Dueling Hypertension Guidelines

What's a good doctor supposed to do now?

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If you have hypertension (high blood pressure), you may have heard rumblings recently - on the news or perhaps from your doctor - about some new hypertension treatment guidelines which were released in 2013.  These new guidelines have created a fair amount of angst in many quarters of the medical community.  

Why rumblings? Why angst? It's because when the new and long-awaited hypertension guidelines were finally announced, doctors were presented not with one set of guidelines, but with three (or four, depending on who's counting), each issued by different expert panels.

 And there are some notable differences among these various sets of treatment guidelines.  

This leaves the modern American doctor, dedicated to practicing high-quality medicine as currently defined (that is, by closely adhering to evidence-based treatment guidelines) in something of a quandary.  If doctors want to be counted as high-quality practitioners (which helps to determine such things as how they are paid, and even whether they are permitted to see patients at all under various plans),  which set of hypertension guidelines should they follow?

Where Did All These New Guidelines Come From?

By convention, the generally accepted treatment guidelines for hypertension have come from the Joint National Committee (JNC), a panel of experts appointed and funded by a Federal agency (the National Heart Lung and Blood Institute, or NHLBI).

 For decades the JNC would issue or update formal hypertension guidelines every few years, a total of 7 times.  But the last set of guidelines (JNC 7) was released way back in 2003, and for several years now the medical community has been expecting a badly needed update.  For a long time they waited in vain for JNC 8 (or, as it eventually came to be known, "JNC late.")  

Then in June, 2013 the NHLBI suddenly announced a change in policy - the NHLBI would no longer directly issue treatment guidelines through their JNC.  Instead, the NHLBI would collaborate with various professional organizations (such as the American College of Cardiology - ACC - and the American Heart Association - AHA) to produce guidelines.  With this new policy, the JNC panel (which had been working away at JNC 8 guidelines for several years) was essentially dissolved.  

At least partly because of the extended delay with JNC 8, other expert groups decided to fill the guidelines vacuum.  In August 2013 the ACC and AHA (which were now beginning their work in collaboration with the NHLBI to produce more-or-less "official" hypertension guidelines at some unknown date in the future), published an interim statement it called a "scientific advisory" on hypertension. 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) also published another set of hypertension treatment guidelines.  

Then, to add to this profusion of new guidelines, in December, 2013 the members of the decommissioned JNC 8 panel (now referring to themselves as the “panel members appointed to the Eighth Joint National Committee"), published their own set of guidelines.  While these JNC 8 guidelines are not considered "official" any longer, and indeed appear merely to represent the consensus opinion of the individuals who comprised the now-defunct JNC 8 panel, their publication nonetheless carries a lot of influence in the medical community.

So, to recap, within a few short months, doctors went from dealing with the outdated, 10-year old 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.  

Presumably, when the new, official, NHLBI-sanctioned guidelines from the ACC/AHA are eventually released, they will likely take precedence over all these others. But that happy event is likely to be a year or longer in the future.

In the meantime, doctors are faced with 3 (or 4) sets of dueling guidelines, all of which say different things. Without an "official" set of guidelines, what is a good doctor supposed to do?

What Is A Good Doctor Supposed To Do?

As we have seen, in the modern era a good doctor gathers up the "official" or consensus guidelines for managing a particular medical condition, and follows them.  But what will a good doctor do when there are no consensus guidelines?

A good doctor will realize that when there are no consensus guidelines, or worse, when there is more than one set of guidelines that differ in substantial ways, that very fact means something important.  It means that, for one reason or another, various expert panels have been unable to agree on treatment rules that can safely be applied to each and every member of the herd.  In other words, it likely means that there isn't a set of simple rules that can be safely and effectively applied to everyone; it means that, at least in some patients, the treatment will have to be individualized, and the doctor's clinical judgment will have to be applied.  

So the good doctor will take into account all the pertinent information about the individual patient being treated and their medical condition, and will use their clinical judgment to make the best possible recommendation for that individual. And in doing so the good doctor will not feel frustration, but will gain a sense of fulfillment by a job well done.

It seems quite apparent that hypertension is one of those conditions where herd medicine should not be applied to everyone.  While most relatively young patients with essential hypertension probably can be plugged safely into a standardized treatment algorithm, for other kinds of patients this is not the case.  For instance, for many older patients (who are more likely to have primarily systolic hypertension, and whose therapy has to be approached with caution), any kind of guideline you devise for the group will be likely to be too aggressive for some patients, and too lax for others.  (Indeed, it is in the management of older patients where the most significant differences are found among the different hypertension guidelines.)

It should not be surprising that in trying to devise treatment rules that will be applied to everyone, when they are dealing with people like elderly hypertensives, different guideline writers likely will come up with different sets of answers - and what you end up with is dueling guidelines. 

What is a little surprising is that expert panels seem to think they can and should come up with universal rules for groups of patients whose treatment inherently ought to be individualized.  And it's even more surprising that so many doctors appear frustrated when universal rules cannot be agreed upon for such patients. 

Doctors' anxiety over dueling guidelines may be more understandable, however, when you consider that the application of clinical judgment is a type of "performance" that cannot be easily tabulated, digitized, trended, and graded by the authorities who will ultimately determine their professional viability. 


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.

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