Discord among international, organizational blood pressure guidelines have led to confusion between physicians and patients alike, according to a paper published in the Journal of the American College of Cardiology.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, 2018 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines, and 2017 American College of Physicians (ACP)/American Association of Family Physicians (AAFP) guidelines recommend blood pressure targets of <130/80 mm Hg, <140/90 mm Hg, and <150/90 mm Hg, respectively, for optimal on-treatment blood pressure. For initial antihypertensive therapy, the 2017 ACC/AHA guidelines, 2018 ESH/ESC guidelines, and 2017 ACP/AAFP guidelines recommend treatment with 1 drug, 2 drugs, and no drugs, respectively.

Although these guidelines differ in regard to antihypertensive care, they are all based on the same evidence. The schism in the guidelines has been argued as a primary contributor to low-value care, particularly if physicians follow advice from a guideline that results in inefficient or inappropriate care. The overwhelming number of guidelines published by each organization lead to confusion in practice; for example, of the 2711 recommendations listed in the 2009 ACC/AHA guidelines, a median of 11% of the guidelines were classified as level of evidence A, whereas guidelines classified as level of evidence C were attributed to a median of 48% recommendations.

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According to Franz H. Messerli, MD, and Sripal Bangalore, MD, MHA, from the University Hospital in Bern, Switzerland, and New York University Langdon Health, authors of a case report published in the Journal of the American College of Cardiology, the differences in opinions among physicians in regard to what constitutes hypertension will likely cause anxiety among patients. For instance, a patient may believe they are not receiving the level of care they require if their physician does not deem their blood pressure readings as signs of hypertension or prehypertension. Likewise, some patients may refuse treatment escalations if physicians change therapy regimens based on new, albeit differing, treatment guidelines.

“Unless we make a concerted effort to do so, as the number of guidelines is increasing more rapidly than does iron-clad evidence,” wrote Dr Messerli and Dr Bangalore, “we are prone to see more and more schism among recommendations, confusion among physicians, and anxiety among patients.”


Messerli FH, Bangalore S. The blood pressure landscape: schism among guidelines, confusion among physicians, and anxiety among patients. J Am Coll Cardiol. 2018;72(11):1313-1316.