• Clinical Practice Guidelines
    APR 09, 2014

    When Guidelines Raise Blood Pressure

    PTNow Staff

    What's a clinician to do when blood pressure management guidelines set forth by 3 authoritative medical entities differ in some key areas—and when all of them inadequately address lifestyle interventions such as physical activity? It's a controversy that has launched, if not a thousand editorials and blog posts, certainly a spate of them. Trying to make sense of it all and to discern the "news PTs can use" might cause the very hypertension the guidelines are designed to mitigate.

    Since the beginning of 2013, the Eighth Joint Committee of the American College of Cardiology and American Heart Association (JNC8), a combined task force of the European Society of Hypertension and the European Society of Cardiology (ESH/ESC), and a joint effort of the American Society of Hypertension and the International Society of Hypertension (ASH/ISH) each has issued its own set of guidelines.

    All 3 sets of guidelines strongly advocate for drug therapy, though they differ somewhat on how aggressively to use pharmacologic approaches and on the types of drugs most appropriate for certain populations. The guidelines also differ in their recommendations for target systolic blood pressure (BP) and reached those figures by different means, adhering strictly to evidence or relying more on expert consensus. (Of note, because none of these 3 guideline documents fit PTNow's stringent criteria, also used by the National Guideline Clearinghouse, they will not be included in its Guidelines database.)

    Looking at the bigger picture, Cardiovascular and Pulmonary Section President Daniel Malone, PT, PhD, CCS, says that physical therapists "need to understand the complexity of creating clinical practice guidelines where evidence may be lacking or is not 100% convincing. When I look at JNC8, for example, there is a difference of opinion on the final systolic blood pressure recommendation—the evidence wasn't great enough to fully support 1 position."

    However, and of particular interest to PTs, the guidelines address lifestyle interventions only vaguely (ESH/ESC and JNC8) or fleetingly (ASH/ISH). The developers cite lack of evidence of efficacy as the reason for not covering lifestyle interventions more thoroughly.

    How useful, then, are these documents to PTs, and what is the profession to cull from them?

    Referring specifically to JNC8, but applicable to all 3 sets of guidelines, Malone asks the following questions about the paucity of explicit recommendations for activity/diet/lifestyle modifications:

    1. Did the guideline panel include a representative who is well-versed in lifestyle modification or cardiac rehabilitation?
    2. How can APTA and individual PTs ensure we are invited to the table and directly participate in the discussions? Do we have something valuable to add?
    3. Is there indeed a lack of evidence for activity/diet/lifestyle modification?

    Even if there is no evidence—or no strong evidence, as Dianne V. Jewell, PT, DPT, PhD, CCS, FAACVPR, says—to support physical activity and exercise interventions to directly and dramatically reduce hypertension, physical activity and exercise have been shown to have numerous cardiovascular and pulmonary benefits.

    Will the absence of strong evidence stimulate clinical research and interprofessional investigation regarding the efficacy of physical activity/exercise, along with lifestyle and dietary changes, on cardiovascular health?