The “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)” recommends several major changes from the JNC 7 report (1–2). The 2014 guideline is based on a systematic review of randomized, controlled trials (RCTs) by a multidisciplinary panel using a process informed by Institute of Medicine recommendations for guideline development (3). Although there was almost unanimous agreement on nearly all recommendations, a minority of the panel (the authors of this commentary) disagreed with the recommendation to increase the target systolic blood pressure (SBP) from 140 to 150 mm Hg in persons aged 60 years or older without diabetes mellitus (DM) or chronic kidney disease (CKD). This target guides both the initiation of therapy and treatment goals. Although this issue has major clinical and public health implications, the guideline only briefly summarized the concerns underlying the minority opinion to maintain the target of less than 140 mm Hg. The Institute of Medicine recommendation for guideline development encourages guidelines to provide “a description and explanation of any differences of opinion regarding the recommendation” (3). This article summarizes the evidence and rationale underlying the minority opinion to maintain the SBP target of 140 mm Hg or lower in persons aged 60 years or older until there is greater certainty of the risks and benefits of a higher target.
The authors make a strong case. The more clinical trials published on a topic the more ways there are to combine and interpret the findings. And in hypertension the number of trials is very large. It rivals all of medicine in the number of trials published. There will be much more discussion about this. Guidelines from ACC/AHA are due out soon I'm told.
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