The 2017 high blood pressure clinical practice guideline: The old and the new.

Abstract

The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults was made public on November 13, 2017 (http://www.acc.org/latest‐in‐cardiology/ten‐points‐to‐remember/2017/11/09/11/41/2017‐guideline‐for‐high‐blood‐pressure‐in‐adults).1 The American College of Cardiology (ACC)/American Heart Association (AHA) and other societies, including the American Society for Preventive Cardiology (ASPC), participated in its development. Guidelines are complex work products; they require compromise and a deep evaluation and understanding of current and past evidence. They are intended to help clinicians, patients, payers, and policymakers in their respective decision‐making process. Given the sometimes disparate interests of these stakeholders, construction of guidelines can be extraordinarily complex. Defined by the Institute of Medicine in 1990, guidelines are “systemically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”2 Though intended to improve patient care, guidelines can be unintentionally misused by clinicians, patients, payers, and policymakers, all of whom may fail to recognize the guidelines' limitations. They were created to assist, not dictate, decision making. As an example, patients may decline a therapeutic strategy if it is not in a guideline, even when their physician understands why they might best be served by management that falls outside of a guideline. Payers may extract statements without context to support restricting access to novel or costly therapies. Application of guidelines can also be limited by undue complexity. Finally, the unharmonized nature of competing guidelines for the same disease state can increase confusion instead of reducing it. The 2017 guideline appears to be different. Though a long document, its message is rather simple and straightforward; high blood pressure causes complications, and treating it reduces them. Simple blood pressure cut‐points with associated clear therapeutic recommendations make this guideline easy to follow. Clinical flexibility is also fundamental to the document, respecting clinical acumen in shared decision making, a vital aspect of optimal healthcare. Finally, the involvement of multiple organizations in the construction and endorsement of the document may reduce the risk of confusion driven by diverse high blood pressure guidelines. In sum, what one will find from this guideline is a clinical breath of fresh air; it represents compromise, coordination among groups, and a simple message for patients and clinicians alike. We have chosen to examine this guideline in the context of history: what is old and what is new. By doing so, we hope to highlight salient, clinically relevant changes in blood pressure management.