Updated March 26, 2015.
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Traditionally, when treating hypertension (high blood pressure) doctors have looked to guidelines released periodically by the Joint National Committee (JNC), a panel of experts appointed and funded by the National Heart Lung and Blood Institute (NHLBI). The last JNC official guidelines (JNC 7) were published way back in 2003, and as the years have gone by, and as scores of new clinical trials on hypertension were published, those old JNC 7 guidelines became somewhat long in the tooth.
Accordingly, doctors have been waiting impatiently for the long-promised update, JNC 8. However, the JNC 8 guidelines have been repeatedly and frustratingly delayed.
A Sudden Plethora of Guidelines
Then in June, 2013 the NHLBI suddenly made a change in policy. They dissolved their JCN 8 panel altogether, and announced that new hypertension guidelines would henceforth be developed in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Accordingly, in August 2013, the ACC and AHA published an interim statement it called a "scientific advisory" on hypertension. Likely out of frustration at the delay in new guidelines, in December, 2013, the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) released its own joint set of treatment guidelines. And earlier in 2013 the European Society of Hypertension (ESH) published yet another set of hypertension treatment guidelines.
Then, to add to this profusion of new guidelines, in December, 2013 the officially-defunct JNC 8 panel (now referring to themselves as the “panel members appointed to the Eighth Joint National Committee"), finally published their own set of (now unofficial) guidelines.
So, to recap, within a few short months, doctors went from the outdated JNC 7 guidelines to dealing with three brand new sets of guidelines - from the ESH, from the ASH/ISH, and from the JNC 8 panel members - as well as a very-guideline-like interim statement on hypertension treatment from the ACC/AHA.
As might be expected, there are differences among these four sets of guidelines. And understandably, many doctors are quite disturbed by these differences. For, if their bureucratic overseers are going to grade the quality of their performance by their adherence to guidelines, what are doctors supposed to do when the guidelines disagree?
If you are a patient with hypertension, however, you shouldn’t be too troubled by variations among the new sets of hypertension guidelines. In their major points, these guidelines are in substantial agreement - and they really don’t change things very much from what has become standard medical practice over the past 10 years. Even if you are a doctor, your anxiety should be relatively short-lived. The ACC, AHA and ASH are reportedly collaborating with the NHLBI to devise what appears destined to become the new “official” hypertension guidelines, against which doctors’ “quality” will finally be graded. So the current ambiguity should be temporary.
What Are The Major Differences Among These Guidelines?
In general, all these guidelines agree on the definition of hypertension and its stages, as follows:
- Stage 1 hypertension: systolic pressure 140 - 159 mmHg, OR diastolic pressure 90 - 99 mmHg
- Stage 2 hypertension: systolic pressure greater than 159 mmHg, OR pressure diastolic greater than 99 mmHg
The new guidelines from the ESH emphasize the need for ambulatory blood pressure monitoring - as opposed to purely office-based blood pressure measurements - for diagnosing hypertension. The other sets of guidelines stop well short of requiring ambulatory monitoring, and some (notably the JNC 8 guidelines) don’t even address how hypertension should be evaluated.
- Read about diagnosing hypertension.
- Read about ambulatory blood pressure monitoring and its advantages.
The four sets of guidelines differ somewhat in their specific recommendations regarding the medical therapy of hypertension.
- The ESH guidelines, essentially, say that doctors should individualize medical care, and should feel free to use whichever drugs work for their patients. Most of the other guidelines are more prescriptive about medical therapy.
- All of the new guidelines, except the ESH, discourage the use of beta blockers as the sole initial therapy for hypertension.
- The ASH/ISH guidelines recommend using angiotensin converting enzyme inhibitors (ACE drugs) or angiotensin receptor blockers (ARB drugs) as first-line therapy in people under 60, and thiazide diuretic in people over 60.
- The JNC 8 guidelines allow the use of ACE, ARB, thiazides, and calcium channel blockers (CCB drugs) in all age groups.
- The ACC/AHA advisory suggests using thiazide diuretics first, then adding an ACE, ARB or CCB if needed.
- All four guidelines recognize that black patients with hypertension often do not respond well to ACE and ARB drugs, and suggest using a thiazide or CCB as first-line therapy.
The Big Difference
The most controversial difference among these new guidelines is that JNC 8, in a departure from the other three sets of guidelines and from standard practice, now do not recommend treating patients 60 years of age or older unless they have stage 2 hypertension - that is, unless their blood pressure is higher than 150/90. Further, JNC 8 states that the target of therapy for these older patients should be to achieve a blood pressure lower than 150/90 (and not 140/90, as in other guidelines).
The reason the JNC 8 panel relaxed the hypertension guidelines for older patients is a little difficult to tease out from the guidelines document itself. It appears to be for two reasons. The first is a negative reason - randomized trials have not definitively shown that more aggressive treatment yields better outcomes in older patients. And second, because older people tend to have systolic hypertension, aggressive attempts to reduce their blood pressure can cause problems. In particular, reducing the blood pressure too much can produce symptoms of lightheadedness and dizziness, leading to falls.
But the JNC 8 panel is clearly the outlier in its recommendations for older patients. It is tempting to speculate that its desire to relax treatment goals for older patients had something to do with the official “decommissioning” of the JNC 8 panel in 2013. In any case, when the NHLBI-sanctioned “official” hypertension guidelines are finally published by the ACC/AHA/ASI, I for one will be surprised if this higher treatment threshold for older patients remains.
The Bottom Line
Despite the differences among these various sets of guidelines, the principles of treating hypertension are unchanged from what has become standard practice over the past decade. While recommendations on initial drug therapy vary somewhat among these guidelines, there is little firm evidence that one drug is better than another. All these drugs work reasonably well, and as long as the doctor has a systematic way of approaching the treatment of hypertension in his or her patients, good results can be expected for most patients.
The question of when and how to treat older patients with hypertension is really the only substantial difference among the various guidelines. This difference, I believe, reflects the fact that it is not really possible to issue firm treatment guidelines that are suitable for every older patient with hypertension. Older patients are more likely to have systolic hypertension, and are more likely to be taking drugs that complicate the treatment of hypertension, and therefore it is inherently difficult to generalize about their therapy. Hopefully, the forthcoming and much-anticipated “official” guidelines on hypertension, when they finally appear, will leave plenty of room for individualizing therapy in these often-challenging patients. Because these days, your typical “good doctor” will likely follow guidelines to the letter, whether they fully make sense or not.
Go AS, Bauman M, Coleman King SM, et al. An effective approach to high blood pressure control: A science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension 2013; available at http://hyper.ahajournals.org.
Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens 2013; DOI:10.1111/jch.12237.
Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J 2013; DOI: 10.1093/eurheartj/eht.151.
James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; DOI:10.1001/jama.2013.284427. Available at: http://jama.jamanetwork.com/journal.aspx.