The Journal of Family Practice

For more than a century, clinicians have pondered the significance of elevated blood pressure (BP) and its contribution to cardiovascular disease (CVD). While it is widely understood that high BP increases CVD events, and that treatment lowers that risk, the most appropriate BP goal continues to be a subject of debate.

This article briefly summarizes the evidence to support lower BP goals for patients with hypertension who are commonly seen in family practice, including those needing primary prevention, as well as those with, or at high risk for, atherosclerotic cardiovascular disease (ASCVD), patients with diabetes, and those with chronic kidney disease (CKD). Detailed information regarding specific lifestyle and medication treatment recommendations and thresholds for drug therapy is beyond the scope of this review.

A brief history: ACC/AHA guidelines vs JNC 7 and 8

The most recent comprehensive, evidence-based guideline on the prevention, detection, evaluation, and management of high BP in adults was released in late 2017 by the American College of Cardiology (ACC) and the American Heart Association (AHA).¹ It was the first comprehensive BP guideline since the Seventh Report of the Joint National Committee (JNC 7) in 2003.² The new guideline includes several changes, notably in how BP is classified, the threshold for initiation of antihypertensive drug therapy, and target BP.

While widely viewed as positive, the changes in classification, thresholds, and targets for BP therapy have generated controversy and disagreement. Common reasons cited include concern about the data supporting lower thresholds for treatment, the applicability of trial findings to broad patient populations, and the risk of harm with lower BP goals.³ The American Academy of Family Physicians (AAFP) declined to endorse the ACC/AHA guidelines and continues to support the 2014 report by the panel members appointed to the Eighth Joint National Committee (JNC 8) by the National Heart Lung and Blood Institute (NHLBI).⁴ A primary reason cited for the lack of support for the 2017 guideline is that the majority of recommendations made in the ACC/AHA guideline were not “based on a systematic evidence review.”⁴ However, there are significant differences in purpose, structure, and scope between the ACC/AHA and JNC 8.

Evidence supports lower BP goals for a number of different patient populations and groups.

In 2013, the NHLBI announced that it would cease involvement in creating guidelines and transferred responsibility for development to professional organizations.⁵ Of the 5 guidelines that were in the process of creation (cholesterol, lifestyle intervention, obesity, risk assessment, and high BP), all but the high BP guideline were transferred to the ACC/AHA for completion. The panel members appointed to the JNC 8 elected to publish their recommendations independently and focused only on 3 “critical questions” related to hypertension therapy (eg, therapy initiation, BP goals, and choice of initial agent).⁶

[polldaddy:10041785]

The JNC 8 report generated significant controversy with the recommendation to relax the BP goal for patients ≥60 years of age to <150/90 mm Hg. Members of the JNC 8 panel who disagreed with this goal published a "minority view" citing concerns about the negative impact the goal would have on CVD and public health, and the "insufficient and inconsistent" evidence supporting relaxed goals.⁷ The dissenting group cited additional drawbacks of the recommendation, noting that it was highly focused, included data only from randomized controlled trials (RCTs; no meta-analyses or observational data), and did not address or provide guidance on numerous other issues of importance in the care of hypertension.

While the 2017 ACC/AHA guideline also includes formal systematic evidence reviews on major critical questions (ie, optimal BP targets, preferred antihypertensives, the role of home and ambulatory BP monitoring),⁸ it was designed to be comprehensive and useful for clinicians, providing 106 graded recommendations on commonly encountered questions. It would have been unrealistic to do a formal systematic evidence review and meta-analysis on all clinically relevant questions seen in practice. However, available systematic reviews, meta-analyses, and observational data were scrutinized and used to support the recommendations wherever possible.

Continue to: Say "goodbye" to prehypertension; say "hello" to elevated BP

Say “goodbye” to prehypertension; say “hello” to elevated BP

The 2017 ACC/AHA guideline changed the BP classification for adults (TABLE 1^1,2). While “normal” remained respectively.¹ Removal of the “prehypertension” category and use of the term “elevated” instead was meant to better convey the importance of lifestyle interventions to forestall the development of hypertension.

Don’t underestimate the power of BP measurement technique

The importance of appropriate BP measurement technique to confirm a hypertension diagnosis and assist with medication titration is emphasized in the ACC/AHA guidelines.

The importance of appropriate BP measurement technique to confirm the diagnosis of hypertension and assist with medication titration was also emphasized.¹ BP measurement technique in usual clinical practice is frequently suboptimal, most commonly resulting in falsely elevated readings.^9,10 The guideline recommends the use of out-of-office measurements to confirm elevated clinic readings, screen for white-coat and masked hypertension, and assist in medication adjustment decisions. It is critically important that appropriate BP measurement technique is used, which in many cases, will avoid inappropriate treatment. (See “Getting the hypertension Dx right: Patient positioning matters,” JFP. 2018;67:199-207.)

A look at the evidence supporting lower BP goals

The 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for adults with hypertension commonly seen in clinical practice, including those with CVD or an elevated ASCVD risk (10-year risk ≥10% using the Pooled Cohort Equations¹¹), those with hypertension and low ASCVD risk (10-year risk <10%), and those with hypertension who have concomitant diabetes or CKD.¹ The guideline also recommends an SBP goal <130 mm Hg for independently-living, ambulatory older adults (≥65 years) with hypertension.¹ TABLE 2^1,2,6 compares the BP goals in the new 2017 ACC/AHA guidelines to previous recommendations.

SPRINT. Significant new literature has been generated since the publication of JNC 8 that supports these lower BP goals, particularly in patients with CVD or who are at high ASCVD risk.^8,12-15 For example, the Systolic Blood Pressure Intervention Trial (SPRINT) was the largest RCT to assess whether lower BP goals decrease the risk of adverse CVD outcomes.¹⁶ In SPRINT, 9361 patients with an SBP ≥130 mm Hg and an increased risk of CVD, but without diabetes or a history of stroke, were randomized to intensive BP treatment (SBP goal <120 mm Hg) or standard treatment (SBP goal <140 mm Hg). After a median follow-up of 3.26 years, the study was stopped early due to a decreased risk in the primary composite outcome of myocardial infarction (MI), other acute coronary syndromes (ACS), stroke, heart failure, or death from CV causes (number needed to treat [NNT] to prevent one event=61).

Intensive treatment was also associated with a lower risk of all-cause mortality (NNT=90), heart failure (NNT=123), death from CV causes (NNT=172), and the primary outcome or death (NNT=52). While hypotension was higher in the intensive treatment group (number needed to harm [NNH]=106), as was syncope (NNH=173), electrolyte abnormalities (NNH=126), and acute kidney injury or failure (NNH=61), the authors noted that the benefits of lower BP outweighed the risks. Also, there was no increased risk of injurious falls. Therefore, despite the risk of adverse events, SPRINT demonstrated that lower BP goals significantly reduce the risk of adverse CV outcomes.

Continue to: Meta-analyses that have been conducted since SPRINT...

Meta-analyses that have been conducted since SPRINT, and that have incorporated SPRINT data, also support lower BP goals. In the systematic review performed for the 2017 ACC/AHA guideline, an SBP <130 mm Hg compared to a higher BP target was associated with a reduced risk of major CV events, stroke, MI, and heart failure, although not all-cause mortality.⁸ These findings were largely consistent with other recent meta-analyses.^12-15 For example, Bundy et al¹⁵ reported significant CV benefit with more vs less intensive BP lowering, whether or not the data from SPRINT were included, with the greatest reduction in risk seen in the groups with highest baseline BP.

It is important to consider a patient’s baseline level of risk when evaluating the absolute benefit of lower BP targets on CV outcomes. For patients with higher CV risk, the absolute benefit of treatment is greater.^12-14 These findings support the 2017 ACC/AHA guideline, which recommends initiating drug therapy, in addition to lifestyle modification, in adults with hypertension and high ASCVD risk when the average BP is >130/80 mm Hg, with a goal of <130/80 mm Hg. TABLE 3^12-15,17-22 summarizes recent systematic reviews and meta-analyses conducted since the publication of JNC 8 that assess the association between intensity of BP lowering and adverse CV and related outcomes.

Treating patients with low CV risk

The evidence supporting a lower BP goal in patients with low CV risk is less than for patients at elevated risk. There are no large RCTs for this group that have assessed whether an intensive BP lowering strategy decreases CV outcomes more than a standard BP strategy (eg, <140/90 mm Hg). It is likely that absolute benefit is much smaller than for patients with, or at high risk for, ASCVD. 

However, epidemiologic observational studies have indicated a significant log-linear increase in CV mortality starting at an SBP of 115 mm Hg.²³ A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.²³ Decades worth of exposure to “elevated” BP levels would likely result in significant vascular damage, and attenuation of this process would likely be beneficial.^24,25 An RCT specifically designed to test this hypothesis, however, would not be pragmatic considering the substantial number of patient-years that would be required.

Due to insufficient data documenting the value of antihypertensive drug therapy for primary prevention in adults with “elevated” BP and stage 1 hypertension at low risk for CVD, the 2017 ACC/AHA guideline recommends that drug therapy be initiated for all adults only when their BP average is ≥140/90 mm Hg.¹ In contrast, for patients needing secondary prevention and for those with elevated CVD risk, the guideline recommends medication in addition to lifestyle modifications once the average BP is ≥130/80 mm Hg. The recommendation to withhold drug therapy until the BP is ≥140/90 mm Hg in patients needing primary prevention is supported by a new meta-analysis of 74 trials with 306,273 participants that aimed to assess the association between BP-lowering treatment and death and CVD at various BP levels.¹⁷ In this analysis, pharmacologic treatment was associated with a reduced risk of all-cause mortality, major CVD events, and coronary heart disease if the SBP was ≥140 mm Hg.

Continue to: Treating older patients

Significant controversy has existed regarding the optimal BP goal in older patients, particularly once the JNC 8 recommended relaxing the SBP goal to <150 mm Hg for pateints ≥60 years of age.^6,7 This recommendation was consistent with the guideline from the American College of Physicians (ACP)/AAFP,²⁶ which also recommended a lower SBP of <140 mm Hg in patients with a history of stroke or transient ischemic attack and those at high CV risk.²⁶

A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.

Evidence is available, however, supporting more intensive BP goals in older independently-living ambulatory adults. A pre-planned subgroup analysis was conducted in 2636 SPRINT participants ≥75 years of age.²⁷ Similar to the overall experience in SPRINT, lower SBP goals were associated with significant reductions in CV events, including the composite CVD primary outcome (NNT=27), heart failure (NNT=63), nonfatal heart failure (NNT=66), and all-cause mortality (NNT=41). In addition, the relative benefits were approximately equal whether the patients were the most fit, non-fit, or frail, with the absolute benefit being greatest in those who were frail (recognizing that the SPRINT participants were independently-living ambulatory adults). While the absolute rate of serious adverse events was higher in the more intensive BP goal group, there was no statistically significant difference in the incidence of hypotension, orthostatic hypotension, syncope, electrolyte abnormalities, or acute kidney injury or renal failure.

Use of lower BP goals than recommended by JNC 8 was also supported by another recent meta-analysis that compared the outcomes of intensive BP lowering (SBP <140 mm Hg) to a standard BP-lowering strategy (SBP <150 mm Hg).¹⁸ Using a random-effects model, more intensive BP lowering was associated with a significant reduction in major adverse CV events (29%), CV mortality (33%), and heart failure (37%), with no increase in serious adverse events or renal failure. Findings with the fixed-effects model used to confirm results were largely consistent, with the exception of a possible increase in renal failure.

Although the evidence supporting lower BP goals in older, ambulatory, noninstitutionalized patients is sound, it is important to consider a patient’s overall disease burden. For older adults with multiple comorbidities and limited life expectancy, as well as those who are nonambulatory or institutionalized, decisions on the intensity of BP lowering should be made using a team-based approach, weighing the risks and benefits.¹

Continue to: Treating patients with diabetes

Treating patients with diabetes

The most appropriate BP goal for patients with diabetes has been the subject of much debate, with different goals recommended in different guidelines (TABLE 2^1,2,6). The most recent American Diabetes Association guideline recommends a BP goal <140/90 mm Hg for most patients, with lower targets (<130/80 mm Hg) for patients at high CV risk if it is achievable without undue treatment burden,²⁸ whereas the 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for all adults with diabetes.¹

The ACCORD trial. There is limited evidence to suggest which BP goal is most appropriate for patients with diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is the only RCT specifically designed to assess the impact of intensive vs standard BP goals in patients with diabetes.²⁹ In ACCORD, 4733 patients with type 2 diabetes were randomized to either an intensive BP-lowering group (SBP <120 mm Hg) or a standard BP-lowering group (SBP <140 mm Hg). After a mean follow-up of 4.7 years, there was no difference in the primary composite endpoint of nonfatal MI, nonfatal stroke, or death from CV causes. However, the risk of stroke was reduced (NNT=89). Interpretation of ACCORD is limited due to its factorial design and because the trial was significantly underpowered.

Systematic reviews and meta-analyses. Literature supporting lower BP goals in patients with diabetes primarily comes from systematic reviews and meta-analyses.³⁰ In the evidence-based review performed for the 2017 ACC/AHA guidelines, more intensive treatment was associated with a decrease in fatal or nonfatal stroke.⁸ The results from the ACCORD trial and SPRINT are consistent,³¹ and a sub-study of SPRINT patients with pre-diabetes showed preservation of CV benefit.³² Also, a meta-analysis of subgroups of trial participants with diabetes showed that more intensive BP lowering in patients is associated with a decrease in major CV events.¹⁴

Treating patients with chronic kidney disease

As with diabetes and older patients, recommended goals for patients with CKD have varied (TABLE 2^1,2,6). The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guideline recommended the same target BP as JNC 7 and the 2017 ACC/AHA guideline: ≤130/80 mm Hg in patients with CKD and urine albumin excretion ≥30 mg/24 hours (or equivalent).^1,2,33 KDIGO recommended a more relaxed target (≤140/90 mm Hg), however, for patients with CKD and urine albumin excretion <30 mg/24 hours.^1,33

Scant data exist from RCTs designed to assess the CV effects of intensive BP targets in patients with CKD. In SPRINT, where 28% of patients had stage 3 or 4 CKD, benefits of more intensive therapy were similar to those observed in the overall cohort.^16,34 While some RCTs have assessed the effect of more intensive BP lowering on progression of CKD, they were not specifically designed or powered to address CV outcomes.^35,36

Continue to: In recent meta-analyses assessing the effects...

In recent meta-analyses assessing the effects of intensive BP lowering on renal and CV events in patients with CKD, a lower BP strategy was not associated with a decrease in CV events.^8,14,19 However, more intensive therapy was associated with a 17% reduced risk of composite kidney failure events and an 18% reduction in end-stage kidney disease.¹⁹ The risk of kidney failure with lower BP goals was 27% lower in patients with baseline proteinuria, but was not significant in patients who did not have proteinuria.¹⁹

Evidence supports lower BP goals, but guidelines should guide

The lower BP goals advised in the 2017 ACC/AHA guideline are supported by substantial new high-quality evidence that was not available at the time of the JNC 8 report.¹ The strongest evidence for lower goals is found in patients with, or at high risk for, CVD, but other patients commonly seen by primary care providers, including those at lower CVD risk, older patients, and those with diabetes or CKD are also likely to benefit.¹

Despite the debates, it is important to remember that guidelines are intended to “guide.” As stated in the guideline, “Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.”¹ They should be easy to understand and apply, and a consistent, evidence-based BP goal of <130/80 mm Hg for most patients facilitates implementation.

Although more of the US population is categorized as hypertensive under the new guideline, only 1.9% more require drug therapy.

Although more of the US population is categorized as hypertensive under the new guideline (46% now vs 32% before), only 1.9% more require drug therapy, as the vast majority of the newly classified hypertensives are primary prevention patients for whom only lifestyle modification is recommended.³⁷ However, to attain these goals, greater emphasis will be needed on utilizing team-based care, health information technology including electronic medical records and telehealth, performance measures, quality improvement strategies, and financial incentives.¹

Finally, as emphasized in the guidelines, BP monitoring technique matters. Clinicians should not accept flawed BP measurement techniques any more than they would accept flawed results from studies performed incorrectly.

CORRESPONDENCE
Eric J. MacLaughlin, PharmD, BCPS, FASHP, FCCP, Texas Tech University Health Sciences Center,1300 S. Coulter Dr., Amarillo, TX 79106; [email protected].

ACKNOWLEDGEMENTS

The authors thank Paul K. Whelton, MB, MD, MSc, FAHA, and Robert M. Carey, MD, FAHA, for their review of this manuscript. 

For more than a century, clinicians have pondered the significance of elevated blood pressure (BP) and its contribution to cardiovascular disease (CVD). While it is widely understood that high BP increases CVD events, and that treatment lowers that risk, the most appropriate BP goal continues to be a subject of debate.

This article briefly summarizes the evidence to support lower BP goals for patients with hypertension who are commonly seen in family practice, including those needing primary prevention, as well as those with, or at high risk for, atherosclerotic cardiovascular disease (ASCVD), patients with diabetes, and those with chronic kidney disease (CKD). Detailed information regarding specific lifestyle and medication treatment recommendations and thresholds for drug therapy is beyond the scope of this review.

A brief history: ACC/AHA guidelines vs JNC 7 and 8

The most recent comprehensive, evidence-based guideline on the prevention, detection, evaluation, and management of high BP in adults was released in late 2017 by the American College of Cardiology (ACC) and the American Heart Association (AHA).¹ It was the first comprehensive BP guideline since the Seventh Report of the Joint National Committee (JNC 7) in 2003.² The new guideline includes several changes, notably in how BP is classified, the threshold for initiation of antihypertensive drug therapy, and target BP.

While widely viewed as positive, the changes in classification, thresholds, and targets for BP therapy have generated controversy and disagreement. Common reasons cited include concern about the data supporting lower thresholds for treatment, the applicability of trial findings to broad patient populations, and the risk of harm with lower BP goals.³ The American Academy of Family Physicians (AAFP) declined to endorse the ACC/AHA guidelines and continues to support the 2014 report by the panel members appointed to the Eighth Joint National Committee (JNC 8) by the National Heart Lung and Blood Institute (NHLBI).⁴ A primary reason cited for the lack of support for the 2017 guideline is that the majority of recommendations made in the ACC/AHA guideline were not “based on a systematic evidence review.”⁴ However, there are significant differences in purpose, structure, and scope between the ACC/AHA and JNC 8.

Evidence supports lower BP goals for a number of different patient populations and groups.

In 2013, the NHLBI announced that it would cease involvement in creating guidelines and transferred responsibility for development to professional organizations.⁵ Of the 5 guidelines that were in the process of creation (cholesterol, lifestyle intervention, obesity, risk assessment, and high BP), all but the high BP guideline were transferred to the ACC/AHA for completion. The panel members appointed to the JNC 8 elected to publish their recommendations independently and focused only on 3 “critical questions” related to hypertension therapy (eg, therapy initiation, BP goals, and choice of initial agent).⁶

[polldaddy:10041785]

The JNC 8 report generated significant controversy with the recommendation to relax the BP goal for patients ≥60 years of age to <150/90 mm Hg. Members of the JNC 8 panel who disagreed with this goal published a "minority view" citing concerns about the negative impact the goal would have on CVD and public health, and the "insufficient and inconsistent" evidence supporting relaxed goals.⁷ The dissenting group cited additional drawbacks of the recommendation, noting that it was highly focused, included data only from randomized controlled trials (RCTs; no meta-analyses or observational data), and did not address or provide guidance on numerous other issues of importance in the care of hypertension.

While the 2017 ACC/AHA guideline also includes formal systematic evidence reviews on major critical questions (ie, optimal BP targets, preferred antihypertensives, the role of home and ambulatory BP monitoring),⁸ it was designed to be comprehensive and useful for clinicians, providing 106 graded recommendations on commonly encountered questions. It would have been unrealistic to do a formal systematic evidence review and meta-analysis on all clinically relevant questions seen in practice. However, available systematic reviews, meta-analyses, and observational data were scrutinized and used to support the recommendations wherever possible.

Continue to: Say "goodbye" to prehypertension; say "hello" to elevated BP

Say “goodbye” to prehypertension; say “hello” to elevated BP

The 2017 ACC/AHA guideline changed the BP classification for adults (TABLE 1^1,2). While “normal” remained respectively.¹ Removal of the “prehypertension” category and use of the term “elevated” instead was meant to better convey the importance of lifestyle interventions to forestall the development of hypertension.

Don’t underestimate the power of BP measurement technique

The importance of appropriate BP measurement technique to confirm a hypertension diagnosis and assist with medication titration is emphasized in the ACC/AHA guidelines.

The importance of appropriate BP measurement technique to confirm the diagnosis of hypertension and assist with medication titration was also emphasized.¹ BP measurement technique in usual clinical practice is frequently suboptimal, most commonly resulting in falsely elevated readings.^9,10 The guideline recommends the use of out-of-office measurements to confirm elevated clinic readings, screen for white-coat and masked hypertension, and assist in medication adjustment decisions. It is critically important that appropriate BP measurement technique is used, which in many cases, will avoid inappropriate treatment. (See “Getting the hypertension Dx right: Patient positioning matters,” JFP. 2018;67:199-207.)

A look at the evidence supporting lower BP goals

The 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for adults with hypertension commonly seen in clinical practice, including those with CVD or an elevated ASCVD risk (10-year risk ≥10% using the Pooled Cohort Equations¹¹), those with hypertension and low ASCVD risk (10-year risk <10%), and those with hypertension who have concomitant diabetes or CKD.¹ The guideline also recommends an SBP goal <130 mm Hg for independently-living, ambulatory older adults (≥65 years) with hypertension.¹ TABLE 2^1,2,6 compares the BP goals in the new 2017 ACC/AHA guidelines to previous recommendations.

SPRINT. Significant new literature has been generated since the publication of JNC 8 that supports these lower BP goals, particularly in patients with CVD or who are at high ASCVD risk.^8,12-15 For example, the Systolic Blood Pressure Intervention Trial (SPRINT) was the largest RCT to assess whether lower BP goals decrease the risk of adverse CVD outcomes.¹⁶ In SPRINT, 9361 patients with an SBP ≥130 mm Hg and an increased risk of CVD, but without diabetes or a history of stroke, were randomized to intensive BP treatment (SBP goal <120 mm Hg) or standard treatment (SBP goal <140 mm Hg). After a median follow-up of 3.26 years, the study was stopped early due to a decreased risk in the primary composite outcome of myocardial infarction (MI), other acute coronary syndromes (ACS), stroke, heart failure, or death from CV causes (number needed to treat [NNT] to prevent one event=61).

Intensive treatment was also associated with a lower risk of all-cause mortality (NNT=90), heart failure (NNT=123), death from CV causes (NNT=172), and the primary outcome or death (NNT=52). While hypotension was higher in the intensive treatment group (number needed to harm [NNH]=106), as was syncope (NNH=173), electrolyte abnormalities (NNH=126), and acute kidney injury or failure (NNH=61), the authors noted that the benefits of lower BP outweighed the risks. Also, there was no increased risk of injurious falls. Therefore, despite the risk of adverse events, SPRINT demonstrated that lower BP goals significantly reduce the risk of adverse CV outcomes.

Continue to: Meta-analyses that have been conducted since SPRINT...

Meta-analyses that have been conducted since SPRINT, and that have incorporated SPRINT data, also support lower BP goals. In the systematic review performed for the 2017 ACC/AHA guideline, an SBP <130 mm Hg compared to a higher BP target was associated with a reduced risk of major CV events, stroke, MI, and heart failure, although not all-cause mortality.⁸ These findings were largely consistent with other recent meta-analyses.^12-15 For example, Bundy et al¹⁵ reported significant CV benefit with more vs less intensive BP lowering, whether or not the data from SPRINT were included, with the greatest reduction in risk seen in the groups with highest baseline BP.

It is important to consider a patient’s baseline level of risk when evaluating the absolute benefit of lower BP targets on CV outcomes. For patients with higher CV risk, the absolute benefit of treatment is greater.^12-14 These findings support the 2017 ACC/AHA guideline, which recommends initiating drug therapy, in addition to lifestyle modification, in adults with hypertension and high ASCVD risk when the average BP is >130/80 mm Hg, with a goal of <130/80 mm Hg. TABLE 3^12-15,17-22 summarizes recent systematic reviews and meta-analyses conducted since the publication of JNC 8 that assess the association between intensity of BP lowering and adverse CV and related outcomes.

Treating patients with low CV risk

The evidence supporting a lower BP goal in patients with low CV risk is less than for patients at elevated risk. There are no large RCTs for this group that have assessed whether an intensive BP lowering strategy decreases CV outcomes more than a standard BP strategy (eg, <140/90 mm Hg). It is likely that absolute benefit is much smaller than for patients with, or at high risk for, ASCVD. 

However, epidemiologic observational studies have indicated a significant log-linear increase in CV mortality starting at an SBP of 115 mm Hg.²³ A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.²³ Decades worth of exposure to “elevated” BP levels would likely result in significant vascular damage, and attenuation of this process would likely be beneficial.^24,25 An RCT specifically designed to test this hypothesis, however, would not be pragmatic considering the substantial number of patient-years that would be required.

Due to insufficient data documenting the value of antihypertensive drug therapy for primary prevention in adults with “elevated” BP and stage 1 hypertension at low risk for CVD, the 2017 ACC/AHA guideline recommends that drug therapy be initiated for all adults only when their BP average is ≥140/90 mm Hg.¹ In contrast, for patients needing secondary prevention and for those with elevated CVD risk, the guideline recommends medication in addition to lifestyle modifications once the average BP is ≥130/80 mm Hg. The recommendation to withhold drug therapy until the BP is ≥140/90 mm Hg in patients needing primary prevention is supported by a new meta-analysis of 74 trials with 306,273 participants that aimed to assess the association between BP-lowering treatment and death and CVD at various BP levels.¹⁷ In this analysis, pharmacologic treatment was associated with a reduced risk of all-cause mortality, major CVD events, and coronary heart disease if the SBP was ≥140 mm Hg.

Continue to: Treating older patients

Significant controversy has existed regarding the optimal BP goal in older patients, particularly once the JNC 8 recommended relaxing the SBP goal to <150 mm Hg for pateints ≥60 years of age.^6,7 This recommendation was consistent with the guideline from the American College of Physicians (ACP)/AAFP,²⁶ which also recommended a lower SBP of <140 mm Hg in patients with a history of stroke or transient ischemic attack and those at high CV risk.²⁶

A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.

Evidence is available, however, supporting more intensive BP goals in older independently-living ambulatory adults. A pre-planned subgroup analysis was conducted in 2636 SPRINT participants ≥75 years of age.²⁷ Similar to the overall experience in SPRINT, lower SBP goals were associated with significant reductions in CV events, including the composite CVD primary outcome (NNT=27), heart failure (NNT=63), nonfatal heart failure (NNT=66), and all-cause mortality (NNT=41). In addition, the relative benefits were approximately equal whether the patients were the most fit, non-fit, or frail, with the absolute benefit being greatest in those who were frail (recognizing that the SPRINT participants were independently-living ambulatory adults). While the absolute rate of serious adverse events was higher in the more intensive BP goal group, there was no statistically significant difference in the incidence of hypotension, orthostatic hypotension, syncope, electrolyte abnormalities, or acute kidney injury or renal failure.

Use of lower BP goals than recommended by JNC 8 was also supported by another recent meta-analysis that compared the outcomes of intensive BP lowering (SBP <140 mm Hg) to a standard BP-lowering strategy (SBP <150 mm Hg).¹⁸ Using a random-effects model, more intensive BP lowering was associated with a significant reduction in major adverse CV events (29%), CV mortality (33%), and heart failure (37%), with no increase in serious adverse events or renal failure. Findings with the fixed-effects model used to confirm results were largely consistent, with the exception of a possible increase in renal failure.

Although the evidence supporting lower BP goals in older, ambulatory, noninstitutionalized patients is sound, it is important to consider a patient’s overall disease burden. For older adults with multiple comorbidities and limited life expectancy, as well as those who are nonambulatory or institutionalized, decisions on the intensity of BP lowering should be made using a team-based approach, weighing the risks and benefits.¹

Continue to: Treating patients with diabetes

Treating patients with diabetes

The most appropriate BP goal for patients with diabetes has been the subject of much debate, with different goals recommended in different guidelines (TABLE 2^1,2,6). The most recent American Diabetes Association guideline recommends a BP goal <140/90 mm Hg for most patients, with lower targets (<130/80 mm Hg) for patients at high CV risk if it is achievable without undue treatment burden,²⁸ whereas the 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for all adults with diabetes.¹

The ACCORD trial. There is limited evidence to suggest which BP goal is most appropriate for patients with diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is the only RCT specifically designed to assess the impact of intensive vs standard BP goals in patients with diabetes.²⁹ In ACCORD, 4733 patients with type 2 diabetes were randomized to either an intensive BP-lowering group (SBP <120 mm Hg) or a standard BP-lowering group (SBP <140 mm Hg). After a mean follow-up of 4.7 years, there was no difference in the primary composite endpoint of nonfatal MI, nonfatal stroke, or death from CV causes. However, the risk of stroke was reduced (NNT=89). Interpretation of ACCORD is limited due to its factorial design and because the trial was significantly underpowered.

Systematic reviews and meta-analyses. Literature supporting lower BP goals in patients with diabetes primarily comes from systematic reviews and meta-analyses.³⁰ In the evidence-based review performed for the 2017 ACC/AHA guidelines, more intensive treatment was associated with a decrease in fatal or nonfatal stroke.⁸ The results from the ACCORD trial and SPRINT are consistent,³¹ and a sub-study of SPRINT patients with pre-diabetes showed preservation of CV benefit.³² Also, a meta-analysis of subgroups of trial participants with diabetes showed that more intensive BP lowering in patients is associated with a decrease in major CV events.¹⁴

Treating patients with chronic kidney disease

As with diabetes and older patients, recommended goals for patients with CKD have varied (TABLE 2^1,2,6). The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guideline recommended the same target BP as JNC 7 and the 2017 ACC/AHA guideline: ≤130/80 mm Hg in patients with CKD and urine albumin excretion ≥30 mg/24 hours (or equivalent).^1,2,33 KDIGO recommended a more relaxed target (≤140/90 mm Hg), however, for patients with CKD and urine albumin excretion <30 mg/24 hours.^1,33

Scant data exist from RCTs designed to assess the CV effects of intensive BP targets in patients with CKD. In SPRINT, where 28% of patients had stage 3 or 4 CKD, benefits of more intensive therapy were similar to those observed in the overall cohort.^16,34 While some RCTs have assessed the effect of more intensive BP lowering on progression of CKD, they were not specifically designed or powered to address CV outcomes.^35,36

Continue to: In recent meta-analyses assessing the effects...

In recent meta-analyses assessing the effects of intensive BP lowering on renal and CV events in patients with CKD, a lower BP strategy was not associated with a decrease in CV events.^8,14,19 However, more intensive therapy was associated with a 17% reduced risk of composite kidney failure events and an 18% reduction in end-stage kidney disease.¹⁹ The risk of kidney failure with lower BP goals was 27% lower in patients with baseline proteinuria, but was not significant in patients who did not have proteinuria.¹⁹

Evidence supports lower BP goals, but guidelines should guide

The lower BP goals advised in the 2017 ACC/AHA guideline are supported by substantial new high-quality evidence that was not available at the time of the JNC 8 report.¹ The strongest evidence for lower goals is found in patients with, or at high risk for, CVD, but other patients commonly seen by primary care providers, including those at lower CVD risk, older patients, and those with diabetes or CKD are also likely to benefit.¹

Despite the debates, it is important to remember that guidelines are intended to “guide.” As stated in the guideline, “Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.”¹ They should be easy to understand and apply, and a consistent, evidence-based BP goal of <130/80 mm Hg for most patients facilitates implementation.

Although more of the US population is categorized as hypertensive under the new guideline, only 1.9% more require drug therapy.

Although more of the US population is categorized as hypertensive under the new guideline (46% now vs 32% before), only 1.9% more require drug therapy, as the vast majority of the newly classified hypertensives are primary prevention patients for whom only lifestyle modification is recommended.³⁷ However, to attain these goals, greater emphasis will be needed on utilizing team-based care, health information technology including electronic medical records and telehealth, performance measures, quality improvement strategies, and financial incentives.¹

Finally, as emphasized in the guidelines, BP monitoring technique matters. Clinicians should not accept flawed BP measurement techniques any more than they would accept flawed results from studies performed incorrectly.

CORRESPONDENCE
Eric J. MacLaughlin, PharmD, BCPS, FASHP, FCCP, Texas Tech University Health Sciences Center,1300 S. Coulter Dr., Amarillo, TX 79106; [email protected].

ACKNOWLEDGEMENTS

The authors thank Paul K. Whelton, MB, MD, MSc, FAHA, and Robert M. Carey, MD, FAHA, for their review of this manuscript. 

For more than a century, clinicians have pondered the significance of elevated blood pressure (BP) and its contribution to cardiovascular disease (CVD). While it is widely understood that high BP increases CVD events, and that treatment lowers that risk, the most appropriate BP goal continues to be a subject of debate.

This article briefly summarizes the evidence to support lower BP goals for patients with hypertension who are commonly seen in family practice, including those needing primary prevention, as well as those with, or at high risk for, atherosclerotic cardiovascular disease (ASCVD), patients with diabetes, and those with chronic kidney disease (CKD). Detailed information regarding specific lifestyle and medication treatment recommendations and thresholds for drug therapy is beyond the scope of this review.

A brief history: ACC/AHA guidelines vs JNC 7 and 8

The most recent comprehensive, evidence-based guideline on the prevention, detection, evaluation, and management of high BP in adults was released in late 2017 by the American College of Cardiology (ACC) and the American Heart Association (AHA).¹ It was the first comprehensive BP guideline since the Seventh Report of the Joint National Committee (JNC 7) in 2003.² The new guideline includes several changes, notably in how BP is classified, the threshold for initiation of antihypertensive drug therapy, and target BP.

While widely viewed as positive, the changes in classification, thresholds, and targets for BP therapy have generated controversy and disagreement. Common reasons cited include concern about the data supporting lower thresholds for treatment, the applicability of trial findings to broad patient populations, and the risk of harm with lower BP goals.³ The American Academy of Family Physicians (AAFP) declined to endorse the ACC/AHA guidelines and continues to support the 2014 report by the panel members appointed to the Eighth Joint National Committee (JNC 8) by the National Heart Lung and Blood Institute (NHLBI).⁴ A primary reason cited for the lack of support for the 2017 guideline is that the majority of recommendations made in the ACC/AHA guideline were not “based on a systematic evidence review.”⁴ However, there are significant differences in purpose, structure, and scope between the ACC/AHA and JNC 8.

Evidence supports lower BP goals for a number of different patient populations and groups.

In 2013, the NHLBI announced that it would cease involvement in creating guidelines and transferred responsibility for development to professional organizations.⁵ Of the 5 guidelines that were in the process of creation (cholesterol, lifestyle intervention, obesity, risk assessment, and high BP), all but the high BP guideline were transferred to the ACC/AHA for completion. The panel members appointed to the JNC 8 elected to publish their recommendations independently and focused only on 3 “critical questions” related to hypertension therapy (eg, therapy initiation, BP goals, and choice of initial agent).⁶

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The JNC 8 report generated significant controversy with the recommendation to relax the BP goal for patients ≥60 years of age to <150/90 mm Hg. Members of the JNC 8 panel who disagreed with this goal published a "minority view" citing concerns about the negative impact the goal would have on CVD and public health, and the "insufficient and inconsistent" evidence supporting relaxed goals.⁷ The dissenting group cited additional drawbacks of the recommendation, noting that it was highly focused, included data only from randomized controlled trials (RCTs; no meta-analyses or observational data), and did not address or provide guidance on numerous other issues of importance in the care of hypertension.

While the 2017 ACC/AHA guideline also includes formal systematic evidence reviews on major critical questions (ie, optimal BP targets, preferred antihypertensives, the role of home and ambulatory BP monitoring),⁸ it was designed to be comprehensive and useful for clinicians, providing 106 graded recommendations on commonly encountered questions. It would have been unrealistic to do a formal systematic evidence review and meta-analysis on all clinically relevant questions seen in practice. However, available systematic reviews, meta-analyses, and observational data were scrutinized and used to support the recommendations wherever possible.

Continue to: Say "goodbye" to prehypertension; say "hello" to elevated BP

Say “goodbye” to prehypertension; say “hello” to elevated BP

The 2017 ACC/AHA guideline changed the BP classification for adults (TABLE 1^1,2). While “normal” remained respectively.¹ Removal of the “prehypertension” category and use of the term “elevated” instead was meant to better convey the importance of lifestyle interventions to forestall the development of hypertension.

Don’t underestimate the power of BP measurement technique

The importance of appropriate BP measurement technique to confirm a hypertension diagnosis and assist with medication titration is emphasized in the ACC/AHA guidelines.

The importance of appropriate BP measurement technique to confirm the diagnosis of hypertension and assist with medication titration was also emphasized.¹ BP measurement technique in usual clinical practice is frequently suboptimal, most commonly resulting in falsely elevated readings.^9,10 The guideline recommends the use of out-of-office measurements to confirm elevated clinic readings, screen for white-coat and masked hypertension, and assist in medication adjustment decisions. It is critically important that appropriate BP measurement technique is used, which in many cases, will avoid inappropriate treatment. (See “Getting the hypertension Dx right: Patient positioning matters,” JFP. 2018;67:199-207.)

A look at the evidence supporting lower BP goals

The 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for adults with hypertension commonly seen in clinical practice, including those with CVD or an elevated ASCVD risk (10-year risk ≥10% using the Pooled Cohort Equations¹¹), those with hypertension and low ASCVD risk (10-year risk <10%), and those with hypertension who have concomitant diabetes or CKD.¹ The guideline also recommends an SBP goal <130 mm Hg for independently-living, ambulatory older adults (≥65 years) with hypertension.¹ TABLE 2^1,2,6 compares the BP goals in the new 2017 ACC/AHA guidelines to previous recommendations.

SPRINT. Significant new literature has been generated since the publication of JNC 8 that supports these lower BP goals, particularly in patients with CVD or who are at high ASCVD risk.^8,12-15 For example, the Systolic Blood Pressure Intervention Trial (SPRINT) was the largest RCT to assess whether lower BP goals decrease the risk of adverse CVD outcomes.¹⁶ In SPRINT, 9361 patients with an SBP ≥130 mm Hg and an increased risk of CVD, but without diabetes or a history of stroke, were randomized to intensive BP treatment (SBP goal <120 mm Hg) or standard treatment (SBP goal <140 mm Hg). After a median follow-up of 3.26 years, the study was stopped early due to a decreased risk in the primary composite outcome of myocardial infarction (MI), other acute coronary syndromes (ACS), stroke, heart failure, or death from CV causes (number needed to treat [NNT] to prevent one event=61).

Intensive treatment was also associated with a lower risk of all-cause mortality (NNT=90), heart failure (NNT=123), death from CV causes (NNT=172), and the primary outcome or death (NNT=52). While hypotension was higher in the intensive treatment group (number needed to harm [NNH]=106), as was syncope (NNH=173), electrolyte abnormalities (NNH=126), and acute kidney injury or failure (NNH=61), the authors noted that the benefits of lower BP outweighed the risks. Also, there was no increased risk of injurious falls. Therefore, despite the risk of adverse events, SPRINT demonstrated that lower BP goals significantly reduce the risk of adverse CV outcomes.

Continue to: Meta-analyses that have been conducted since SPRINT...

Meta-analyses that have been conducted since SPRINT, and that have incorporated SPRINT data, also support lower BP goals. In the systematic review performed for the 2017 ACC/AHA guideline, an SBP <130 mm Hg compared to a higher BP target was associated with a reduced risk of major CV events, stroke, MI, and heart failure, although not all-cause mortality.⁸ These findings were largely consistent with other recent meta-analyses.^12-15 For example, Bundy et al¹⁵ reported significant CV benefit with more vs less intensive BP lowering, whether or not the data from SPRINT were included, with the greatest reduction in risk seen in the groups with highest baseline BP.

It is important to consider a patient’s baseline level of risk when evaluating the absolute benefit of lower BP targets on CV outcomes. For patients with higher CV risk, the absolute benefit of treatment is greater.^12-14 These findings support the 2017 ACC/AHA guideline, which recommends initiating drug therapy, in addition to lifestyle modification, in adults with hypertension and high ASCVD risk when the average BP is >130/80 mm Hg, with a goal of <130/80 mm Hg. TABLE 3^12-15,17-22 summarizes recent systematic reviews and meta-analyses conducted since the publication of JNC 8 that assess the association between intensity of BP lowering and adverse CV and related outcomes.

Treating patients with low CV risk

The evidence supporting a lower BP goal in patients with low CV risk is less than for patients at elevated risk. There are no large RCTs for this group that have assessed whether an intensive BP lowering strategy decreases CV outcomes more than a standard BP strategy (eg, <140/90 mm Hg). It is likely that absolute benefit is much smaller than for patients with, or at high risk for, ASCVD. 

However, epidemiologic observational studies have indicated a significant log-linear increase in CV mortality starting at an SBP of 115 mm Hg.²³ A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.²³ Decades worth of exposure to “elevated” BP levels would likely result in significant vascular damage, and attenuation of this process would likely be beneficial.^24,25 An RCT specifically designed to test this hypothesis, however, would not be pragmatic considering the substantial number of patient-years that would be required.

Due to insufficient data documenting the value of antihypertensive drug therapy for primary prevention in adults with “elevated” BP and stage 1 hypertension at low risk for CVD, the 2017 ACC/AHA guideline recommends that drug therapy be initiated for all adults only when their BP average is ≥140/90 mm Hg.¹ In contrast, for patients needing secondary prevention and for those with elevated CVD risk, the guideline recommends medication in addition to lifestyle modifications once the average BP is ≥130/80 mm Hg. The recommendation to withhold drug therapy until the BP is ≥140/90 mm Hg in patients needing primary prevention is supported by a new meta-analysis of 74 trials with 306,273 participants that aimed to assess the association between BP-lowering treatment and death and CVD at various BP levels.¹⁷ In this analysis, pharmacologic treatment was associated with a reduced risk of all-cause mortality, major CVD events, and coronary heart disease if the SBP was ≥140 mm Hg.

Continue to: Treating older patients

Significant controversy has existed regarding the optimal BP goal in older patients, particularly once the JNC 8 recommended relaxing the SBP goal to <150 mm Hg for pateints ≥60 years of age.^6,7 This recommendation was consistent with the guideline from the American College of Physicians (ACP)/AAFP,²⁶ which also recommended a lower SBP of <140 mm Hg in patients with a history of stroke or transient ischemic attack and those at high CV risk.²⁶

A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.

Evidence is available, however, supporting more intensive BP goals in older independently-living ambulatory adults. A pre-planned subgroup analysis was conducted in 2636 SPRINT participants ≥75 years of age.²⁷ Similar to the overall experience in SPRINT, lower SBP goals were associated with significant reductions in CV events, including the composite CVD primary outcome (NNT=27), heart failure (NNT=63), nonfatal heart failure (NNT=66), and all-cause mortality (NNT=41). In addition, the relative benefits were approximately equal whether the patients were the most fit, non-fit, or frail, with the absolute benefit being greatest in those who were frail (recognizing that the SPRINT participants were independently-living ambulatory adults). While the absolute rate of serious adverse events was higher in the more intensive BP goal group, there was no statistically significant difference in the incidence of hypotension, orthostatic hypotension, syncope, electrolyte abnormalities, or acute kidney injury or renal failure.

Use of lower BP goals than recommended by JNC 8 was also supported by another recent meta-analysis that compared the outcomes of intensive BP lowering (SBP <140 mm Hg) to a standard BP-lowering strategy (SBP <150 mm Hg).¹⁸ Using a random-effects model, more intensive BP lowering was associated with a significant reduction in major adverse CV events (29%), CV mortality (33%), and heart failure (37%), with no increase in serious adverse events or renal failure. Findings with the fixed-effects model used to confirm results were largely consistent, with the exception of a possible increase in renal failure.

Although the evidence supporting lower BP goals in older, ambulatory, noninstitutionalized patients is sound, it is important to consider a patient’s overall disease burden. For older adults with multiple comorbidities and limited life expectancy, as well as those who are nonambulatory or institutionalized, decisions on the intensity of BP lowering should be made using a team-based approach, weighing the risks and benefits.¹

Continue to: Treating patients with diabetes

Treating patients with diabetes

The most appropriate BP goal for patients with diabetes has been the subject of much debate, with different goals recommended in different guidelines (TABLE 2^1,2,6). The most recent American Diabetes Association guideline recommends a BP goal <140/90 mm Hg for most patients, with lower targets (<130/80 mm Hg) for patients at high CV risk if it is achievable without undue treatment burden,²⁸ whereas the 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for all adults with diabetes.¹

The ACCORD trial. There is limited evidence to suggest which BP goal is most appropriate for patients with diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is the only RCT specifically designed to assess the impact of intensive vs standard BP goals in patients with diabetes.²⁹ In ACCORD, 4733 patients with type 2 diabetes were randomized to either an intensive BP-lowering group (SBP <120 mm Hg) or a standard BP-lowering group (SBP <140 mm Hg). After a mean follow-up of 4.7 years, there was no difference in the primary composite endpoint of nonfatal MI, nonfatal stroke, or death from CV causes. However, the risk of stroke was reduced (NNT=89). Interpretation of ACCORD is limited due to its factorial design and because the trial was significantly underpowered.

Systematic reviews and meta-analyses. Literature supporting lower BP goals in patients with diabetes primarily comes from systematic reviews and meta-analyses.³⁰ In the evidence-based review performed for the 2017 ACC/AHA guidelines, more intensive treatment was associated with a decrease in fatal or nonfatal stroke.⁸ The results from the ACCORD trial and SPRINT are consistent,³¹ and a sub-study of SPRINT patients with pre-diabetes showed preservation of CV benefit.³² Also, a meta-analysis of subgroups of trial participants with diabetes showed that more intensive BP lowering in patients is associated with a decrease in major CV events.¹⁴

Treating patients with chronic kidney disease

As with diabetes and older patients, recommended goals for patients with CKD have varied (TABLE 2^1,2,6). The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guideline recommended the same target BP as JNC 7 and the 2017 ACC/AHA guideline: ≤130/80 mm Hg in patients with CKD and urine albumin excretion ≥30 mg/24 hours (or equivalent).^1,2,33 KDIGO recommended a more relaxed target (≤140/90 mm Hg), however, for patients with CKD and urine albumin excretion <30 mg/24 hours.^1,33

Scant data exist from RCTs designed to assess the CV effects of intensive BP targets in patients with CKD. In SPRINT, where 28% of patients had stage 3 or 4 CKD, benefits of more intensive therapy were similar to those observed in the overall cohort.^16,34 While some RCTs have assessed the effect of more intensive BP lowering on progression of CKD, they were not specifically designed or powered to address CV outcomes.^35,36

Continue to: In recent meta-analyses assessing the effects...

In recent meta-analyses assessing the effects of intensive BP lowering on renal and CV events in patients with CKD, a lower BP strategy was not associated with a decrease in CV events.^8,14,19 However, more intensive therapy was associated with a 17% reduced risk of composite kidney failure events and an 18% reduction in end-stage kidney disease.¹⁹ The risk of kidney failure with lower BP goals was 27% lower in patients with baseline proteinuria, but was not significant in patients who did not have proteinuria.¹⁹

Evidence supports lower BP goals, but guidelines should guide

The lower BP goals advised in the 2017 ACC/AHA guideline are supported by substantial new high-quality evidence that was not available at the time of the JNC 8 report.¹ The strongest evidence for lower goals is found in patients with, or at high risk for, CVD, but other patients commonly seen by primary care providers, including those at lower CVD risk, older patients, and those with diabetes or CKD are also likely to benefit.¹

Despite the debates, it is important to remember that guidelines are intended to “guide.” As stated in the guideline, “Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.”¹ They should be easy to understand and apply, and a consistent, evidence-based BP goal of <130/80 mm Hg for most patients facilitates implementation.

Although more of the US population is categorized as hypertensive under the new guideline, only 1.9% more require drug therapy.

Although more of the US population is categorized as hypertensive under the new guideline (46% now vs 32% before), only 1.9% more require drug therapy, as the vast majority of the newly classified hypertensives are primary prevention patients for whom only lifestyle modification is recommended.³⁷ However, to attain these goals, greater emphasis will be needed on utilizing team-based care, health information technology including electronic medical records and telehealth, performance measures, quality improvement strategies, and financial incentives.¹

Finally, as emphasized in the guidelines, BP monitoring technique matters. Clinicians should not accept flawed BP measurement techniques any more than they would accept flawed results from studies performed incorrectly.

CORRESPONDENCE
Eric J. MacLaughlin, PharmD, BCPS, FASHP, FCCP, Texas Tech University Health Sciences Center,1300 S. Coulter Dr., Amarillo, TX 79106; [email protected].

ACKNOWLEDGEMENTS

The authors thank Paul K. Whelton, MB, MD, MSc, FAHA, and Robert M. Carey, MD, FAHA, for their review of this manuscript. 

Resources

Rosenberg R, Lindsey NP, Fischer M, et al. Vital Signs: Trends in reported vectorborne disease cases—United States and territories, 2004-2016. MMWR Morb Mortal Wkly Rep. 2018;67:496-501.

US Environmental Protection Agency. Repellents: protection against mosquitoes, ticks, and other arthropods. Available at: https://www.epa.gov/insect-repellents. Accessed June 6, 2018.

Centers for Disease Control and Prevention. Zika virus: prevent mosquito bites. Available at: https://www.cdc.gov/zika/prevention/prevent-mosquito-bites.html. Accessed June 6, 2018.

Resources

Rosenberg R, Lindsey NP, Fischer M, et al. Vital Signs: Trends in reported vectorborne disease cases—United States and territories, 2004-2016. MMWR Morb Mortal Wkly Rep. 2018;67:496-501.

US Environmental Protection Agency. Repellents: protection against mosquitoes, ticks, and other arthropods. Available at: https://www.epa.gov/insect-repellents. Accessed June 6, 2018.

Centers for Disease Control and Prevention. Zika virus: prevent mosquito bites. Available at: https://www.cdc.gov/zika/prevention/prevent-mosquito-bites.html. Accessed June 6, 2018.

Resources

Rosenberg R, Lindsey NP, Fischer M, et al. Vital Signs: Trends in reported vectorborne disease cases—United States and territories, 2004-2016. MMWR Morb Mortal Wkly Rep. 2018;67:496-501.

US Environmental Protection Agency. Repellents: protection against mosquitoes, ticks, and other arthropods. Available at: https://www.epa.gov/insect-repellents. Accessed June 6, 2018.

Centers for Disease Control and Prevention. Zika virus: prevent mosquito bites. Available at: https://www.cdc.gov/zika/prevention/prevent-mosquito-bites.html. Accessed June 6, 2018.

The FP thought the flat lesion (arrow) might be a nevus sebaceous (NS) and that the new area could be a malignant transformation.

The FP explained that a biopsy would be needed to learn more about the lesion. He explained that he would remove the area that was friable and bleeding along with part of the original flat lesion. After injecting the area with 1% lidocaine and epinephrine, a shave biopsy was performed using a DermaBlade. (See the Watch & Learn video on “Shave biopsy.”) The bleeding was stopped using aluminum chloride in water and some electrosurgery. The pathology results revealed syringocystadenoma papilliferum growing within an NS. This benign tumor is rare, but may develop within an NS.

The FP reassured the family that there was no skin cancer. The FP also referred the patient for full removal of the NS and any remnant of the syringocystadenoma papilliferum to avoid future growth and prevent additional bleeding.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP thought the flat lesion (arrow) might be a nevus sebaceous (NS) and that the new area could be a malignant transformation.

The FP explained that a biopsy would be needed to learn more about the lesion. He explained that he would remove the area that was friable and bleeding along with part of the original flat lesion. After injecting the area with 1% lidocaine and epinephrine, a shave biopsy was performed using a DermaBlade. (See the Watch & Learn video on “Shave biopsy.”) The bleeding was stopped using aluminum chloride in water and some electrosurgery. The pathology results revealed syringocystadenoma papilliferum growing within an NS. This benign tumor is rare, but may develop within an NS.

The FP reassured the family that there was no skin cancer. The FP also referred the patient for full removal of the NS and any remnant of the syringocystadenoma papilliferum to avoid future growth and prevent additional bleeding.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP thought the flat lesion (arrow) might be a nevus sebaceous (NS) and that the new area could be a malignant transformation.

The FP explained that a biopsy would be needed to learn more about the lesion. He explained that he would remove the area that was friable and bleeding along with part of the original flat lesion. After injecting the area with 1% lidocaine and epinephrine, a shave biopsy was performed using a DermaBlade. (See the Watch & Learn video on “Shave biopsy.”) The bleeding was stopped using aluminum chloride in water and some electrosurgery. The pathology results revealed syringocystadenoma papilliferum growing within an NS. This benign tumor is rare, but may develop within an NS.

The FP reassured the family that there was no skin cancer. The FP also referred the patient for full removal of the NS and any remnant of the syringocystadenoma papilliferum to avoid future growth and prevent additional bleeding.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

A 66-year-old man with steroid-dependent asthma, well-controlled diabetes mellitus (DM), and chronic pain on hospice presented to George E. Wahlen Veteran Affairs Medical Center (VAMC) from an extended care facility with a 4-day history of progressive abdominal distention, diffuse pain, and constipation. The patient’s history was remarkable for a 20-year period of managing asthma with 10 to 60 mg prednisone daily. He continued to experience frequent exacerbations despite using maximum medical therapy. Chronic neck, back, and leg pain had been managed with increasing narcotics over the prior year.

On presentation, the patient reported taking the following medications: daily oxycodone 20 to 30 mg, tramadol 200 mg, gabapentin 1,200 mg, and frequent doses of morphine concentrate. Due to episodes of constipation and diarrhea, the veteran had recently self-discontinued taking stool softener (Senna plus). One month prior to this admission, the patient was enrolled in hospice service by his primary physician for severe COPD due to chronic hypoxic respiratory failure and worsening frailty. His baseline oxygen requirement was 4 to 5 L of supplemental oxygen with continued dyspnea upon any ambulation. The patient reported frequent falls prior to admission. Despite chronic steroid use, the patient’s DM was well controlled with metformin His hemoglobin A_1c ranged from 6.0 to 7.8.

The patient was supine and appeared to be uncomfortable but not in acute distress on exam. His body habitus was Cushingoid, and he appeared much older than his stated age. His vitals were as follows: temperature 100.2°F, heart rate of 104 beats per minute, blood pressure of 98/56 mm Hg, and 95% oxygen on 4L nasal cannula (baseline 4-5L). A respiratory exam revealed distant breath sounds without wheeze, rhonchi, or rales, and a cardiac exam revealed no murmurs. He was in sinus rhythm with tachycardia. The abdomen was obese with purple straie and markedly distended. On percussion, his abdomen was tympanic with tinkling bowel sounds. He had no rebound tenderness, peritoneal signs, or fluid wave.

Laboratory results revealed a white blood cell (WBC) count of 13,790 cells/μL with a neutrophilic shift of 82.0, and an elevated creatinine of 2.16 mg/dL up from a baseline of 1.12 mg/dL. The chemistry panel was abnormal with a 125 mmol/L sodium (reference range 137-145 mmol/L). 

Diagnosis

On admission, the authors’ differential diagnosis included fecal impaction with large bowel obstruction, colitis, narcotic induced ileus, dehydration leading to severe constipation, and delayed gastric emptying secondary to long-standing DM. Ciprofloxacin and metronidazole antibiotics were initiated out of concern for possible colitis and potential bacterial translocation. Intravenous fluids were initiated, and the patient was instructed to have nothing by mouth (NPO) aside from the antibiotics. All opioids, including tramadol, were held. Out of concern for narcotic-induced constipation, a dose of methylnaltrexone to induce stooling was administered but had no effect on the constipation.

The gastroenterology department was consulted for a possible endoscopy to aid in decompression of the sigmoid. However, given the amount of distention and concern for perforation with endoscopy, the patient did not undergo endoscopy on admission. The patient remained afebrile on hospital day 3, and all antibiotics were discontinued. His WBC count normalized with complete resolution of the kidney injury. Antibiotic stewardship and infectious disease consults at George E. Wahlen VAMC reviewed the case and supported the decision to stop all antibiotics since it was not clear whether or not the patient was infected. Despite aggressive bowel care that included a nasogastric tube for large-volume polyethylene glycol and lactulose, various enemas and suppositories, the patient remained constipated.

On hospital day 5, still NPO, the patient had several bilious liquid stools that appeared to have a sediment quality to them. His abdomen remained distended, tympanic, and uncomfortable to palpation., He was examined frequently due to concern for possible perforation. On hospital day 8, gastroenterology reevaluated the need for endoscopy and proceeded with a flexible sigmoidoscopy. 

Polymerase chain reaction analysis of the colonoscopy stool samples were positive for Clostridium difficile (C difficile). The patient was started on IV metronidazole and oral vancomycin. His diet advanced and over the next few days he began stooling. He was subsequently discharged back to an extended care facility for rehabilitation. During this hospitalization, he made it clear he wished to be discharged from hospice services. He wanted to regain his strength through aggressive physical and occupational therapies.

Conclusion

Typical clinical manifestations of fulminant colitis include fever, diarrhea, abdominal pain, distention, and frequently WBC counts > 20,000 cells/μL. However, C difficile colitis, also known as pseudomembranous colitis, occasionally can present as an acute ileus, with little or no diarrhea.¹ This veteran had several risk factors for C difficile infection, which included long-term residence in an extended care facility, frequent asthma exacerbations that required antibiotics, severe chronic disease, aged > 65 years,and ciprofloxacin given the first 3 days of this hospitalization.² Until the endoscopy results were presented, no one on the patient’s care team, including gastroenterology and infectious disease, had included an infectious etiology in the differential diagnosis. This case reinforces the need to broaden differential diagnoses and look beyond assumptions that opioids without an adequate bowel regime were the cause. Avoiding anchoring heuristics can be a challenge as this case demonstrates.

A 66-year-old man with steroid-dependent asthma, well-controlled diabetes mellitus (DM), and chronic pain on hospice presented to George E. Wahlen Veteran Affairs Medical Center (VAMC) from an extended care facility with a 4-day history of progressive abdominal distention, diffuse pain, and constipation. The patient’s history was remarkable for a 20-year period of managing asthma with 10 to 60 mg prednisone daily. He continued to experience frequent exacerbations despite using maximum medical therapy. Chronic neck, back, and leg pain had been managed with increasing narcotics over the prior year.

On presentation, the patient reported taking the following medications: daily oxycodone 20 to 30 mg, tramadol 200 mg, gabapentin 1,200 mg, and frequent doses of morphine concentrate. Due to episodes of constipation and diarrhea, the veteran had recently self-discontinued taking stool softener (Senna plus). One month prior to this admission, the patient was enrolled in hospice service by his primary physician for severe COPD due to chronic hypoxic respiratory failure and worsening frailty. His baseline oxygen requirement was 4 to 5 L of supplemental oxygen with continued dyspnea upon any ambulation. The patient reported frequent falls prior to admission. Despite chronic steroid use, the patient’s DM was well controlled with metformin His hemoglobin A_1c ranged from 6.0 to 7.8.

The patient was supine and appeared to be uncomfortable but not in acute distress on exam. His body habitus was Cushingoid, and he appeared much older than his stated age. His vitals were as follows: temperature 100.2°F, heart rate of 104 beats per minute, blood pressure of 98/56 mm Hg, and 95% oxygen on 4L nasal cannula (baseline 4-5L). A respiratory exam revealed distant breath sounds without wheeze, rhonchi, or rales, and a cardiac exam revealed no murmurs. He was in sinus rhythm with tachycardia. The abdomen was obese with purple straie and markedly distended. On percussion, his abdomen was tympanic with tinkling bowel sounds. He had no rebound tenderness, peritoneal signs, or fluid wave.

Laboratory results revealed a white blood cell (WBC) count of 13,790 cells/μL with a neutrophilic shift of 82.0, and an elevated creatinine of 2.16 mg/dL up from a baseline of 1.12 mg/dL. The chemistry panel was abnormal with a 125 mmol/L sodium (reference range 137-145 mmol/L). 

Diagnosis

On admission, the authors’ differential diagnosis included fecal impaction with large bowel obstruction, colitis, narcotic induced ileus, dehydration leading to severe constipation, and delayed gastric emptying secondary to long-standing DM. Ciprofloxacin and metronidazole antibiotics were initiated out of concern for possible colitis and potential bacterial translocation. Intravenous fluids were initiated, and the patient was instructed to have nothing by mouth (NPO) aside from the antibiotics. All opioids, including tramadol, were held. Out of concern for narcotic-induced constipation, a dose of methylnaltrexone to induce stooling was administered but had no effect on the constipation.

The gastroenterology department was consulted for a possible endoscopy to aid in decompression of the sigmoid. However, given the amount of distention and concern for perforation with endoscopy, the patient did not undergo endoscopy on admission. The patient remained afebrile on hospital day 3, and all antibiotics were discontinued. His WBC count normalized with complete resolution of the kidney injury. Antibiotic stewardship and infectious disease consults at George E. Wahlen VAMC reviewed the case and supported the decision to stop all antibiotics since it was not clear whether or not the patient was infected. Despite aggressive bowel care that included a nasogastric tube for large-volume polyethylene glycol and lactulose, various enemas and suppositories, the patient remained constipated.

On hospital day 5, still NPO, the patient had several bilious liquid stools that appeared to have a sediment quality to them. His abdomen remained distended, tympanic, and uncomfortable to palpation., He was examined frequently due to concern for possible perforation. On hospital day 8, gastroenterology reevaluated the need for endoscopy and proceeded with a flexible sigmoidoscopy. 

Polymerase chain reaction analysis of the colonoscopy stool samples were positive for Clostridium difficile (C difficile). The patient was started on IV metronidazole and oral vancomycin. His diet advanced and over the next few days he began stooling. He was subsequently discharged back to an extended care facility for rehabilitation. During this hospitalization, he made it clear he wished to be discharged from hospice services. He wanted to regain his strength through aggressive physical and occupational therapies.

Conclusion

Typical clinical manifestations of fulminant colitis include fever, diarrhea, abdominal pain, distention, and frequently WBC counts > 20,000 cells/μL. However, C difficile colitis, also known as pseudomembranous colitis, occasionally can present as an acute ileus, with little or no diarrhea.¹ This veteran had several risk factors for C difficile infection, which included long-term residence in an extended care facility, frequent asthma exacerbations that required antibiotics, severe chronic disease, aged > 65 years,and ciprofloxacin given the first 3 days of this hospitalization.² Until the endoscopy results were presented, no one on the patient’s care team, including gastroenterology and infectious disease, had included an infectious etiology in the differential diagnosis. This case reinforces the need to broaden differential diagnoses and look beyond assumptions that opioids without an adequate bowel regime were the cause. Avoiding anchoring heuristics can be a challenge as this case demonstrates.

A 66-year-old man with steroid-dependent asthma, well-controlled diabetes mellitus (DM), and chronic pain on hospice presented to George E. Wahlen Veteran Affairs Medical Center (VAMC) from an extended care facility with a 4-day history of progressive abdominal distention, diffuse pain, and constipation. The patient’s history was remarkable for a 20-year period of managing asthma with 10 to 60 mg prednisone daily. He continued to experience frequent exacerbations despite using maximum medical therapy. Chronic neck, back, and leg pain had been managed with increasing narcotics over the prior year.

On presentation, the patient reported taking the following medications: daily oxycodone 20 to 30 mg, tramadol 200 mg, gabapentin 1,200 mg, and frequent doses of morphine concentrate. Due to episodes of constipation and diarrhea, the veteran had recently self-discontinued taking stool softener (Senna plus). One month prior to this admission, the patient was enrolled in hospice service by his primary physician for severe COPD due to chronic hypoxic respiratory failure and worsening frailty. His baseline oxygen requirement was 4 to 5 L of supplemental oxygen with continued dyspnea upon any ambulation. The patient reported frequent falls prior to admission. Despite chronic steroid use, the patient’s DM was well controlled with metformin His hemoglobin A_1c ranged from 6.0 to 7.8.

The patient was supine and appeared to be uncomfortable but not in acute distress on exam. His body habitus was Cushingoid, and he appeared much older than his stated age. His vitals were as follows: temperature 100.2°F, heart rate of 104 beats per minute, blood pressure of 98/56 mm Hg, and 95% oxygen on 4L nasal cannula (baseline 4-5L). A respiratory exam revealed distant breath sounds without wheeze, rhonchi, or rales, and a cardiac exam revealed no murmurs. He was in sinus rhythm with tachycardia. The abdomen was obese with purple straie and markedly distended. On percussion, his abdomen was tympanic with tinkling bowel sounds. He had no rebound tenderness, peritoneal signs, or fluid wave.

Laboratory results revealed a white blood cell (WBC) count of 13,790 cells/μL with a neutrophilic shift of 82.0, and an elevated creatinine of 2.16 mg/dL up from a baseline of 1.12 mg/dL. The chemistry panel was abnormal with a 125 mmol/L sodium (reference range 137-145 mmol/L). 

Diagnosis

On admission, the authors’ differential diagnosis included fecal impaction with large bowel obstruction, colitis, narcotic induced ileus, dehydration leading to severe constipation, and delayed gastric emptying secondary to long-standing DM. Ciprofloxacin and metronidazole antibiotics were initiated out of concern for possible colitis and potential bacterial translocation. Intravenous fluids were initiated, and the patient was instructed to have nothing by mouth (NPO) aside from the antibiotics. All opioids, including tramadol, were held. Out of concern for narcotic-induced constipation, a dose of methylnaltrexone to induce stooling was administered but had no effect on the constipation.

The gastroenterology department was consulted for a possible endoscopy to aid in decompression of the sigmoid. However, given the amount of distention and concern for perforation with endoscopy, the patient did not undergo endoscopy on admission. The patient remained afebrile on hospital day 3, and all antibiotics were discontinued. His WBC count normalized with complete resolution of the kidney injury. Antibiotic stewardship and infectious disease consults at George E. Wahlen VAMC reviewed the case and supported the decision to stop all antibiotics since it was not clear whether or not the patient was infected. Despite aggressive bowel care that included a nasogastric tube for large-volume polyethylene glycol and lactulose, various enemas and suppositories, the patient remained constipated.

On hospital day 5, still NPO, the patient had several bilious liquid stools that appeared to have a sediment quality to them. His abdomen remained distended, tympanic, and uncomfortable to palpation., He was examined frequently due to concern for possible perforation. On hospital day 8, gastroenterology reevaluated the need for endoscopy and proceeded with a flexible sigmoidoscopy. 

Polymerase chain reaction analysis of the colonoscopy stool samples were positive for Clostridium difficile (C difficile). The patient was started on IV metronidazole and oral vancomycin. His diet advanced and over the next few days he began stooling. He was subsequently discharged back to an extended care facility for rehabilitation. During this hospitalization, he made it clear he wished to be discharged from hospice services. He wanted to regain his strength through aggressive physical and occupational therapies.

Conclusion

Typical clinical manifestations of fulminant colitis include fever, diarrhea, abdominal pain, distention, and frequently WBC counts > 20,000 cells/μL. However, C difficile colitis, also known as pseudomembranous colitis, occasionally can present as an acute ileus, with little or no diarrhea.¹ This veteran had several risk factors for C difficile infection, which included long-term residence in an extended care facility, frequent asthma exacerbations that required antibiotics, severe chronic disease, aged > 65 years,and ciprofloxacin given the first 3 days of this hospitalization.² Until the endoscopy results were presented, no one on the patient’s care team, including gastroenterology and infectious disease, had included an infectious etiology in the differential diagnosis. This case reinforces the need to broaden differential diagnoses and look beyond assumptions that opioids without an adequate bowel regime were the cause. Avoiding anchoring heuristics can be a challenge as this case demonstrates.

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the lesion as a linear epidermal nevus.

Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.

EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.

The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the lesion as a linear epidermal nevus.

Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.

EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.

The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the lesion as a linear epidermal nevus.

Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.

EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.

The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.