treatment for this lower-risk group would significantly improve meaningful outcomes.  But as a Commentary in the issue points out, what may be good about both these controversies is that it reinforces the need to make individualized judgments about each patient and that guidelines are only one factor in a treatment decision.  Human biology and disease processes are perhaps too complex and too idiosyncratic to be amenable to universal treatment by guideline.  And the implications for the current fad of pay-for-performance, usually based on guideline compliance, and value-based purchasing, may need to be pulled back some and replaced with more flexible approaches to measuring quality.  What really matters is the patient’s health and health improvement.