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terol guidelines, cardiovascular (CV) risk assessment, and lifestyle
management to reduce CV risk and Obesity. There were immediate
rebuttals, critiques and differing perspectives from various corners,
which will undoubtedly continue regarding many guidelines. The
National Lipid Association decided not to sponsor the ACC/AHA
cholesterol guidelines, which had not included the Non-HDL as
an important component for assessing cardiac risk, and had eliminated specific LDL goals after more than a decade of stressing the
importance of “know your numbers.” The Risk Analysis Ruler has
been criticized for over-stating the problem and for having not been
rigorously tested before the widespread recommendations for its use.
European guideline groups (ESH & ESC- European Society of
Hypertension & European Society of Cardiology respectively) have
managed to get a sizable number of their updated guidelines out
quickly. European hypertension guidelines of June 20131 recommend
optimal blood pressure to be less than 140/90 for all, moving away
from their 2007 recommendations of super-low blood pressure
(<130/80) in previously recommended specific high- risk groups
of diabetics and chronic kidney disease patients. On November 15,
2013, a Science Advisory on high blood pressure control “ intended
to complement and support clinical guidelines, providing clinicians and health systems tools to improve treatment and control
of hypertension” authored by 25 national and international writers
under the auspices of ACC, AHA and CDC was published in the
AHA journal Hypertension.2 The long-awaited and interminably
late JNC-8 hypertension guidelines were published in JAMA on
December 18, 2013.3 Controversy has reared its ugly head and
ACC/AHA as well as NHLBI have not endorsed these guidelines
and there has been at least one call to retract the guidelines! The
American Society of Hypertension (ASH) in conjunction with the
International Society of Hypertension (ISH) published its own
guidelines in the Journal of Clinical Hypertension on December
19, 2013.4 Some confusing differences between the guidelines are
worth noting: in the ASH/ISH guidelines, treatment threshold to
start therapy has been set at >150/90 mm Hg for patients 80 years
or older; however it still applies to 60 years or older patients in the
JNC 8 guidelines. For initial drug choices in non-black patients,
JNC 8 has recommended an ACE inhibitor, angiotensin-receptor
blocker (ARB), calcium channel blocker (CCB), or thiazide-type
diuretic as all reasonable. But the ASH/ISH guidelines recommend
an ACE inhibitor or ARB for nonblack patients under age 60 and
a CCB or thiazide in nonblack patients over 60. Many points in
these guidelines remain contentious and will be the subject of
endless discussions. The latest news is quite revelatory that ASH
will collaborate with ACC and AHA for yet another set of new new
guidelines that will be out in about one year! Can hardly wait…….
Canadian guidelines for dyslipidemia came out in 2012 and their
hypertension guidelines (CHEP- Canadian Hypertension Education
Program)5 have been published in a timely and organized annual
basis for many years. Collectively, all these references provide a
standardized framework for the best evidence-based patient care
except of course when there are disagreements, differences, discord
and disharmony. Another outfit by the name of “Institute for Clinical
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Systems Improvement (ICSI)” published its 14th edition of Hypertension Diagnosis and Treatment Health Care guidelines in 2012.
The seeds of discord and disharmony have been sown in the
medical community, which again re-emphasizes the lesson that
pushers of what has sometimes been called “cookbook medicine”
(the guidelines gurus) will have to contend with the objections of the
physicians in the trenches. There will be and already are questions
about the optimal level of LDL and the goal of blood pressure in
different patient populations. And here the attorneys and the quality
care assurance personnel thought that guidelines were immutable
and if anyone dared to steer away from these gospel truths, they
could be cited and hounded in quality improvement committees,
if not tarred and feathered.
Most guidelines are too long, boringly unreadable with nothing
substantial or game-changing and generally do not contain any
earth-shattering pronouncements. All in all, I am rather underwhelmed by the whole guidelines process. The writing committees
of these elaborate guidelines do not believe in brevity and succinctness. To be fair, some guidelines have separate “translations” and
condensed recommendations in the form of executive summaries,
which are helpful for practicing physicians and other healthcare
providers who cannot find time to read these guidelines cover to
cover. Controversies and disagreements abound in the guidelines
issued by specialty societies. Disagreements about guidelines by
different entities about the same disease process or screening are
commonplace, and the practicing clinicians are understandably
confused and overwhelme