Seth Bilazarian, MD


January 30, 2014

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Ideal Guidelines

Hi, I'm Seth Bilazarian on on Medscape. For my Private Practice blog, I've been trying to make sense of guidelines now for a couple of months. We had lipid guidelines that came out in November at the American Heart Association (AHA) meeting, and then in December we had the publication of the new Joint National Committee (JNC 8) guidelines,[1] also called the "2014 hypertension guidelines," and I'm trying to make sense of it.

Some basic ideas about guidelines for me, as a clinician in community practice, is that my ideal guidelines would be written by a jury of my expert peers who are presumably not tainted by financial or other conflicts, and they would be of practical use for me to be able to share with patients or general referring doctors in deciding the best way forward. The definition of a guideline is that it puts forward a set of standards or determines a course of action.

I understand they ultimately will probably be focused on both individual and population strategies for optimal disease prevention for the lipid, hypertension, and diabetes guidelines.


The history around JNC 8 is very interesting. JNC 7 was published 10 years earlier than JNC 8 was published.[2] There was an AHA scientific session in 2007 that dealt with hypertension and other risk factors for secondary prevention for coronary disease, diabetes, kidney disease, left ventricular dysfunction, and peripheral arterial disease (PAD) patients.[3] The National Heart, Lung, and Blood Institute (NHLBI) formed JNC 8 in 2008, 5 years before the ultimate publication. It was expected to be released in the spring of 2010.

After that expected release, there was another secondary prevention guideline from the American College of Cardiology (ACC)/AHA in 2011.[4]

Finally, we had the publication on December 18, 2013, 10 years after the last guidelines and 5 years after the JNC 8 was formed. It's available free on the JAMA Website. Unfortunately, right at the same time as the release, the AHA President-Elect said that they had reservations about the recommendations. And frankly, from reading that statement, it seemed like they don't even recognize these JNC 8 guidelines.

Then, unfortunately, there were further complications. On January 14, a little less than a month later, 5 of the 17 authors of JNC 8 wrote a dissenting paper published in Annals of Internal Medicine explaining why they don't agree with the guidelines.[5] And then, ACC/AHA released a statement that they anticipated new guidelines in 2015 -- next year.


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