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Indian guidelines on hypertension-IV (2019): response to Dr. Pareek et al.

Journal of Human Hypertension volume 35, pages 751–752 (2021)Cite this article

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We thank Dr. Anil Pareek et al for their observations on Indian guidelines on hypertension-IV (2019) [1]. They have made some observations which need discussion. They have remarked “new-generation β-blockers must be considered as first-line option for specific profiles like young hypertensives”. However, beta blockers are no longer considered as first line agents in any guideline. The ACC/AHA guidelines suggest 4 class of agents. To quote their recommendation “for initiation of anti-hypertensive drug therapy, first line agents like thiazide diuretics, calcium channel blockers (CCB) and angiotensin converting enzyme inhibitors (ACEI) or an angiotensin receptor blocker (ARB)” can be used [2]. Similarly the NICE guidelines of 2019 suggest that we offer an ACEI or an ARB as step 1 to those who have type 2 diabetes (any age) and to those under 55 years. We should offer a CCB to those more than 55 years and who do not have type 2 diabetes as the first step [3]. Regarding beta blockers NICE guidelines recommend that we consider an alpha blocker or beta blocker for adults with resistant hypertension as step 4. Even in the latest International society of hypertension (ISH) 2020 guidelines, in the algorithm for optimal and essential standards, the step 1 of therapy is low dose combination of ACEI/ARB and CCB. Step 2 is high dose combination of ACEI/ARB and CCB. The step 3 is ACEI/ARB+CCB+Diuretic. Infact step 4 is above three plus spironolactone [4]. So, these three other recent guidelines suggest that beta blockers are not the first, second or third line agents in any of these guidelines. Also we can notice that ACEIs and CCBs are preferred over diuretics in NICE and ISH guidelines (contrary to the second point made in the correspondence). In that sense, all these guidelines are consistent with IGH-IV. Beta blockers have been mentioned in IGH-IV as agents to be used for hypertension with special circumstances, like patients with coronary artery disease, atrial fibrillation, and in heart failure.

In the second point authors feel that thiazide and thiazide-like diuretic are to be mentioned separately. Infact to quote from ESC/ESH guidelines “there has been debate about whether thiazide-like diuretic such as chlorthalidone and indapamide should be given preference over classical thiazide diuretic (hydrochlorothiazide), but their superiority on outcomes has never been tested in head to head RCT’s….. Therefore in the absence of evidence from direct comparator trials and recognizing that many of the approved single pill combinations are based on hydrochlorothiazide, we recommend that thiazides, chlorthalidone and indapamide can all be considered suitable anti hypertensive agents”. A similar thought as the ESC/ESH is reflected in the IGH IV guidelines [5].

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References

  1. Shah SN, Munjal YP, Kamath SA, Wander GS, Mehta N, Mukherjee S, et al. Indian guidelines on hypertension-IV (2019). J Hum Hypertens. 2020. https://doi.org/10.1038/s41371-020-0349-x.

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Authors and Affiliations

  1. Consultant physician, Bhatia hospital, Saifee hospital, Sir H.N. reliance hospital and SL Raheja hospital, Mumbai, Maharashtra, India

    Siddharth N. Shah

  2. Banarsidas Chandiwala Institute of Medical Sciences, New Delhi, India

    Y. P. Munjal

  3. Seth GS Medical College and KEM Hospital College, Mumbai, Maharashtra, India

    Sandhya A. Kamath

  4. Hero DMC Heart Institute, Dayanand Medical College & Hospital, Ludhiana, Punjab, India

    Gurpreet S. Wander

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  1. Siddharth N. Shah
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  2. Y. P. Munjal
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  4. Gurpreet S. Wander
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Correspondence to Gurpreet S. Wander.

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Shah, S.N., Munjal, Y.P., Kamath, S.A. et al. Indian guidelines on hypertension-IV (2019): response to Dr. Pareek et al.. J Hum Hypertens 35, 751–752 (2021). https://doi.org/10.1038/s41371-020-00413-3

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