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LETTERS: Peter Littlejohns, Gillian Leng, and Andrea Sutcliffe NICE responds to criticism of hypertension guidelines BMJ 2005; 330: 309 [Full text]

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NICE Guidelines: a contribution to rationalising hypertension care globally

Pedro O. Ordúñez-García, Yanelis La Rosa Linares   (9 February 2005)

I repudiate with indignation and abhorrence those new-fangled theories

Dr. Herbert H. Nehrlich   (10 February 2005)

Hypertension guidelines and choice

Hugh F McIntyre   (15 March 2005)

NICE Guidelines: a contribution to rationalising hypertension care globally 9 February 2005
Pedro O. Ordúñez-García, MD. General Director Hospital Gustavo ALdereguía, Cienfuegos 55 100. Cuba, Yanelis La Rosa Linares Send response to journal: Re: NICE Guidelines: a contribution to rationalising hypertension care globally	EDITOR— Cuba, like many other countries, is suffering the effect of hypertension guidelines mania, a consequence of The Guideline Wars. May be in the North of the Globe there are resources and time to invest in multiple guidelines, but in our countries the time is running and the resources are very limited. For this reason the Littlejohns announcement1 to limit the number of hypertension guidelines will be expected with hopefulness. As the coordinator of the Cienfuegos guideline development group I want to accept publicly that our group avoided a complicated and formal process to evaluate the best evidence because after long revision we don’t found any signal of essential differences between that guidelines. In summary, the evaluation of best evidence is time consuming and it is not cost-effective particularly on the post-7th JNC report scenario.2 So, our process was dedicated to cutting and sticking the more suitable, acceptable and didactic recommendations to be more easy work for our very busy physicians.3 Regarding implementation I would like to share some results that are proxy indicators of implementation process during the last clinical guidelines (2000 yr). Recently a study from Cienfuegos4 informs us that 78% of people with hypertension (greater than 140/90 or medication) are aware of their condition, 61% of persons known to have hypertension are being treated by their family physician and of those treated, 65% have controlled their blood pressure. These figures are higher than those of many industrialized countries and are plausible due to the large health care infrastructure. After long process of revision we can conclude that hypertension guideline sponsored by NICE is an excellent document that diverges from others, not only from those of the BHS because NICE provide a very well written cost effectiveness recommendations in addition to clinical effectiveness one, both critical components on the strategy to hypertension control. References 1. Littlejohns P, Leng G, Sutcliffe A. NICE responds to criticism of hypertension guidelines. BMJ 2005;330:309 2. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. U.S Department of Health and Human Services. National Instutes of Health. National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program. NIH Publication No. 03-5233. May 2003 3. Ordúñez P, La Rosa Y, Espinosa A, Alvarez F. Hipertensión Arterial: recomendaciones básicas para la prevención, detección, evaluación y tratamiento. Rev Finlay 2005 (in press). 4. Ordúnez P, Bernal JL, Espinosa-Brito A, Silva LC, Cooper RS. Ethnicity, education and blood pressure in Cuba. Am J Epidemiol , (in review) Pedro Ordúñez García, MD. Cienfuegos, Guideline Development Group on Hypertension. Coordinator Yanelis La Rosa Linares, MD. Cienfuegos, Guideline Development Group on Hypertension. Member Department of Internal Medicine, Hospital Gustavo Aldereguía Lima, Cienfuegos 55 100. Cuba. e-mail: pordunez @gal.sld.cu Competing interests: None declared
I repudiate with indignation and abhorrence those new-fangled theories 10 February 2005
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: I repudiate with indignation and abhorrence those new-fangled theories	Firstly, where is the evidence that hypertension is a disease? Secondly, where is the evidence that intervention in your "run of the mill" high blood pressure benefits anyone. Thirdly, is there not enough money to be made already in the so-called healthcare industry without having to resort to changing long-established guidelines for hypertension and other "normal" values for various measurements that one can subject unsuspecting people to. The disgraceful exploitation of the (faulty) diet-heart theory and the billions made from the out of control mania of prescribing statins is one thing, new, hard to meet BP values that make no sense to me from a scientific standpoint must be assumed to be dreamed up for only one reason. And I think it is a crying shame to have to witness what morass Medicine has sunk into. I am all in favour of re-viving the old 100-plus-your-age idea, with a minor attachment concerning diastolic pressure. Progress, Sophistication and High Tech are not nearly as impressive as the dollars made from them. Competing interests: None declared
Hypertension guidelines and choice 15 March 2005
Hugh F McIntyre, Consultant Physician The Conquest Hospital, Hastings, East Sussex TN 37 7RD Send response to journal: Re: Hypertension guidelines and choice	Dear Sir I struggle with “choice”. If I had elevated blood pressure (which, as yet, I do not) I would choose to take an angiotensin receptor blocker with the relevant evidence-base. Should this not be sufficient to control my blood pressure at optimal dose, I would take the smallest dose of thiazide diuretic that would suffice, in combination with the angiotensin receptor blocker, to control my blood pressure. These would ideally be taken in one tablet. Should my blood pressure remain above target (for my vascular risk) I would choose a calcium antagonist, again at the lowest dose possible. I would be wary of taking a beta-blocker. If the evidence changed then so would my choice. I can make this informed choice because I have all of the available evidence – including efficacy, tolerability, side effects and cost. It is surely my duty to make the same choice for my patients or, better still, give them the information so that they can choose. We patronise patients, and fool ourselves, if we offer choice in one area of care but pursue financial expediency in another. Of course choice carries a cost, bringing this cost to the patient is already implicit in licensing statins for over the counter purchase. As we should not deceive ourselves, so we should not deceive our patients. Yours faithfully Hugh F McIntyre Competing interests: HFM has received honoraria for advisory work, consultancy and lecturing, and reimbursement for attendance at educational conferences, from members of the pharmaceutical industry.