Henry R. Black, MD


December 19, 2013

In This Article

Critical Questions Addressed and Trials Reviewed

What this committee did as well as the 2 others -- the American Heart Association/American College of Cardiology (AHA/ACC) and the National Heart, Lung, and Blood Institute (NHLBI) recommendations -- was to come up with questions to guide the evidence review things they call critical questions, or CQs. They needed to come up with 3 of them from all members and the committee. And the committee was quite large -- much larger than JNC 7. These were the questions that they chose to do:

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes? That's a good question.

2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? That is also a good question.

3. And the third question that guided this evidence review was: In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

What the group chose to do was to review all trials that were published until the end of 2009. Now this is a little curious, because it means that everything that was done is almost outdated by the time it's written because there were things done after 2009 that could be important.

The group tried to deal with this by doing what they called a "bridge review" of things published after 2009. But they also changed the criteria to what they would include. There had to be at least 2000 patients instead of fewer than that. The follow-up had to be longer than they originally had planned to do. So it isn't quite the same.

If they had applied the same criteria to the earlier studies, I wonder if they would have come up with the same answer. It's pretty interesting too that if one looks at the references in JNC 8, there are about 43 or so references. Twenty-eight of them were published before 2009. Four of them were about methodology. And 8 of them were comparing other guidelines. Only 4 papers were cited after 2009 in trials, and all but 1 of these was rejected as not meeting their predetermined criteria. So whether this group liked it or not, this is a somewhat biased sample.

The other thing that's particularly important is a comparison with JNC 7.[2] There are some important things. A major one is that they took out beta-blockers as an appropriate first choice of antihypertensive therapy. This is in direct conflict with what the Europeans did in the European Society of Hypertension/European Society of Cardiology guidelines, which included beta-blockers as one of the options for first-line treatment.[3]


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