Henry R. Black, MD

Disclosures

December 19, 2013

In This Article

Evidence Grading and Recommendations 1-5

They also graded the strength of recommendations. This is very important as well, because it does color what is said later on. Grade A was a strong recommendation: high certainty, on the basis of evidence, that a net benefit is substantial. Grade B was a moderate recommendation -- moderately certain, on the basis of evidence, that net benefit was moderate to substantial.

Grade C was a weak recommendation. There was at least moderate certainty, on the basis of evidence, that there was a small net benefit. Grade D meant there was no net benefit or the risks of harm outweighed the benefit, and N was no recommendation because they didn't feel there was enough to go on.

Grade E -- and this is important -- grade E was expert opinion. This is a quote. "There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends." Now this is very curious, because after spending all this time reviewing the literature and setting up evidence criteria, 6 of the 11 recommendations (more than one half) were based on consensus opinion. For a consensus opinion, 75% of the committee had to agree, whereas for other recommendations based on trials, only two thirds did.

So here we have these curious paradoxes recommending things with a long genuflecting to clinical trials, and then having more than one half of the recommendations based on consensus opinion. It doesn't seem to make sense.

So let's go over the recommendations.

Recommendation 1

In the general population aged 60 years or older, initiate pharmacologic treatment to lower blood pressure. That's systolic blood pressure of 150 mm Hg or higher or diastolic of 90 mm Hg or higher, and treat to a goal of lower than 150 mm Hg and lower than 90 mm Hg. This is a grade A recommendation. That was the only one that they did that was a grade A recommendation.

Corollary Recommendation

A corollary to that was in the general population aged 60 years or older: If pharmacologic treatment for high blood pressure results in a lower achieved systolic pressure -- for example, less than 140 mm Hg -- and treatment is not associated with adverse effects on health or quality of life, then treatment need not be adjusted.

This was grade E, for expert opinion. This is important, because sometimes people think that if you reach a lower-than-average goal, the committee recommends that you should back down on therapy. That's not the case at all. If your patient is doing well with the treatment and not having a problem, then you should leave well enough alone. And they made that pretty clear.

Recommendation 2

In the general population younger than 60 years, initiate pharmacologic treatment to lower blood pressure at diastolic greater than 90 mm Hg and treat to a goal diastolic blood pressure of less than 90 mm Hg. For patients aged 30-59 years, this was a strong recommendation (grade A). For those 18-29 years of age, there's a similar recommendation, but it was based on expert opinion (grade E).

Recommendation 3

In the general population younger than 60 years, initiate pharmacologic treatment to lower blood pressure at systolic blood pressure greater than or equal to 140 mm Hg and treat to a goal of less than 140 mm Hg. This was expert opinion (grade E).

Recommendation 4

In the population older than 18 years with chronic kidney disease, initiate pharmacologic treatment to lower blood pressure at systolic values greater than or equal to 140 mm Hg or diastolic values greater than or equal to 90 mm Hg, and treat to a goal systolic blood pressure of less than 140 mm Hg and a goal diastolic of less than 90 mm Hg. This was also expert opinion (grade E).

Recommendation 5

In the population aged 18 years or older with diabetes, initiate pharmacologic treatment to lower blood pressure with systolic values greater than or equal 140 mm Hg or diastolic values greater than or equal to 90 mm Hg, and treat to a goal systolic blood pressure of less than 140 mm Hg and a goal diastolic of less than 90 mm Hg. This was expert opinion (grade E).

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