Blog | Wednesday, December 18, 2013

QD: News Every Day--Hypertension guidelines lead to debate about creating any new recommendations

A new hypertension management guideline offers 9 recommendations and a treatment algorithm to help doctors treat patients, but its publication also triggered editorials about the development and trustworthiness of any and all guidelines.

Briefly, the 9 hypertension recommendations state that there is strong evidence to support treating hypertensive patients ages 60 years or older to a blood pressure goal of less than 150/90 mm Hg and those 30 through 59 years of age to a diastolic goal of less than 90 mm Hg. There is insufficient evidence in people younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommended a blood pressure of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease as for the general hypertensive population younger than 60.

The guideline, “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,” was developed by panel members appointed to the Eighth Joint National Committee and appeared online Dec. 18 at JAMA.

As for which medical regimen, there is moderate evidence to support starting with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on ACE inhibitors or ARBs in patients with chronic kidney disease.

In a difference from previous guidelines, evidence was drawn from randomized controlled trials, and evidence quality and recommendations were graded based on their effect on important health outcomes. These guidelines also sought to establish similar treatment goals for all hypertensive populations except when evidence supported different goals for a particular subpopulation.

Also, rather than defining hypertension, the panel addressed threshold blood pressure for starting treatment. The report recommends beginning treatment for people aged 60 and older at a blood pressure of 150/90, and treating to below that level based on trial evidence, but the authors emphasize that “this evidence-based guideline has not redefined high BP and the panel believes that the 140/90 mm Hg definition from Joint National Committee 7 remains reasonable.”

And, clinicians should emphasize lifestyle changes to improve control and possibly reduce the need for medicines. “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized.”

JAMA’s editor in chief recalled controversies about other guidelines, such as the U.S. Preventive Services Task Force’s updated recommendations regarding mammography screening in women, the Infectious Diseases Society of America’s guidelines for Lyme disease, and American College of Cardiology and the American Heart Association’s guidelines on assessment of cardiovascular risk and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk. Producing guidelines has become increasingly more complicated and contentious, the editor noted, adding, “Rigorously developed, thoroughly reviewed, evidence-based, trustworthy guidelines are critical to advance clinical medicine and improve health, and biomedical journals have a responsibility to disseminate important guidelines in an objective manner.”

In another editorial, Harold C. Sox, MD, MACP, former editor of ACP’s Annals of Internal Medicine and currently with the Dartmouth Institute for Health Policy and Clinical Practice, noted that the guideline did not undergo specialty society review as originally planned. He addressed the trustworthiness of the guideline, and guidelines in general.

He wrote that guideline authors, by agreeing to share its record of the review process with anyone who asks, meets the standard of transparency and review that proper guideline development now requires. “A rigorous, transparent process for developing and reviewing guidelines matters a great deal because guidelines are increasingly driving the practice of medicine.”

A third editorialist noted that, while the hypertension guidelines will follow suit in generating controversy, there is still room to keep searching for answers. Larger randomized, controlled trials need to be done to increase generalizability of results to different patient populations. A national consensus group should draft an updated comprehensive practice guideline that would harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations to create a more coherent overall cardiovascular prevention strategy. The process of translating practice guidelines into performance measures needs to be more deliberate, such as by deriving performance measures to create awareness of the potential unintended consequences of setting treatment goals that are too strict or adherence goals that are too rigid.