The Japanese Society of Hypertension (JSH) has now revised its hypertension guidelines from 2009 (JSH 2009) and the authors are to be congratulated on a very comprehensive and most detailed document, citing no less than 1152 references.1 The primary objective of these recommendations is to present standard treatment of high blood pressure to prevent the onset and/or progression of hypertensive complications in the brain, heart and/or kidneys, also taking the patients’ concomitant disease(s) into consideration. In the 1960s Japan was one of the countries with the highest mortality rate due to stroke. Considerable progress has been made but the age-adjusted morbidity rate of stroke is still four times higher than that of myocardial infarction in Japan. Hence, it is very important that the hypertension issues are considered from a Japanese perspective. More than 40 scientists have written these guidelines, which have been extensively reviewed by no less than 79 reviewers. The results of the retracted KYOTO and JIKEI Heart studies as well some other studies under investigation have not been considered in these guidelines.

The original term for ‘guide-lines’ has been borrowed from a mountain climbing technique in which experienced guides marked the best and safest paths up and down a particular mountain for hikers to take by placing ropes along the way.2 In medicine, clinicians initially formed short guidelines to suggest a safe direction when managing difficult clinical situations and this is what the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) have done recently3 with the ‘2014 Clinical Practice Guidelines for the Management of Hypertension in the Community’.

We have recently seen two sets of new recommendations on hypertension from the USA. First, in 2008, the eighth Joint National Committee (JNC 8) committee for hypertension was appointed by the National Heart, Lung, and Blood Institute (NHLBI) to provide guidance for clinicians on the best approaches to manage and control high blood pressure. Recently (in 2014), the panel members decided to pursue publication of their findings independently of NHLBI.4 Second, recognizing the urgent need to address inadequate control of high blood pressure, the American Heart Association (AHA) has made hypertension a primary focus area of its strategic plans for 2014–17 as it seeks to reduce the death rate from cardiovascular disease and stroke by 20%, before 2020. With endorsement of the AHA, and also of the American College of Cardiology (ACC), and the Centres for disease control (CDC), Go et al.5 have recently published surprisingly short treatment recommendations of high blood pressure.

In Table 1, we have selected a few important variables to show how the new Japanese recommendations compare with the other three recent guidelines, mentioned above. For comparison, we have also added two more, one from the UK (National Institute for Health and Clinical Excellence, NICE)6 published in 2011 and one from the rest of Europe (European Society of Hypertension, ESH and European Society of Cardiology, ESC), published in 2013.7 In summary, all these guidelines are similar but not alike and can be looked upon as different interpretations of more or less the same set of scientific data.

Table 1 Comparison of hypertension guidelines 2011–2014

When diagnosing hypertension, NICE differs from the others by requesting ambulatory recordings. They also have higher levels (160/100 mm Hg) for initiating drug treatment in low-risk patients than ASH/ISH (140/90 mm Hg). Also the ‘JNC-8’ guidelines have higher levels (150/90 mm Hg) for initiating treatment in patients aged 60. The Japanese recommendations are similar to those from ASH/ISH and ESH/ESC.

The six guidelines recommend different drugs for starting treatment in non-black patients. ASH/ISH recommend ACE-I or ARB and ‘JNC 8’ recommends ACE-I, ARB, CCB, or thiazide-type diuretic. In the paper by Go et al.5—supported by AHA, ACC and CDC in the US—treatment is recommended to start with a thiazide in most patients (alternatively ACE-I, ARB or CCB). JSH recommends CCB, ACE-I, ARB or thiazide/thiazide-type diuretics first. Beta-blockers come as the fourth (or third) drug in five of the six guidelines, that is, in all except those from the ESH/ESC, where beta-blockers are included among the drugs suitable for the initiation of treatment, surprisingly also when there are no compelling indications for that drug class.

The treatment goal is the same (<140/90 mm Hg) in all six guidelines except for elderly patients. In ‘JNC-8’ a higher level (<150/90 mm Hg) is recommended for those aged 60. ASH/ISH recommends that target is for those aged 80 and JSH for those aged >75.

Needless to say, doctors should always consider the patients co-morbidities when prescribing blood pressure-lowering drugs and deciding on treatment targets. For hypertensive patients with diabetes, the targets are similar (<140/90 mm Hg) in several of the recommendations. In the ESH/ESC guidelines, the diastolic blood pressure target is 5 mm Hg lower (<140/85 mm Hg), taking the results of HOT and UKPDS into consideration.8, 9 and in the JSH recommendation, the goal is much lower (<130/80 mm Hg) most likely taking the high risk of stroke in Japan into account.

Finally, more guidelines from the US and the UK are said to be on their way in 2014–15. Hopefully, we will also see a widening consensus as time goes by.