Blacher Jacques, Lelong Hélène, Kretz Sandrine, Yannoutsos Alexandra, Kondo Takeshi, Safar Michel
Université Paris-Descartes, AP-HP, hôpital Hôtel-Dieu, unité HTA, prévention et thérapeutique cardiovasculaires, centre de diagnostic et thérapeutique, 75004 Paris, France.
Université Paris-Descartes, AP-HP, hôpital Hôtel-Dieu, unité HTA, prévention et thérapeutique cardiovasculaires, centre de diagnostic et thérapeutique, 75004 Paris, France.
Presse Med. 2014 Oct;43(10 Pt 1):1048-55. doi: 10.1016/j.lpm.2014.03.031. Epub 2014 Sep 5.
During year 2013, several recommendations for the management of hypertension were published: recommendations of the French and European Societies of Hypertension and two recommendations from the USA, those from the ACC/AHA/CDC groups and those from the JNC 8. The recommendations of the JNC 8 are not, strictly speaking, the recommendations of JNC 8, since they are neither endorsed by their sponsor: the National Heart, Lung and Blood Institute (NHLBI), nor by any other supervisor. They only commit their authors. Just before the publication of the JNC 8, "competing" recommendations, jointly produced by the AHA, ACC and CDC, were jointly published in Hypertension and in the Journal of American College of Cardiology, with different preferred treatment choices and significantly different algorithms. The authors of the JNC 8 have only included in their literature review randomized controlled trials of sufficient power. Randomized controlled trials are clearly the gold standard of comparative trials in medicine, but can they summarize all the knowledge? The authors of the JNC 8 propose in subjects over 60, a therapeutic threshold and target blood pressure of 150/90mmHg. This original threshold is poorly supported by the evidence and possibly increases the risk of physicians' inertia. The issue of experts' conflicts of interest has greatly changed the rules of drafting guidelines for clinical practice. Knowing that the vast majority of clinical trials is promoted by drug industry, could guidelines be strictly without any conflict of interest? Finally, recommendations for practice should have as primary, if not unique, objective to improve the practice.
2013年期间，发布了多项高血压管理建议：法国和欧洲高血压学会的建议以及美国的两项建议，即美国心脏病学会/美国心脏协会/美国疾病控制与预防中心（ACC/AHA/CDC）小组的建议和美国国立卫生研究院第八次全国联合委员会（JNC 8）的建议。严格来讲，JNC 8的建议并非JNC 8的官方建议，因为它们既未得到其发起机构——美国国立心肺血液研究所（NHLBI）的认可，也未得到任何其他监管机构的认可。这些建议仅代表其作者的观点。就在JNC 8发布之前，由美国心脏协会（AHA）、美国心脏病学会（ACC）和美国疾病控制与预防中心（CDC）联合制定的“竞争性”建议同时发表在《高血压》杂志和《美国心脏病学会杂志》上，这些建议的首选治疗方案不同，算法也有显著差异。JNC 8的作者在其文献综述中仅纳入了具有足够效力的随机对照试验。随机对照试验显然是医学比较试验的金标准，但它们能总结所有知识吗？JNC 8的作者建议，60岁以上的患者，治疗阈值和血压目标为150/90mmHg。这一初始阈值缺乏充分证据支持，可能会增加医生不作为的风险。专家利益冲突问题极大地改变了临床实践指南的制定规则。鉴于绝大多数临床试验是由制药行业推动的，临床实践指南能完全没有任何利益冲突吗？最后，实践建议的首要目标（即便不是唯一目标）应该是改善临床实践。
