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Comment & Response
July 16, 2014

Guidelines for Managing High Blood Pressure—Reply

Author Affiliations
  • 1Rockville, Maryland
  • 4Dr Ortiz was with the National Heart, Lung, and Blood Institute, Bethesda, Maryland, at the time of the project
  • 2University of Alabama at Birmingham School of Medicine
  • 3University of Iowa, Iowa City
JAMA. 2014;312(3):295-296. doi:10.1001/jama.2014.6599

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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