Comments on the JNC 7 guidelines in the light of the upcoming European guidelines for the management of arterial hypertension were offered at the ASH session by Professor Alberto Zanchetti, MD (University of Milan, Italy). Professor Zanchetti is a past-president of the European Society of Hypertension (ESH) and of ISH, and continues to be a distinguished member of ISH.

ESH, in collaboration with the European Society of Cardiology, has prepared its own guidelines, which will be released at the 13th Congress of ESH, to be held June 13-17 in Milan, and published in the June issue of the Journal of Hypertension. The European societies have some disagreements with the JNC 7 guidelines, Professor Zanchetti revealed. In JNC 7 there is much less emphasis on the total cardiovascular risk in guiding the management of hypertension, unlike JNC 6 and the current WHO/ISH guidelines, whereas this is emphasized in the new European guidelines. The European guidelines will retain the old classification of hypertension, as in the JNC 6 and the WHO/ISH guidelines, including the definition of high normal blood pressure.
The European guidelines will be flexible in their definition of hypertension, Professor Zanchetti noted, quoting the late Geoffrey Rose, who referred to hypertension as "that level of blood pressure at which and about which detection and treatment do more good than harm." The European guidelines will emphasize the concept that what JNC 7 calls prehypertension may be hypertension in diabetic patients or in patients after a stroke or MI, whereas it may be considered normotension in patients with no additional risk factors.

The European guidelines committee was diffident about the term "prehypertension" for both scientific and practical reasons, Professor Zanchetti explained: scientific, because all those patients with SBP 120-140 mm Hg are not necessarily going to become hypertensive; and practical, because such an increase in the population that must now be considered abnormal will reduce the impact of the message about treating hypertension.

With regard to antihypertensive treatment, the European guidelines will be based on much the same evidence as JNC 7, but the conclusions of the European committee were somewhat less rigid and more liberal, Professor Zanchetti said. If most of the recent trials have shown that lowering blood pressure per se is the most important aspect of antihypertensive treatment, then in the choice of the drug to be used in individual cases, many factors other than cost alone should guide the physician's choice, he declared. If an increased adherence to scientific advice is to be the goal, he believes that more flexible guidelines are needed that take more account of the physician's individual choice and the patient's preference.

Professor Zanchetti also pointed to a limitation of all the guidelines, namely that they provide advice for lifelong therapy -- which, in the middle-aged hypertensive, can last for 20-25 years -- based exclusively on evidence accumulated from trials that lasted only 3-5 years. Most of these trials were unable to evaluate the long-term impact of changes in so-called intermediate endpoints such as LVH, microalbuminuria, carotid changes, and new-onset diabetes. This is a problem that is difficult to solve but which must not be neglected, Professor Zanchetti asserted. Overall, to achieve the aim of better treatment of hypertension in practice, guidelines should be more flexible, more informative, more educational, and less prescriptive, he believes.

At this point, the debate and discussion will no doubt continue and intensify, with more content to be incorporated once the ESH guidelines are announced in June in Milan.