Primary care guidelines should be written by primary care physicians

I have concerns about the recent Hypertension Canada primary care guideline update in the article, “Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care”¹ published in the July/August 2025 issue of Canadian Family Physician, specifically about how the composition of the guideline committee may limit the applicability of the recommendations to primary care.

Guidelines meant for primary care should be primarily written by primary care specialists, not academic subspecialists who see a very different spectrum of patients. The Hypertension Canada guideline committee was composed of 3 family physicians and 1 nurse practitioner, as well as 6 internal medicine subspecialists (including the committee chair and co-chair), 2 academic pharmacists, and a methodologist.

Why does this matter? Baseline disease prevalences are completely different for primary and tertiary care, and diagnostic and treatment strategies that work in 1 setting are not necessarily best practice in another. In this case, Hypertension Canada chose to adopt the American College of Cardiology (ACC) and American Heart Association (AHA) recommendations concerning diagnosing hypertension at 130/80 mm Hg and commencing pharmacotherapy at lower thresholds than previous Hypertension Canada recommendations. This is despite the fact the most recent Cochrane review² does not support more aggressive treatment thresholds for most primary prevention. The 2 main organizations in the United States representing primary care physicians, the American College of Physicians and the American Academy of Family Physicians, both chose not to adopt the ACC/AHA recommendations.

Academic nephrologists and cardiologists see patients with end-stage renal and cardiac failure who may have been spared those terrible outcomes with earlier intervention. Primary care physicians see some of those patients, too (although fewer), but also see patients with different benefit-to-harm ratios who suffer the emotional and physical consequences of lower diagnostic and therapeutic thresholds, including overdiagnosis and medication-related adverse events. Different settings require different diagnostic and treatment strategies.

Family physicians are the experts in primary care, and primary care guidelines should be written by primary care physicians with content expert input, as is the case with the Canadian Task Force on Preventive Health Care. I suspect that if this happened with the hypertension guideline update, more aggressive diagnostic and treatment recommendations may not have been adopted.

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