Henry R. Black, MD


December 19, 2013

In This Article

What's Good, What's Missing

What do we think about all this? Well, I think for what they covered, this is useful. But there are many, many important things that were left out.

One is how you make the diagnosis of hypertension. The National Institute for Health and Care Excellence (NICE) in the United Kingdom recommended ambulatory blood pressure monitoring as necessary to diagnose hypertension, recognizing how common white-coat hypertension is and how common masked hypertension is.[4] This wasn't addressed at all. So this is a very important thing.

They did nothing about work-up -- what you should do with your patients. This is something that doctors really need to know, and it wasn't discussed at all.

Also, they left out verapamil as a nondihydropyridine calcium-channel blocker. This is an important drug commonly used. In fact, it was the first calcium-channel blocker introduced of the nondihydropyridine classes. It's not listed here at all because they felt that some of the studies that used verapamil and showed benefit were not done in hypertensive patients.

They left out the ADVANCE study, which showed the benefits of adding indapamide with an ACE inhibitor to actually reduce mortality.[5] This was a study done in Australia, but some of the patients who were enrolled were not hypertensive. This is somewhat important, because a lot of people that we deal with may not have hypertension when we first see them because they're on treatment or because they're in the prehypertensive range. And we do know some epidemiologic studies that prehypertensive patients have a greater risk. Because there wasn't a clinical trial that directly organized things this way, those studies were not talked about in JNC 8.

They also do some things that I really don't agree with. They have a list of what drugs to use and what doses to use, and they make a point of a targeted dose in the trials reviewed of going up to 100 mg of hydrochlorothiazide. We did not like that in JNC 7. We think that dose is too high, as do most people who treat hypertension now. But that was considered evidence-based dosing in JNC 8.

It was evidence-based dosing because in the earlier studies, which they included, that was the dose used. There hasn't been a modern trial that's used any dose of that nature. In fact, more modern trials used indapamide often and chlorthalidone, such as was used in ALLHAT.[6] That's an important gap, I think, in the program.

What do we do with this? Well, I think what we have to do is take it for what it is. It does update some things. This actually changes relatively little. JNC 7 took us only 3-4 months to do. But this has taken about 3 or 4 years, and it changed very little. I think it's important to look at Table 6 in the publication, which compares goals and initial therapy in the various guidelines that have been in hypertension . I think that's valuable.

But I think that the clinician who is looking at it will be able to see that these guidelines don't agree, which disturbs me a little bit, because the editorial talked about a need for harmonizing guidelines.[7] I think that's a nice idea, but I don't see how that's going to happen. It's very tough to get a consensus. I think the informed clinician will have to make his or her own judgment about which of these guidelines to follow, and more important, what they think when they're looking at that individual patient.

One of my problems with using clinical trials as the gold standard -- and they used that term several times -- is that if you read the clinical trial inclusions and exclusions carefully and your patient would not have been in one of those clinical trials, how relevant are guidelines in those trials? In my opinion, they're not very relevant. I think that's a very important objection to using clinical trials as the major way to decide things because even with all this work, 6 of the 11 recommendations had to be based on expert opinion. We could worry whether this entire idea is a flawed idea from the beginning.

I know that this is a very confusing thing for clinicians who see a lot of hypertensive patients. And I think we also know that hypertension is the major reason that people see doctors in the United States right now, and probably in the rest of the world as well. It was the most important contributor to mortality and to quality of life, and I think we have to better understand how to do this.

I think lightening up on the goals and making them less strict may or may not be a good thing. But I think it's not clear from what we have right now whether that's going to help or hurt. So I appreciate your attention, and thank you very much.


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