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Comment & Response |

Guidelines for Managing High Blood Pressure—Reply

Eduardo Ortiz, MD, MPH1,4; Suzanne Oparil, MD2; Paul A. James, MD3
[+] Author Affiliations
1Rockville, Maryland
2University of Alabama at Birmingham School of Medicine
3University of Iowa, Iowa City
4Dr Ortiz was with the National Heart, Lung, and Blood Institute, Bethesda, Maryland, at the time of the project
JAMA. 2014;312(3):295-296. doi:10.1001/jama.2014.6599.
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In Reply Dr Morales-Salinas and colleagues raise concerns about the panel’s decision to exclude β-blockers as first-line therapy for hypertension, which was driven by the results of LIFE.1 The evidence quality was graded low because it was based on 1 study with a population limited to individuals with hypertension and left ventricular hypertrophy by electrocardiogram. We agree that atenolol may have less favorable properties than some of the newer β-blockers, but the latter have not been well studied in comparative RCTs. In other studies, β-blockers performed similarly to the comparator drugs or the evidence was insufficient. This is an example in which the evidence is not clear-cut. In light of such uncertainty, the panel relied on predefined rules for making decisions. After review of the evidence and discussions about issues such as those raised by Morales-Salinas and colleagues, the panel voted to exclude β-blockers as initial therapy. However, the vote was not unanimous, which is not surprising given that diverse panel members may draw different conclusions when presented with evidence that is uncertain and requires interpretation. We believe the guideline enhances the understanding of how to apply clinical trial evidence in the uncertain world of clinical practice by explicitly clarifying which recommendations are supported by evidence and which are opinion-based.

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July 16, 2014
Alberto Morales-Salinas, MD, MPH; Antonio Coca, MD, PhD, FRCP; Fernando Stuardo Wyss, MD, PhD
1Department of Cardiology, Cardiocentro “Ernesto Che Guevara,” Santa Clara, Cuba
2Department of Internal Medicine, University of Barcelona, Barcelona, Spain
3Department of Cardiology, Hospital General San Juan de Dios, Guatemala City, Guatemala
JAMA. 2014;312(3):293-294. doi:10.1001/jama.2014.6590.
July 16, 2014
Wendy S. Klein, MD; C. Noel Bairey Merz, MD; Marjorie R. Jenkins, MD
1Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond
2Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
3Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo
JAMA. 2014;312(3):294-295. doi:10.1001/jama.2014.6593.
July 16, 2014
David K. Cundiff, MD; Francois Gueyffier, MD, PhD; James M. Wright, MD, PhD
1Independent researcher, Long Beach, California
2Laboratoire de Biométrie et Biologie Evolutive, Université Claude Bernard Lyon 1, Villeurbanne, France
3Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
JAMA. 2014;312(3):294. doi:10.1001/jama.2014.6596.
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