NIH Says ATP 4, JNC 8 Guidance Out 'in a Matter of Months' (With a Twist)

Shelley Wood

June 19, 2013

BETHESDA, MD — The National Heart, Lung, and Blood Institute (NHLBI) announced today that the long-awaited guidelines for high blood pressure, high cholesterol, and other pressing CVD risk factors will be out "in a matter of months," but they will not necessarily go by the same names[1]. The biggest surprise in today's announcement was news that the institute has opted to partner with other "expert" groups to get the guidance out the door.

As previously reported by heartwire , physicians and other stakeholders have grown increasingly perplexed and frustrated over the seemingly endless delay to publishing the JNC 8, ATP 4, and Obesity guidelines. Today, on a National Institutes of Health (NIH)-hosted media briefing, Drs Gary Gibbons and Michael Lauer (NHLBI, Bethesda, MD) explained that the evidence review and guideline development process has been changed.

Going forward--and in a move that affects ATP 4 and JNC 8--the NHLBI has opted to publish five "integrated cardiovascular guideline products" as evidentiary reviews "and will subsequently collaborate with other organizations to prepare and issue the related clinical-practice guidelines."

The five CV "guideline products" include cholesterol, blood pressure, risk assessment, lifestyle interventions, and obesity.

Gibbons stated that the decision of whether the guidelines will go by the same "NHLBI legacy" "monikers" will be decided in collaboration with the "partnership organizations." And while those organizations have not been named, an essay by Gibbons and other NHBLI staff outlining plans for future guidelines documents has been published simultaneously on the Journal of the American College of Cardiology and Circulation (the AHA's flagship journal) websites.

Lauer and Gibbons on today's call insisted that the work already done by the NIH guidelines committees will be used by the partner organizations and that the involvement of these new partners will not further delay the protracted process; rather, that by partnering with other organizations, the expert reviews and guidelines will be out "not in a matter of years but a matter of months," as Lauer put it.

"The current state of the documents [is] such that indeed they can be formulated into . . . systematic reviews [that] inform the generation of the recommendations that are part of clinical-practice guidelines," Gibbons said. "Those processes can be formulated into publications within this timeframe of months."

In fact, he added, "This is the opportunity we have to make sure that this is done expeditiously, to take advantage of the considerable high-quality work that has already been done. And that's what gives us confidence that this can be accomplished in relatively short order."

News that professional societies like the ACC and AHA will be involved was a surprise to many who have actively been working on the different guidance documents. Dr Roger Blumenthal (Johns Hopkins University, Baltimore, MD), who is a member of the National Program to Reduce Cardiovascular Risk (NPRCR), says the NPRCR has had two face-to-face fly-in meetings with the writing group over the past few years. He only learned of the NHLBI decision yesterday.

"It's very unclear what the next step is. I think clinicians will be very disappointed by this decision because there is very strong need to synthesize all the information that is out there about risk assessment, cholesterol, high BP, and obesity, and we would have hoped that there would have been a well-laid out plan. I can understand politically if the NHLBI thought there were certain reasons why guidelines shouldn't be under their auspices, but it would have been better if the ACC and AHA would take the mature drafts of all the guidelines that have already been done and give us some kind of time frame."

It's also unclear whether the AHA and ACC form separate panels for the four major guideline areas and just how the "state-of-the-art" reviews will be linked with recommendations and level of evidence in the guidelines, Blumenthal noted.

The last Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Report from the Adult Treatment Panel (ATP 3) document came out in 2001, with an update in 2004. The seventh version of Managing Blood Pressure in Adults: Report from the Joint National Committee (JNC 7) was released in 2003. And the first Managing Overweight and Obesity in Adults: Report from the Obesity Expert Panel (Obesity 1) dates from 1998.

This is by no means the first time the NHLBI has suggested its different guideline documents were on the brink of publication. "We thought that some of the guidelines would be presented not just at last AHA but at the AHA before that," Blumenthal told heartwire . He points out that the European guideline groups have managed to get a number of important recent updates out much more quickly.

"Clinicians really want to hear what the experts in these fields would say. We have a lot of mixed messages out there about how aggressive to be with lipid and blood-pressure management in the primary- and secondary-prevention settings. Moreover, my colleagues who have worked on these panels for five years must be more even more frustrated than the practicing busy clinician is. When the guideline panelists signed up for this process, they didn't think it would last this long and they would have thought their hard work would be published by now, so the public and other experts would have the chance to react so we all could reach a better consensus."

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