Guidelines Developed by External Organizations Not Endorsed by the AAFP

The AAFP believes that guidelines should be informed by an independent systematic review of the evidence, an assessment of the benefits and harms, and should follow a sound, transparent methodology with limited potential for financial and intellectual bias.

Clinical guidelines:

• serve as a framework to provide guidance for clincial decisions and evidence-based best practices, but cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician.
  
• reflect the best understanding of the science of medicine at the time of publication, but should be used with the clear understanding that continued research may result in new knowledge and recommendations.

In addition to developing its own guidelines, the AAFP considers endorsement of guidelines developed by other organizations. These guidelines undergo a structured review process by the AAFP’s Commission on Health of the Public and Science and are approved by the Board of Directors.

Dependent on specific criteria, clinical practice guidelines that are reviewed may be placed in the following categories:

• Endorsed
• Affirmation of Value
  
• Not Endorsed by the AAFP
  

The following guidelines have been reviewed by the AAFP but did not meet criteria for endorsement or affirmation of value.

Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Developed by: ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

Publication date: 2017

This guideline was reviewed and did not meet the criteria for endorsement or affirmation of value for the following reasons:

• The majority of the guideline recommendations were not based on a systematic review of the evidence: over 100 recommendations were provided but a systematic review was performed for only four key questions. Harms of treating to a lower blood pressure were not assessed in the systematic review.
• The systematic review provided had similar results to the review used for other guidelines (AAFP/ACP guideline) suggesting that may be a small benefit for lower treatment targets in cardiovascular events, there was no benefit observed in all-cause mortality, cardiovascular disease mortality, myocardial infarction, and renal events. Therefore, the AAFP and ACP recommend considering treatment to lower targets for some patients in the context of shared decision making.
• While the recommendation statements included a grade for the strength of evidence, assessments of the quality of individual studies or systematic reviews were not provided.
• Substantial weight was given to the SPRINT trial while results from other trials were minimized. The SPRINT trial stopped early due to benefit leading to the potential for exaggerated benefits and an under reporting of harms. The SPRINT trial was an important trial, but needs to be considered in the context of the totality of the evidence. 
• The guideline recommends the use of the ASCVD risk assessment tool to determine whether medications should be initiated for BP control (strong recommendation). This recommendation is not based on evidence that using the tool in this way improves outcomes.
• Conflict of interest is a major concern for the trustworthiness of guidelines and plays a key role in assessment of guidelines by the AAFP. The Chair of the SPRINT trial steering committee was commissioned as chair of the guideline panel, even though that trial provides the basis for the recommended change in blood pressure targets. Several other members of the panel also have intellectual conflicts of interest. While relationship to industry was addressed, intellectual conflicts of interest were not considered.

The information provided above is intended to inform family physicians about the potential deficits or issues in a specific guideline but is not meant to imply that family physicians should not consider the recommendations, particularly when other guidance is not available on the topic.