Hypertension Guidelines: But Wait, There's More!

Shelley Wood

January 03, 2014

NEW YORK, NY — Depending on how things turn out, advice on treating hypertension is about to get a whole lot simpler or a heck of a lot more contentious.

heartwire has learned that the American Society of Hypertension (ASH), which released its own hypertension guidelines last month in conjunction with the International Society of Hypertension (ISH), is now collaborating with the American Heart Association (AHA) and the American College of Cardiology (ACC) on yet another set of guidelines.

ASH president Dr William B White (University of Connecticut, Farmington) told heartwire that ASH will be signing on as an "equal partner."

"Optimistically," said AHA president Dr Mariell Jessup, the new new guidelines "will be out at the end of 2014 or early 2015."

After a Long Wait: Debate

After a decade of waiting for updated hypertension guidelines from "JNC-late," cardiologists and primary-care physicians found themselves reeling from a hypertension guideline glut that peaked at the end of 2013. The European Society of Hypertension had released new guidance in June. Then, in late December, a majority of members from the original eighth Joint National Commission (JNC 8) published guidelines in JAMA just hours after the ASH/ISH announced they'd released their own guidelines.

As reported by heartwire , the two December documents contained important points of disagreement. For one, the start-treatment threshold of >150/90 mm Hg applies to patients 80 years or older in the ASH/ISH guidelines but to patients 60 years or older in the JNC 8 document. The two guidelines also recommend different drugs for initial therapy, depending on the patients' race, age, and blood-pressure level. While JNC 8 stated that an ACE inhibitor, angiotensin-receptor blocker (ARB), calcium-channel blocker (CCB), or thiazide-type diuretic were all reasonable initial choices in nonblack patients, the ASH/ISH guidelines recommend an ACE inhibitor or ARB for nonblack patients under age 60 and a CCB or thiazide in nonblack patients over 60.

Dr Michael Weber (State University of New York, Brooklyn), lead author on the ASH/ISH guidance, speculated on the reasons behind the latest, planned, joint guidelines to heartwire .

"I assume that the motive for this plan is dissatisfaction with the outcomes of the JNC process, since if this were not the case the AHA and ACC, which had been given the rights to the JNC work by the [National Heart, Lung, and Blood Institute] NHLBI, would have formally endorsed the JNC committee's work and the matter would now be closed," he said. "My feeling is that although the JNC's article was not endorsed by any organization—as clearly stated in their article—their recommendations nevertheless have resulted from the review of the published literature according to the rules set up by the NHLBI. It is possible that these rules were excessively stringent in light of the absence of definitive evidence regarding the BP criteria for diagnosing hypertension and setting treating targets."

Weber, however, stressed that, based on a careful read of the JAMA paper, the JNC-8 writing committee "clearly acknowledged that they were not unanimous in reaching this decision; they also acknowledged that there were no adverse safety or efficacy issues associated with using the widely accepted 140/90 recommendation; and indicated that further clinical trials would be required to determine which criterion would be better."

Weber continued: "Since the candor of the JNC committee report left the door open for other experts and clinicians to draw their own conclusions, I'm not certain—despite the rigor of the AHA/ACC guidelines process—whether further value would be provided by yet a further exploration of the same evidence that has been available for the past several years."

Who Thinks What (and When), for Whom?

It's clear hypertension experts themselves are not sure what to make of the evidence, or lack thereof. Three of the authors on the JNC 8/JAMA guidelines are also authors on the ASH/ISH guidelines: Drs Sandra Taler, Raymond Townsend,and Barry Carter. In a statement emailed to heartwire , the three authors explained that the JNC report, published in JAMA, had not yet been completed at the time they reviewed and contributed to the ASH/ISH document.

 
The timing of the release of the two documents was unfortunate.
 

"There was no publication decision or dates for the JNC report, and we were not at liberty to divulge the contents of JNC when we participated in the ASH/ISH document," they wrote in the email. "The ASH/ISH document was intended as an international primer with general information, especially in communities and countries with low resources."

Moreover, they continued, the ASH/ISH document is "clearly" not evidence based and should be considered more as "an opinion piece," adding: "We did not consider it a guideline in the same way as the JAMA paper. It was not developed using a guideline process."

Finally, said Taler, Townsend, and Carter, "We believe the timing of the release of the two documents was unfortunate. We stand behind the JAMA paper as the most up-to-date guidelines based on the highest-level, scientific evidence as much as there is evidence available. It was rapidly processed by JAMA, so the release immediately after the ASH/ISH paper still makes it the most current document and the most evidence-based report to date."

Whether and how the AHA/ACC can pull together the various voices into a semblance of harmony within a matter of months remains to be seen. ""Hopefully it will serve a broad and diverse population," Jessup told heartwire . A "wide range" of different organizations have been invited to participate in the process, she noted.

CORRECTION:  An earlier version of this story incorrectly stated that the American College of Physicians (ACP) had signed on to help develop the joint new guidelines; an ACP spokesperson says the ACP has not officially decided whether to participate.

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