George Bakris, MD: I’m Dr. George Bakris, Professor of Medicine and Director of the Hypertensive Diseases Unit at the University of Chicago, Chicago. We’re going to be talking about guidelines, and I’d like to introduce a good friend and colleague Dr. Rajiv Agarwal, Professor of Medicine in the Department of Medicine at Indiana University, Indianapolis, Indiana, and a well-known authority in the field of hypertension and kidney disease.

The JNC 8 was due to come out over a year and a half ago and we’re still pending: It looks like they’re going to be out next year. On the basis of all of the guidelines, Rajiv, that have come out from the American College of Cardiology (ACC), American Heart Association (AHA), and the position papers from the American Society of Hypertension what do you think the JNC 8 is going to add by the time they come out? It’s a new format as you know. Why don’t you tell us about it?

Rajiv Agarwal, MD: First of all, here’s a disclaimer: I am not part of the JNC 8, and I really don’t have any inside information on how the JNC 8 will work. However, I think that the JNC 7, 6, and 8 are very important documents because they are social documents; they are guidelines that Medicare follows, insurance agents follow, and it allows people to pay for the services that they recommend.

The way that I understand it is that the JNC 8 is going to be much more evidence based than JNC 7 or 6. The JNC 6, for instance, used to have the blood pressure in people with hypertension and kidney disease who should be lowered to something like 125/75 mm Hg if they have proteinuria of more than 1 g, and the JNC 7 took that right away because they said it was a post hoc analysis.

Dr. Bakris: Well, let me give you a little bit of a lay of the land. The JNC 8 is going to be paired after the NICE [National Institute for Health and Clinical Excellence] guidelines in the United Kingdom, so it is, as you said, perfectly evidence based. One of the questions is combination therapy; one of the questions is blood pressure in the elderly; one of the questions is going to be, exactly as you said, on blood pressure goals.

Dr. Agarwal: George, you are absolutely right. Any guideline that you open up, the first page will say that these are guidelines and they will help you in making decisions, but individual decisions should not be based on these edicts.

Dr. Bakris: Let me move a little bit to the topic of the elderly. As you may or may not be aware, a very large guideline is now finished. It’s in the proof stage; people are signing off on it as we’re talking — the ACC/AHA guideline for the elderly. I was privileged to be a part of that guideline, and one of the blood pressure goal changes in that guideline is going to be a change to a slightly higher pressure, in fact, < 150/80 mm Hg as a goal. What do you think about that? Do you think that that’s appropriate? Do you think that there are problems with it? There’s been some controversy and I’m just wondering what your thoughts are.

Dr. Agarwal: I believe that the guideline — raising the blood pressure target– is probably fair. I think that many elderly people who don’t have comorbidities probably can tolerate a blood pressure that is lower than 150 mm Hg, but if you have comorbidities, which is more a rule than an exception, such as obesity, diabetes, coronary artery disease, and peripheral vascular disease, then perhaps a higher blood pressure wouldn’t hurt.

Dr. Bakris: Any other comments that you want to make about the guidelines as a final parting?

Dr. Agarwal: Yes, I want to go back and reiterate some of the points that I made. The guidelines sometimes can hurt us. I’ll give you an example of a guideline that is potentially hurting us; the guideline relates to hemoglobin targets: When should a particular patient receive a therapy? Not too long ago I had a patient, who had a hemoglobin level of 8.2, and his blood pressure usually ran in the 140s to 150s, and I said, “Well, let’s give this person an erythropoiesis-stimulating agent (ESA) because he’s quite anemic. He’s diabetic; he’s had peripheral vascular disease and an amputation; and his creatinine is 5. He should be given therapy.”

I was denied the therapy by the pharmacist who said, “You know, the patient is hypertensive and therefore we should not use this therapy.” The guidelines can hurt because somewhere in them it is written: Be cautious when the patient is hypertensive. But if we were putting that guideline to an absolute, make it a rule, then I think a third of our patients would get an ESA because most of them have poorly controlled hypertension.

Dr. Bakris: I fully agree with that, and lisinopril is a lot cheaper than an ESA — that’s for sure — so listen, thank you very much for spending the time with us and discussing this issue.

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