Editorial 189
Recent guidelines for the management of hypertension: what is missing? Lawrence R. Krakoff Blood Pressure Monitoring 2014, 19:189–191 Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA Correspondence to Lawrence R. Krakoff, MD, Department of Medicine, Icahn School of Medicine at Mount Sinai, 5 East 98th Street Box 1030,
The last advisory for the management of hypertension, JNC-7, supported by the US National Heart Lung and Blood Institute (NHLBI) was published in 2003, more than 10 years ago [1]. Previously, these guidelines were released at roughly 5 year intervals beginning the first one in 1977 [2]. A new version of the NHLBI advisory, named JNC-8, was in the process of its necessarily thorough and lengthy preparation when the institute chose to remove itself from the sponsorship of such guidelines and, instead, assist professional organizations in their efforts to fill in the gap [3]. An enormous effort by a respected and dedicated group, chosen by NHLBI to author JNC-8, was not wasted as this group published the results of their deliberations [4]. As this much publicized publication was not sponsored by NHLBI, but derived from the process, I will refer to it as JNC-8D. At present it is an orphan without an official sponsorship, but may well be adopted by organizations that find it valuable for their views of how hypertension should be managed. JNC-8D does not stand alone, but is among several guidelines for the management of hypertension in general or in the context of important subgroups that have separate guidelines published in the last 3 years. The joint sponsorship of the ACC and AHA provided a guideline for the management of hypertension in the elderly [5]. This combined organization (AHA/ACC) also published a brief guideline featuring a simple algorithm and emphasized how healthcare systems could improve the overall control of hypertension [6], based on the experience in the Kaiser Permanente-captured population [7]. The American Diabetes Association (ADA) published a guideline for the management of diabetes that included detailed and important information for the management of hypertension in the diabetic population [8]. An extensive and highly detailed guideline was put forth by the combined efforts of the European Society of Hypertension and the European Society of Cardiology [9]. Only a few months after publication of that guideline, the American Society of Hypertension joined the International Society of Hypertension for a separate, somewhat streamlined, advisory [10]. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1359-5237
New York, NY 10029-6574, USA Tel: + 1 212 241 1789; fax: + 1 212 410 7196; e-mail: [email protected] Received 30 December 2013 Revised 13 March 2014 Accepted 20 March 2014
Even a brief glance at each of these guidelines (Table 1) exposes important differences that may determine how they will be used by the various audiences. For the busy generalist, will the long and reference heavy guidelines be attractive or will the shorter, concise advisories be more appealing (Table 1)? The shorter guidelines lack the detail needed when complex problems need attention. Will those who need the details turn to the more detailed guidelines or use rapidly accessible on-line resources? For the researcher, on-line searches for original sources will probably never replace the compendia of guidelines, unless one is comparing guidelines, per se. Among the six guidelines, there is some agreement on the criteria for diagnosis of hypertension and for defining control of hypertension. However, for older patients the criteria of 140/90 mmHg have been relaxed and shifted upward to 150 mmHg systolic pressure [4,5] or even 160 mmHg systolic pressure [9]. The change in the recommended control levels for hypertension in diabetes from 130/80 mmHg to 140/90 mmHg is strongly evidence based and accepted by the ADA guidelines [8]. These guidelines also accept the potential value for blood pressure control to lower levels in healthy and younger diabetic hypertensives – a flexibility that many clinicians will find appealing. Clinical research in hypertension has decisively supported the value of out-of-office measurement of blood pressure by either ambulatory blood pressure monitoring (ABPM) [11], or home blood pressure recording [12,13]. The UK NICE guidelines have gone so far as to recommend ABPM for secondary screening of all identified as hypertensive at their initial clinic visit, that is, the primary screen [14]. Four of the six guidelines summarized here accept the value of ABPM (Table 2). It is a surprise that neither the JNC-8D [4] nor the AHA/ACC guideline by Go et al. [6] recognize the importance of ABPM for the detection of white coat hypertension, masked hypertension, or for evaluating resistant hypertension [15]. Go and colleagues accept home blood pressure as a modality, but only for the DOI: 10.1097/MBP.0000000000000047
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
190
Blood Pressure Monitoring 2014, Vol 19 No 4
Table 1
Recent guidelines with length, number of references, and criteria for diagnosis of hypertension and goals for treatment
Guidelines
Focus
Definition of hypertension
Treatment goals
Elderly AHA/ACC [5]
Older or the elderly
ADA diabetes [8]
Diabetic hypertensives
AHA uncomplicated (> 140/90) DM CRD, CVD (> 130/80) Z 140/90
AHA/ACC [6] ESH/ESC [9] JNC-8D [4] Not endorsed by NIH or other organization
Adult hypertensives Adult hypertensives Adult hypertensives
< 140 (55–80 years) < 145 (80 + years) < 140/90 for most; 80 years, then 60 (Z 150/90) Z 140/90 until age 80, then Z 150 systolic
< 140/90 for most;
Recent guidelines for the management of hypertension: what is missing? Lawrence R. Krakoff Blood Pressure Monitoring 2014, 19:189–191 Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA Correspondence to Lawrence R. Krakoff, MD, Department of Medicine, Icahn School of Medicine at Mount Sinai, 5 East 98th Street Box 1030,
The last advisory for the management of hypertension, JNC-7, supported by the US National Heart Lung and Blood Institute (NHLBI) was published in 2003, more than 10 years ago [1]. Previously, these guidelines were released at roughly 5 year intervals beginning the first one in 1977 [2]. A new version of the NHLBI advisory, named JNC-8, was in the process of its necessarily thorough and lengthy preparation when the institute chose to remove itself from the sponsorship of such guidelines and, instead, assist professional organizations in their efforts to fill in the gap [3]. An enormous effort by a respected and dedicated group, chosen by NHLBI to author JNC-8, was not wasted as this group published the results of their deliberations [4]. As this much publicized publication was not sponsored by NHLBI, but derived from the process, I will refer to it as JNC-8D. At present it is an orphan without an official sponsorship, but may well be adopted by organizations that find it valuable for their views of how hypertension should be managed. JNC-8D does not stand alone, but is among several guidelines for the management of hypertension in general or in the context of important subgroups that have separate guidelines published in the last 3 years. The joint sponsorship of the ACC and AHA provided a guideline for the management of hypertension in the elderly [5]. This combined organization (AHA/ACC) also published a brief guideline featuring a simple algorithm and emphasized how healthcare systems could improve the overall control of hypertension [6], based on the experience in the Kaiser Permanente-captured population [7]. The American Diabetes Association (ADA) published a guideline for the management of diabetes that included detailed and important information for the management of hypertension in the diabetic population [8]. An extensive and highly detailed guideline was put forth by the combined efforts of the European Society of Hypertension and the European Society of Cardiology [9]. Only a few months after publication of that guideline, the American Society of Hypertension joined the International Society of Hypertension for a separate, somewhat streamlined, advisory [10]. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1359-5237
New York, NY 10029-6574, USA Tel: + 1 212 241 1789; fax: + 1 212 410 7196; e-mail: [email protected] Received 30 December 2013 Revised 13 March 2014 Accepted 20 March 2014
Even a brief glance at each of these guidelines (Table 1) exposes important differences that may determine how they will be used by the various audiences. For the busy generalist, will the long and reference heavy guidelines be attractive or will the shorter, concise advisories be more appealing (Table 1)? The shorter guidelines lack the detail needed when complex problems need attention. Will those who need the details turn to the more detailed guidelines or use rapidly accessible on-line resources? For the researcher, on-line searches for original sources will probably never replace the compendia of guidelines, unless one is comparing guidelines, per se. Among the six guidelines, there is some agreement on the criteria for diagnosis of hypertension and for defining control of hypertension. However, for older patients the criteria of 140/90 mmHg have been relaxed and shifted upward to 150 mmHg systolic pressure [4,5] or even 160 mmHg systolic pressure [9]. The change in the recommended control levels for hypertension in diabetes from 130/80 mmHg to 140/90 mmHg is strongly evidence based and accepted by the ADA guidelines [8]. These guidelines also accept the potential value for blood pressure control to lower levels in healthy and younger diabetic hypertensives – a flexibility that many clinicians will find appealing. Clinical research in hypertension has decisively supported the value of out-of-office measurement of blood pressure by either ambulatory blood pressure monitoring (ABPM) [11], or home blood pressure recording [12,13]. The UK NICE guidelines have gone so far as to recommend ABPM for secondary screening of all identified as hypertensive at their initial clinic visit, that is, the primary screen [14]. Four of the six guidelines summarized here accept the value of ABPM (Table 2). It is a surprise that neither the JNC-8D [4] nor the AHA/ACC guideline by Go et al. [6] recognize the importance of ABPM for the detection of white coat hypertension, masked hypertension, or for evaluating resistant hypertension [15]. Go and colleagues accept home blood pressure as a modality, but only for the DOI: 10.1097/MBP.0000000000000047
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
190
Blood Pressure Monitoring 2014, Vol 19 No 4
Table 1
Recent guidelines with length, number of references, and criteria for diagnosis of hypertension and goals for treatment
Guidelines
Focus
Definition of hypertension
Treatment goals
Elderly AHA/ACC [5]
Older or the elderly
ADA diabetes [8]
Diabetic hypertensives
AHA uncomplicated (> 140/90) DM CRD, CVD (> 130/80) Z 140/90
AHA/ACC [6] ESH/ESC [9] JNC-8D [4] Not endorsed by NIH or other organization
Adult hypertensives Adult hypertensives Adult hypertensives
< 140 (55–80 years) < 145 (80 + years) < 140/90 for most; 80 years, then 60 (Z 150/90) Z 140/90 until age 80, then Z 150 systolic
< 140/90 for most;
