State of the Art
Developing Hypertension Guidelines: An Evolving Process
Theodore A. Kotchen1
Hypertension guidelines provide up-to-date information and recom-
mendations for hypertension management to healthcare providers,
and they facilitate translation of new knowledge into clinical practice.
Guidelines represent consensus statements by expert panels, and the
process of guideline development has inherent vulnerabilities. Between
1977 and 2003, under the direction of the National Institutes of Health
(NIH), the Joint National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC) issued 7 reports. The evolution
of the JNC recommendations reflects the acquisition of observational
and clinical trial data and the availability of newer antihypertensive
drugs. Despite 5 years in preparation, NIH did not release a JNC 8 report
and recently made the decision to withdraw from issuing guidelines.
The responsibility for issuing hypertension-related guidelines was
transferred to the American Heart Association (AHA) and the American
College of Cardiology. Without the endorsement of the NIH or the AHA,
The National High Blood Pressure Education Program
(NHBPEP) was established in 1972, with the overall goal to
reduce death and disability related to high blood pressure
through programs of professional, patient, and public edu-
cation. The program was designed and implemented by the
then US National Heart and Lung Institute of the National
Institutes of Health (NIH). It evolved into a cooperative
effort among professional and voluntary health agencies,
state health departments, and community groups, coordi-
nated by the same organization, subsequently named the
National Heart, Lung, and Blood Institute. One strategy of
the NHBPEP was to create the Joint National Committee
on Detection, Evaluation, and Treatment of High Blood
Pressure (JNC). The initial charge to the JNC was to provide
practical recommendations for the following: identifica-
tion of the segment of the total population with high blood
pressure, determination of those who could be expected
to benefit from antihypertensive therapy and, proposal of
appropriate therapeutic regimens.
Between 1977 and 2003, JNC issued 7 reports (Table 1).1–7
The intent of these reports has been to provide up-to-date
information about hypertension management to healthcare
providers and to facilitate translation of new knowledge into
clinical practice.8–26 The purpose of this review is both to
track the changing recommendations for hypertension man-
agement over time as well as to review vulnerabilities in the
process of developing treatment guidelines by expert panels.
Correspondence: Theodore A. Kotchen (tkotchen@mcw.edu).
Initially submitted November 4, 2013; date of first revision December 8,
2013; accepted for publication December 23, 2013; online publication
February 26, 2014.
JNC 8 committee members recently published their guideline report.
Notably, there have been discrepancies of JNC recommendations over
time as well as discrepancies with recommendations of other profes-
sional organizations. The Institute of Medicine recently recommended
criteria for “trustworthy” guidelines. Criticisms of the guideline process,
and of the guidelines themselves, should not obscure their likely con-
tribution to improved hypertension control and to decreases of mor-
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tality rates of stroke and cardiovascular disease over the past several
decades. Nevertheless, translation of guidelines into clinical practice
remains a challenge.
Keywords: blood pressure; clinical guidelines; evaluation and treatment
of hypertensions; hypertension; JNC.
doi:10.1093/ajh/hpt298
EVOLUTION OF JNC REPORTS
The first JNC report was issued in 1977.1 Based on limited
clinical trial data, JNC 1 recommended that “virtually all per-
sons with a diastolic blood pressure ≥105 mm Hg be treated
with antihypertensive drug therapy.” For persons with dias-
tolic blood pressures of 90–104 mm Hg, the recommenda-
tion was to individualize drug therapy, giving consideration
to other risk factors. The report emphasized that the “ben-
efits of treatment of systolic blood pressure are unclear,” and
in the early JNC reports there were no recommendations for
classifying or treating systolic blood pressure (Table 2). The
recommended drug strategy was a “stepped-care” approach,
ordinarily beginning with a “thiazide-type diuretic” and
subsequently adding additional available drugs, as necessary.
Subsequent JNC reports have modified guidelines for
defining and treating hypertension, based on newer under-
standings of pathophysiology, actuarial considerations of the
life insurance industry, studies of blood pressure in diverse
populations, consideration of the interaction of blood pres-
sure with comorbid conditions, and the development of
effective antihypertensive agents. The updated reports have
recommended progressively more rigorous criteria for
defining and treating hypertension.
In patients with moderate and severe hypertension, the
early reports acknowledged that a more limited blood pres-
sure goal might have to be accepted. In JNC 2, drug therapy
1Department of Medicine, Medical College of Wisconsin, Milwaukee,
Wisconsin.
© American Journal of Hypertension, Ltd 2014. All rights reserved.
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American Journal of Hypertension  27(6)  June 2014  765
Kotchen

Table 1.  Blood pressure goals for hypertension control, JNC 1–JNC 7

Report number Examples of seminal

(year of publication) Committee chair BP Goal (mm Hg) studies/influential reports

1 (1977) Marvin Moser DBP <90 8

2 (1980) Iqbal Krishan a. DBP <90 9
b. DBP 90–100 for individuals with
moderate or severe hypertension
3 (1984) Harriet Dustan DBP <90 10–14
4 (1988) Aram Chobanian BP <140/90 15–17
5 (1993) Ray Gifford BP <140/90 18,19
6 (1997) Sheldon Sheps BP <140/90 and “lower if tolerated” 20–24
7 (2003) Aram Chobanian a. BP <140/90 25,26
b. <130/80 in patients with diabetes

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or renal disease

Abbreviations: BP, blood pressure; DBP, diastolic blood pressure; JNC, Joint National Committee on Detection, Evaluation, and Treatment
of High Blood Pressure.

Table 2.  JNC 2 classification of hypertension Table 3.  JNC 3 and JNC 4 classification of hypertension

Diastolic blood BP Range

Classification pressure (mmHg) Classification (mm Hg)

Stratum 1 (mild) 90–104 Diastolic

Stratum 2 (moderate) 105–114   Normal BP <85
Stratum 3 (severe) ≥115   High normal BP 85–89
  Mild hypertension 90–104
Abbreviation: JNC, Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure.   Moderate hypertension 105–114
  Severe hypertension ≥115

was advocated for persons with diastolic blood pressures
>104 mm Hg and possibly for patients with “mild hyperten-
sion” (diastolic blood pressure 90–104 mm Hg) in the pres-
ence of target organ disease or increased cardiovascular risk.
A  stepped-care approach, similar to that recommended in
JNC 1, was advocated.2 At each step, the recommendation
was to gradually increase the dose of agents until blood pres-
sure control was attained, “intolerable” side effects occurred,
or the maximum dose was achieved.
JNC 3 continued to define therapeutic goals on the basis
of diastolic blood pressure, reporting that “…evidence for
elevated levels of systolic blood pressure awaits the results
of ongoing clinical trials.”3 Nevertheless, classification of
blood pressure acknowledged the importance of systolic
blood pressure (Table  3). Nonpharmacological therapy
was advocated for patients with diastolic blood pressure
of 90–94 mm Hg who were otherwise at low cardiovascu-
lar risk. For patients with diastolic blood pressure >94 mm
Hg, a stepped-care approach for antihypertensive drugs,
beginning with either a diuretic or beta blocker, was again
recommended. An additional recommendation was to indi-
vidualize drug therapy for individuals with diastolic blood
pressures of 90–94 mm Hg (despite lifestyle interventions)
and individuals with isolated systolic hypertension.
For patients with persistent diastolic blood pressures
of 90–94 mm Hg after nonpharmacological therapy, JNC
4 allowed some flexibility about initiating drug therapy;
however, drug therapy was recommended for patients
Systolic, when diastolic BP <90
  Normal BP <140
  Borderline isolated systolic hypertension 140–159
  Isolated systolic hypertension ≥160
Abbreviations: BP, blood pressure; JNC, Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure.
with target organ disease or increased cardiovascular risk.
Similar to earlier JNC reports, JNC 4 also recommended a
stepped-care approach. However, following nonpharma-
cological approaches, the initial step for drug therapy was
more flexible (diuretic, beta blocker, calcium antagonist, or
angiotensin-converting enzyme (ACE) inhibitor) than JNC
3.4 The new emphasis was to individualize the selection of an
initial drug, based on patient demographics, comorbidities,
and other risk factors. An additional recommendation was
to combine small doses of antihypertensive drug with differ-
ent mechanisms of action, using the stepped-care approach,
to maximize effectiveness and minimize the potential for
dose-dependent side effects. In part, this strategy reflected
the increasing availability of newer agents and the recogni-
tion that the goal of therapy is not simply to lower blood
pressure, but also to protect organ function.
JNC 5 proposed a new classification system for hyperten-
sion (Table 4).5 Prior to JNC 5, recommendations for drug
therapy were based on diastolic blood pressure, reflecting

766  American Journal of Hypertension  27(6)  June 2014


Table 4.  JNC 5 classification of hypertension
Systolic BP Diastolic BP
Classification (mm Hg) (mm Hg)
Normal <130 <85
High normal 130–139 86–89
Hypertension
  Stage 1 (mild) 140–159 90–99
  Stage 2 (moderate) 160–179 100–109
  Stage 3 (severe) 180–209 110–119
  Stage 4 (very severe) ≥210 ≥120
Abbreviations: BP, blood pressure; JNC, Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure.
“When systolic and diastolic pressures fall into different categories,
the higher category should be selected to classify the individual’s
blood pressure status.”
the design of studies completed before 1988. Based in part
on the results of clinical trials, JNC 5 also emphasized the
importance of systolic hypertension. JNC 5 also emphasized
the importance of target organ damage and, in addition to
controlling blood pressure, concurrently controlling other
modifiable cardiovascular risk factors. Drug therapy was
recommended for patients with systolic blood pressure of
140–149 mm Hg and diastolic blood pressure of 90–94 mm
Hg after introducing lifestyle modifications and who also
had target organ disease or other risk factors. As in earlier
JNC reports, in the absence of target organ disease and
other risk factors, “flexibility” about initiating drug ther-
apy was advised for patients with blood pressures in these
ranges. Also, similar to previous JNC reports, a stepped-care
approach to drug therapy was recommended. However, in
contrast to the more flexible step 1 strategy in JNC 4, JNC
5 recommended either a diuretic or beta blocker as the pre-
ferred step 1 choice, following the introduction of lifestyle
modifications. As in JNC 4, the blood pressure goal was
<140/90 mm Hg, with emphasis on early initiation of anti-
hypertensive drug therapy in individuals with target organ
damage and/or other risk factors. “Further reduction to lev-
els of 130/85 mm Hg may be pursued, with due regard for
cardiovascular function, especially in older persons.”5
Classification of hypertension in JNC 6 was slightly differ-
ent from that in JNC 5 (Table 5).6 Expanding on earlier JNC
reports, JNC 6 placed more emphasis on absolute risk and
benefit and used risk stratification as part of the treatment
strategy. In persons with high normal blood pressure deemed
to be at high risk (target organ damage/clinical cardiovascu-
lar disease and/or diabetes with or without other risk factors),
initiation of drug therapy was recommended if blood pres-
sure remained >140/90 mm Hg after lifestyle modifications.
The report again recommended starting pharmacologi-
cal therapy with diuretics or beta blockers for patients with
uncomplicated hypertension but provided “compelling indi-
cations” for other specific agents in certain clinical situations
(e.g., diabetes, congestive heart failure and systolic dysfunc-
tion, myocardial infarction, chronic renal insufficiency).
Evolving Hypertension Guidelines
Table 5.  JNC 6 classification of hypertension
Systolic BP Diastolic BP
Classification (mm Hg) (mm Hg)
Optimal <120 AND <80
Normal <130 AND <85
High normal 130–139 OR 80–89
Hypertension
  Stage 1 140–159 OR 90–99
  Stage 2 160–179 OR 100–109
  Stage 3 ≥180 OR ≥110
Abbreviations: BP, blood pressure; JNC, Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure.
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Claude Lenfant, then director of NHLBI, commissioned
JNC 7 to incorporate updated information about hyperten-
sion; provide “new, clear, and concise guidelines” for clini-
cians; and “simplify” the classification of blood pressure
(Table 6).7 Due to the absence of clinical trial data, in contrast
to JNC 6, JNC 7 did not use global risk assessment in mak-
ing treatment decisions. Drug therapy was recommended
for persons with blood pressure >140/90 mm Hg after life-
style interventions and for blood pressure >130/80 mm
Hg for persons with diabetes or chronic kidney disease.
Thiazide diuretics were recommended as initial therapy for
most patients with hypertension, unless there was a “com-
pelling indication” for beginning with an agent of another
class. The report suggested that most patients would require
2 or more agents to achieve blood pressure goals and rec-
ommended initiating therapy with 2 agents if blood pressure
was >20/10 mm Hg above goal.
Throughout their evolution, the JNC reports have pro-
vided progressively more detailed information regarding
patient evaluation, including recommendations for assess-
ment of overall cardiovascular risk, target organ damage,
and, in the later reports, suggestions for home blood pres-
sure monitoring and ambulatory blood pressure monitoring.
Over time, although recommendations for health-promot-
ing lifestyle modifications have become more prominent,
only scant information has been provided concerning strat-
egies for implementing these recommendations.
Since the publication of JNC 7, a number of professional
societies have developed recommendations for hypertension
management. For example, in 2007, the American Heart
Association (AHA) recommended a target blood pressure
goal <130/80 mm Hg among those at high risk for coro-
nary artery disease and individuals with diabetes, chronic
kidney disease, or coronary artery disease or increased risk
for coronary artery disease.27 In a “consensus statement”
regarding goal blood pressure for hypertension control in
blacks, the International Society for Hypertension in Blacks
recommended a blood pressure goal of <135/85 mm Hg
for primary prevention and a goal of <130/80 mm Hg for
secondary prevention (individuals with target organ dam-
age and/or additional cardiovascular disease risk factors).28
However, these recommendations for lower blood pressures
have been criticized on the basis of insufficient evidence to
American Journal of Hypertension  27(6)  June 2014  767
Kotchen
Table 6.  JNC 7 classification of hypertension
Systolic BP Diastolic BP
Classification (mm Hg) (mm Hg)
Normal <120 AND <80
Prehypertension 120–139 OR 80–89
Stage 1 hypertension 140–159 OR 90–99
Stage 2 hypertension ≥160 OR ≥100
Abbreviations: BP, blood pressure; JNC, Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure.
support them.29 In collaboration with several other profes-
sional societies, the American College of Cardiology (ACC)
and the AHA jointly issued a “consensus document” on
hypertension in the elderly.30 That report states, “Typically,
formal recommendations are not provided in expert consen-
sus documents as these documents do not formally grade
the quality of evidence.” Nevertheless, this consensus docu-
ment recommended a less aggressive target for blood pres-
sure control (<145/90 mm Hg) in individuals aged >80 years.
COMPARISON WITH EUROPEAN AND CANADIAN
GUIDELINES
To illustrate the nuances and complexities of guide-
line development, it is instructive to compare the evolu-
tion of JNC reports with hypertension guidelines jointly
developed by other professional societies. In the 1970s, the
World Health Organization (WHO)/International Society of
Hypertension (ISH) began issuing guidelines, with periodic
updates.31–33 The aim was to offer “balanced information” to
guide clinical decision making rather than “rigid rules” to
clinicians. Initially, similar to JNC, WHO/ISH also recom-
mended a stepped-care approach to drug therapy, beginning
with a diuretic. However, subsequent WHO/ISH reports
expanded the recommendation for an initial drug to 1 of 5
different classes of antihypertensive agents (diuretic, beta
blocker, ACE inhibitor, calcium antagonist, alpha blocker).
Prior to 2003, the WHO/ISH guidelines were endorsed
by the European Society of Hypertension (ESH) and the
European Society of Cardiology (ESC). However, suggest-
ing that universal guidelines may not be reliable because
countries vary in the availability of healthcare and economic
resources, the ESH/ESC issued their first guideline statement
in 2003.34 The intent was to be “informative and educational”
rather than proscriptive. ESH/ESC issued updated guide-
lines in 2007,35 a reappraisal of these guidelines in 2009,36
and a new guideline statement in 2013.37 For the first time,
the 2013 guidelines provided information about the strength
of evidence supporting its various recommendations.
Similar to the JNC reports, the ESH/ESC guidelines rec-
ommend specific lifestyle interventions for prevention and
treatment of hypertension. To a greater extent than JNC7,
the ESH/ESC guidelines base clinical decision making on
overall cardiovascular risk and target organ damage, includ-
ing evidence of subclinical cardiovascular disease. In the
2003 guidelines, classification of hypertension was simi-
lar to that in JNC 7, and indications for ambulatory blood
768  American Journal of Hypertension  27(6)  June 2014
pressure monitoring and measurement of home blood pres-
sure were suggested. Compared to 2003 guidelines, classifi-
cation of hypertension changed only slightly in 2007, with
no subsequent change in 2013. Although this classification
is based on office blood pressure measurements, in these
updates, ambulatory blood pressure monitoring and home
blood pressure measurements received increasing attention
as “adjuncts” for predicting cardiovascular risk.
In contrast to the JNC 7 recommendation that a diuretic
be used as the initial drug in most hypertensive patients, the
ESH/ESC guidelines indicate that major classes of antihyper-
tensive drugs (diuretics, beta blockers, calcium antagonists,
ACE inhibitors, angiotensin receptor blockers) are “suitable
for initiation and maintenance of therapy.” The ESH/ESC
guidelines emphasize that the benefit of antihypertensive
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therapy is primarily related to a reduction in blood pressure
and that differences of cardiovascular morbidity and mor-
tality among different classes of antihypertensive agents are
small. Indications and contraindications for different classes
of agents are reviewed, and the advantage of low-dose com-
bination therapy with 2 agents is emphasized. Specific com-
binations of agents are recommended.
In the 2003 and 2007 guidelines, the goal of therapy was
blood pressure <140/90 mm Hg and lower if tolerated. In
2003, the goal for diabetic patients was <130/80 mm Hg, and
in 2007, this lower goal was also recommended for patients
with a history of stroke, myocardial infarction, or renal dys-
function. However, the most recent ESH/ESC guidelines
recommend a systolic blood pressure goal of <140 mm Hg
for most patients, including patients with diabetes, previous
stroke or transient ischemic attack, coronary heart disease,
or chronic kidney disease. In individuals aged >80 years, a
systolic blood pressure of 140–150 mm Hg is recommended.
Also in the latest guidelines, a diastolic target of <90 mm Hg
is always recommended, except in patients with diabetes,
in whom values <85 mm Hg are recommended. The 2007
guidelines had recommended antihypertensive drug treat-
ment for “high-risk” persons (because of diabetes, cardio-
vascular, or renal disease) with high normal blood pressures.
In contrast, the 2013 guidelines recommend only lifestyle
interventions for these groups of patients.
The Canadian Hypertension Education Program (CHEP)
was established in 1999 by a group of national societies
(headed by the Canadian Hypertension Society, the Heart
and Stroke Foundation of Canada, the Canadian Coalition
for High Blood Pressure Prevention and Control, and Health
Canada) to maintain annually updated recommendations
for hypertension management and to provide greater oppor-
tunities for their implementation into clinical practice.38 In
contrast to JNC 7 recommendations to institute drug treat-
ment for patients with stage 1 hypertension,39 CHEP cur-
rently recommends initiating drug therapy when blood
pressure is >160/100 mm Hg in patients without target organ
damage or other cardiovascular risk factors. However, medi-
cations are strongly suggested for patients with blood pres-
sures >140/90 mm Hg who also have macrovascular target
organ damage or other cardiovascular risk factors. Separate
blood pressure targets are recommended for patients with
diabetes (<130/80 mm Hg) and patients with nondiabetic
chronic kidney disease (<140/90 mm Hg). Also, in contrast

to JNC 7, diuretics are not necessarily favored as the initial
drug, even among patients without compelling indications
for other classes of antihypertensive agents.
PROCESS OF GUIDELINE DEVELOPMENT
All of the JNC, European, and Canadian reports repre-
sent consensus documents written by panels of experts. JNC
committees have been appointed by NIH and have included
representatives of professional organizations and healthcare
agencies. Inevitably, recommendations of guideline commit-
tees reflect the expertise and judgments of the experts writ-
ing the recommendations. However, both for hypertension
guidelines and for guidelines for other disease entities, con-
cerns have been raised about their reliability and the pro-
cess involved in guideline development. In a 1993 editorial
written in response to JNC 5 and WHO/ISH guidelines, as
well as guidelines issued by several other national bodies,
John Swales wrote, “The multiplicity and diversity of ‘expert
guidelines’ emphasize some of the concerns that have been
expressed about the impact of such official advice even when
the authors state expressly that their objective is simply to
provide guidance rather than instruction.”40
There is concordance among guidelines for many aspects
of hypertension management. Guideline disparities may be
due to insufficient relevant data and/or uncertain interpre-
tation as well as disagreement about whether cost should
be taken into account in developing guidelines. In addi-
tion to the difficulty of keeping abreast of the explosion of
new information, guideline developers have been criticized
for failing to adequately control for conflicts of interest, for
issuing guidelines of variable quality, and for issuing contra-
dictory guidelines that leave clinicians feeling confused and
vulnerable.41 One recent review has concluded that “….wide-
spread financial conflicts of interest among the authors and
sponsors of clinical practice guidelines have turned many
guidelines into marketing tools of industry. Financial con-
flicts of interest are pervasive, under-reported, influential
in marketing, and uncurbed over time.”42 Notably, despite
ongoing efforts, JNC has not issued updated guidelines since
publication of JNC 7 in 2003. This delay has been attributed
to the desire of the JNC Committee to make recommenda-
tions based on exhaustive scrutiny of available evidence.43
In contrast the ESH/ESC has maintained a more pragmatic
approach to issuing guidelines, with a willingness to “reap-
praise” or amend the guidelines as new information becomes
available.
In response to the concerns and the changing landscape
of guideline development, in 2011 the Institute of Medicine
(IOM) issued 2 related reports, one on standards for system-
atic reviews and the second on standards for the development
of trustworthy guidelines.44,45 Although these 2 activities
are distinct, the IOM emphasized that they are related and
require careful intersection and coordination. Specifically,
“clinical practice guideline developers should use systematic
reviews that meet standards [and should interact with] the
systematic review teams regarding the scope, approach, and
output of both processes.” Subsequently, the leadership of
NHLBI announced that it will “refocus our health education
Evolving Hypertension Guidelines
agenda on our core mission of knowledge generation and
synthesis by supporting and producing rigorous systematic
reviews that can then be used by other collaborating organi-
zations to generate guideline products that serve the pub-
lic interest….History has taught us that there are very few
immutable practices in science or medicine; and the time
has come for a change in the NHLBI practice of generating
clinical guidelines.”46
More recently, NHLBI has “asked the American Heart
Association (AHA) and the American College of Cardiology,
jointly, to assume the governance and management of (their)
preventive guidelines (five including hypertension) and to
ensure their completion and dissemination to the public.”47
The AHA and ACC have accepted this responsibility and
have invited all chairs and members of current writing pan-
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els to continue to work together with them to finalize the
hypertension guidelines. These guidelines are expected in
late 2014.
In the interim, there has recently been a flurry of guide-
line activity. The AHA, the ACC, and the Centers for Disease
Control and Prevention published a “scientific advisory” for
an effective approach to high blood pressure control.48 The
report describes successful healthcare system approaches
(e.g., Kaiser Permanente) and hypertension treatment algo-
rithms based on current guidelines. Additionally, the AHA/
ACC recently released the following 4 cardiovascular pre-
vention guidelines: for treatment of blood cholesterol to
reduce atherosclerotic cardiovascular risk in adults; for life-
style management to reduce cardiovascular risk; for manage-
ment of overweight and obesity in adults; and for assessment
of cardiovascular risk.49
The American Society of Hypertension and the
International Society of Hypertension have jointly issued
guidelines for the management of hypertension in the com-
munity.50 Drug treatment is recommended for patients with
blood pressure >140/90 mm Hg in whom lifestyle modifi-
cations have not been effective. Due to insufficient clinical
trial evidence, blood pressure targets of <140/90 mm Hg
are generally not recommended for patients with diabetes,
chronic kidney disease, or coronary artery disease. For per-
sons aged > 80 years, the recommended threshold for start-
ing drug therapy is blood pressure >150/90 mm Hg. The
recommended choice of an initial antihypertensive agent is
dependent on age, ethnicity, and comorbidities.
An additional guideline statement has recently been
published by the panel members appointed to the eighth
JNC (JNC 8).51 The primary difference from JNC 7 is that
this report raises target systolic blood pressure goals from
140 mm Hg to 150 mm Hg in persons aged ≥60 years, while
eliminating recommendations for tighter control in persons
with diabetes or chronic kidney disease. The stated rationale
for these changes is based on insufficient randomized clinical
trial data to support earlier recommendations. Notably, the
authors indicate that this is not an NHLBI sanctioned report
and does not reflect the views of NHLBI. Gary Gibbons,
NHLBI director, issued a similar statement, indicating that
the newer report has not been sanctioned by NHLBI.52 The
AHA has expressed concerns about the panel’s recommenda-
tions. Elliott Antman, AHA president elect, stated, “We are
concerned that relaxing the recommendations may expose
American Journal of Hypertension  27(6)  June 2014  769
Kotchen

more persons to the problem of inadequately controlled
blood pressure.53 Additionally, five members of the JNC8
panel have recently issued a minority report, also expressing
disagreement with the panel’s recommendation to increase
the target systolic blood pressure from 140 to 150 mm Hg in
persons ≥60 years of age without diabetes or chronic kidney
disease.54
IMPACT OF GUIDELINES
Between 1950 and 1996, the age-adjusted mortality rates
for stroke and cardiovascular disease in the United States
declined by 70% and 60%, respectively.55 These declines
began at least 1 to 2 decades before the appearance of JNC
1, and the favorable trends have continued. Between 1999
remains to be addressed. Guidelines and recommendations
alone will not be sufficient. Innovative strategies to improve
hypertension control are more apt to be successful if they
are responsive to the factors that contribute to the gap (or
chasm) between knowledge and clinical practice.
CONCLUSION AND PERSPECTIVES
In conclusion, guidelines are consensus reports developed
by panels of experts. Undoubtedly, provision of up-to-date
information and guidelines for hypertension control has
contributed to improved hypertension control and reduced
death rates attributable to cardiovascular diseases over the
past half century. Not unexpectedly, guidelines change over
time, based on new information and the development and

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and 2009, the relative rates of death attributable to stroke
increased availability of effective antihypertensive agents.
and cardiovascular disease declined by 37% and 33%,
Nevertheless, the rates of uncontrolled hypertension remain
respectively.56 Although it is difficult to evaluate their rela-
unacceptably high, and cardiovascular diseases remain the
tive contributions, these declines have been attributed to
leading cause of mortality in the United States, accounting
improvements in cardiovascular risk factors and medical
for approximately 34% of all deaths annually.61
treatments. In addition to hypertension-related guidelines,
According to a recent IOM report, “most guidelines used
recommendations for lifestyle modifications and aggressive
today suffer from shortcomings in development.”44 The delay
targets for cholesterol and glucose have been developed and
in producing an up-to-date revision of JNC 7 guidelines
promulgated for both primary and secondary prevention.
reflects a vulnerability of the guideline process. In contrast to
Since publication of JNC 1guidelines in 1977, in the
the NIH’s historical involvement in directing the JNC reports,
US rates of hypertension control have improved consid-
European and Canadian guidelines have been directed by
erably. Based on NHANES data, between 1976 and 1980
professional societies rather than by a funding agency. Both
and between 2009 and 2010, there have been progressive
Europeans and Canadians approaches have been more prag-
increases in the rates of hypertension awareness (51%–82%),
matic than the JNC reports in their approaches to guideline
treatment (31%–76%), and control (10%–53%).56,57 Overall,
development, in terms of frequency of reports, a willingness
these beneficial trends reflect increased recognition of the
to “reappraise” earlier recommendations, flexibility of recom-
benefits of hypertension control, increased availability of
mendations for clinical care, and emphasis on implementa-
antihypertensive drugs, the impact of government-spon-
tion strategies. The recent decision by NHLBI to transfer the
sored public health programs, and a variety of education
responsibility for guideline development to the AHA and
programs for healthcare providers for the public at large,
ACC is a reasonable step. However, the current discrepant
developed and implemented by professional societies. It is
recommendations by different professional groups high-
difficult to evaluate the specific impact of guidelines on the
lights the difficulty of translating science into public policy.
improved rates of hypertension control. In a survey of physi-
Although critical appraisal of current science may expose
cians before and 1 year after dissemination of JNC 3, despite
ambiguities and uncertainties, conflicting recommendations
being familiar with the recommendations, respondents
may confuse the public and potentially undermine the cred-
reported that their practice behaviors were not significantly
ibility of all recommendations. A challenge to all professional
changed by the guidelines.58
groups is to be more sensitive to the potential adverse impact
Despite favorable trends in hypertension treatment and
of discrepant or conflicting recommendations.
control, the high prevalence of uncontrolled hyperten-
The following additional strategies might be considered to
sion, especially among minority groups, remains a chal-
enhance the impact of guidelines:
lenge. A  number of observers, including a former director
of NHLBI, have expressed concern about the slow diffusion
of treatment guidelines into clinical practice.59 In addition • Guideline committees might recommend research strat-
to “physician inertia,” it is likely that uncontrolled hyperten- egies to resolve uncertainties or differences of opinion
sion is also related to a variety of other factors, including regarding hypertension management. The goal would
patient behaviors, complexity or difficulty of achieving rec- be resolution by evidence rather than by consensus. This
ommended blood pressure targets, and/or deficiencies in the would require collaboration with funding agencies
system of healthcare.60 Both physicians and asymptomatic • The association of hypertension with other cardiovascular
patients may be satisfied with less than “optimum” blood disease risk factors has been known for decades. As sug-
pressure control and may consider that the potential added gested in a recent editorial by Peterson et al., an integrated
benefits of more rigorous control do not warrant the added approach for prevention, detection, evaluation, and treat-
investment of time, energy, money, and potential for adverse ment of overall cardiovascular disease might have a greater
side effects. Indeed, there may be skepticism about the sci- impact than discrete guidelines for each risk factor.62
entific validity of guidelines recommended by expert pan- • From a clinical perspective, the primary impediments to
els. Nevertheless, the high rate of uncontrolled hypertension hypertension control may be related to the failure of both

770  American Journal of Hypertension  27(6)  June 2014


providers and patients to implement recommendations
rather than to the guidelines themselves. In the lengthy
guideline documents, surprisingly little space is devoted to
a consideration of strategies for overcoming these imple-
mentation barriers. Addressing these thorny issues will
require collaboration with disciplines and patient groups
that historically have not been involved in guideline
development.
In the final analysis, based on objective review of the evi-
dence, guidelines currently serve an important educational
function. However, they should not be considered as rigid
prescriptions for action but rather serve to allow the health-
care provider to make informed clinical judgments regard-
ing the treatment of individual patients.
DISCLOSURE
The author declared no conflict of interest.
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