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Ambiguities in the Guidelines for the Management of Arterial Hypertension: Indian Perspective with a Call for Global Harmonization

  • Guidelines/Clinical Trials/Meta-Analysis (JB Kostis, Section Editor)
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Abstract

Many medical professional societies have formulated guidelines to treat hypertension, but there existed differences with respect to diagnosis, blood pressure (BP) targets, pharmacotherapy of hypertension, and grades of evidence. A MEDLINE search for hypertension guidelines was performed to compare Indian guidelines for hypertension (IGH) with these guidelines. A majority of the guidelines had consensus on the cutoff value (140/90 mmHg, recorded twice) to diagnose hypertension. The Joint National Committee 8 (JNC 8), IGH, Japanese Society of hypertension (JSH), Canadian Hypertension Education Program (CHEP), and American Society of Hypertension/International Society of Hypertension (ASH/ISH) guidelines provide a higher BP target for the elderly hypertensive populations, while the National Institute for Health and Care Excellence (NICE) and European Society of Hypertension (ESH) guidelines provided a lower BP target for the elderly patients. However, a meta-analysis showed benefits of having a systolic BP target of <130 mmHg for all patients. Treatment of hypertension according to JNC 8, NICE, and ASH/ISH guidelines varies among the black and the non-black population which recommended thiazide or calcium channel blockers for the black population. There is no special mention of pharmacotherapy or BP targets for the South Asian population in various guidelines including IGH despite evidence of higher risk of hypertension-associated complications in this population. It is suggested that all the available guidelines should be harmonized with highest level of evidence available to minimize ambiguities associated with management of hypertension.

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References

  1. Michel T, Hoffman BB. Treatment of myocardial ischemia and hypertension. In: Brunton LL, Chabner BA, Knollman BC, editors. The pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill Medical; 2011. p. 745–88.

    Google Scholar 

  2. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet. 2004;364(9438):937–52.

    Article  PubMed  Google Scholar 

  3. Chobanian AV, Barkis GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. The JNC seventh report. JAMA. 2003;289(19):2560–71.

    Article  CAS  PubMed  Google Scholar 

  4. Chalmers J, Arima H, Harrap S, et al. Global survey of current practice in management of hypertension as reported by societies affiliated with the International Society of Hypertension. J Hypertens. 2013;31(5):1043–8.

    Article  CAS  PubMed  Google Scholar 

  5. Association of Physicians of India. Indian guidelines on hypertension (I.G.H.)—III. 2013. J Assoc Physicians India. 2013;61(2 Suppl):6–36.

    Google Scholar 

  6. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159–219.

    Article  PubMed  Google Scholar 

  7. Virdis A, Ghiadoni L, Taddei S. Clinical management of drug-induced hypertension: 2013 Practical Recommendations of the Italian Society of Hypertension (SIIA). High Blood Press Cardiovasc Prev. 2014;21(1):77–9. doi:10.1007/s40292-014-0038-3.

    Article  CAS  PubMed  Google Scholar 

  8. Filipovský J, Widimský Jr J, Ceral J, et al. Diagnosis and treatment of arterial hypertension. 2012 Guidelines of the Czech Hypertension Society. Vnitr Lek. 2012;58(10):785–801.

    PubMed  Google Scholar 

  9. Blacher J, Halimi JM, Hanon O, et al. Management of arterial hypertension in adults: 2013 guidelines of the French Society of Arterial Hypertension. Ann Cardiol Angeiol. 2013;62(3):132–8. doi:10.1016/j.ancard.2013.04.009.

    Article  CAS  Google Scholar 

  10. 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;311:507–20.

    Article  CAS  PubMed  Google Scholar 

  11. Shimamoto K, Ando K, Fukita T, et al. The Japanese society of hypertension guidelines for the management of hypertension (JSH 2014). Hypertens Res. 2014;37(4):253–387.

    Article  PubMed  Google Scholar 

  12. Dasgupta K, Quinn RR, Zarnke KB, et al. The 2014 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention and treatment of hypertension. Can J Cardiol. 2014;30:485–501.

    Article  PubMed  Google Scholar 

  13. 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 Hypertens. 2014;32:3–15.

    Article  CAS  PubMed  Google Scholar 

  14. National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults (Clinical guideline 127). http://guidance.nice.org.uk/CG127. Accessed 10 July 2016.

  15. World Health Organisation. A global brief on hypertension: silent killer, global public health crisis. 2013. http://apps.who.int/iris/bitstream/10665/79059/1/WHO_DCO_WHD_2013.2_eng.pdf?ua=1. Accessed 10 July 2016.

  16. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31(12):2115–27.

    Article  Google Scholar 

  17. Ogihara T, Saruta T, Rakugi H, et al. Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: Valsartan in Elderly Isolated Systolic Hypertension Study. Hypertension. 2010;56(2):196–202.

    Article  CAS  PubMed  Google Scholar 

  18. Gueyffier F, Boutitie F, Boisset JP, et al. Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men. A meta-analysis of individual patient data from randomized, controlled trials. The INDANA Investigators. Ann Intern Med. 1997;126:761–7.

    Article  CAS  PubMed  Google Scholar 

  19. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet. 1990;335:827–38.

    Article  CAS  PubMed  Google Scholar 

  20. Blood Pressure Lowering Treatment Trialists Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591–8.

    Article  Google Scholar 

  21. Neal B, MacMahon S, Chapman N, for the Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;356:1955–64.

    Article  CAS  PubMed  Google Scholar 

  22. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387(10017):435–43. doi:10.1016/S0140-6736(15)00805-3.

    Article  PubMed  Google Scholar 

  23. Lonn EM, Bosch J, López-Jaramillo P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374(21):2009–20. doi:10.1056/NEJMoa1600175.

    Article  CAS  PubMed  Google Scholar 

  24. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial: major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. JAMA. 2002;288(23):2981–97.

    Article  Google Scholar 

  25. Brewster LM, van Montfrans GA, Oehlers GP, et al. Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med. 2016;11(3):355–74. doi:10.1007/s11739-016-1422-x.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Brewster LM, Seedat YK. Why do hypertensive patients of African ancestry respond better to calcium blockers and diuretics than to ACE inhibitors and b-adrenergic blockers? A systematic review. BMC Med. 2013;11:141.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Brewster LM, van Montfrans GA, Kleijnen J. Systematic review: antihypertensive drug therapy in black patients. Ann Intern Med. 2004;141:614–27.

    Article  PubMed  Google Scholar 

  28. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl Med. 2000;342:145–53.

    Article  Google Scholar 

  29. The ONTARGET investigators. Telmisartan, ramipril or both in patients at high risk for vascular events. NEJM. 2008;358:1547–59.

    Article  Google Scholar 

  30. Dahlöf B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as requiredversus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895–906.

    Article  PubMed  Google Scholar 

  31. Hippisley-Cox J, Coupland C, Robson J, Brindle P. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ. 2010;341:c6624.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Brindle P, May M, Gill P, Cappuccio F, D’Agostino Sr R, Fischbacher C, et al. Primary prevention of cardiovascular disease: a web-based risk score for seven British black and minority ethnic groups. Heart. 2006;92:1595–602.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors’ Contributions

Harmeet Singh Rehan—Hypothesis generation, manuscript writing

Abhinav Grover—Hypothesis generation, protocol writing

APS Hungin—Manuscript writing

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Correspondence to Harmeet Singh Rehan.

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Drs. Rehan, Grover, and Hungin declare no conflicts of interest relevant to this manuscript.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Guidelines/Clinical Trials/Meta-Analysis

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Rehan, H.S., Grover, A. & Hungin, A.P.S. Ambiguities in the Guidelines for the Management of Arterial Hypertension: Indian Perspective with a Call for Global Harmonization. Curr Hypertens Rep 19, 17 (2017). https://doi.org/10.1007/s11906-017-0715-4

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