Response to letters about Hypertension Canada guideline

We thank Drs René Wittmer, Guylène Thériault, Samuel Boudreault, and Marc-Antoine Turgeon, as well as Dr Rémy Boussageon, and Dr David M. Allen, for their thoughtful engagement^1-3 with our article, “ Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care,”⁴ published in the July/August 2025 issue of Canadian Family Physician. Their letters raised important questions about diagnosis, evidence interpretation, and guideline development. We welcome this opportunity to clarify several key points.

Response to Wittmer et al. Wittmer and colleagues highlighted enduring tensions in hypertension care: Where is the balance between early identification and unnecessary labelling? How should clinicians weigh subtle psychological harms against long-term cardiovascular benefit?¹ These are complex and legitimate concerns. Because the term overdiagnosis carries substantial implications, precision in terminology matters. Overdiagnosis refers to identifying a condition that would never cause symptoms or harm. This concept applies well in some screening contexts, such as certain cancers or incidental imaging findings. Hypertension, however, differs.

Blood pressure (BP) is a well-established, continuous, causal, and graded cardiovascular risk factor. Decades of evidence show that long-term risk increases at levels well below the traditional 140/90 mm Hg threshold.⁵ Individuals with BP in the 130-139/80-89 mm Hg range consistently demonstrate a real and measurable increase in cardiovascular risk. This is not a harmless physiologic state. Large contemporary randomized trials show that identifying and managing elevated BP (>120 mm Hg systolic BP) in a risk-guided manner reduces cardiovascular events and mortality.^6-9 Benefits are greatest in those with higher absolute risk. Our guideline is built to capture these benefits without promoting unnecessary or premature drug therapy.

The key question, therefore, is not whether elevated BP carries risk—the evidence is clear that it does—but how to respond proportionately. The guideline distinguishes diagnosis from treatment.⁴ A diagnosis of hypertension in the 130-139/80-89 mm Hg range does not trigger automatic pharmacotherapy. Rather, it initiates structured lifestyle counselling, home BP monitoring, and cardiovascular risk assessment. For low-risk individuals, lifestyle modification alone is recommended; for higher-risk individuals, early pharmacotherapy is evidence based.

Diagnostic labels do carry psychological weight, and hypertension is no exception.¹⁰ These harms must be taken seriously, as Wittmer et al emphasized.¹ Yet, studies show that early therapy in people with BP 130-139/80-89 mm Hg reduces progression to ≥140/90 mm Hg,^11-13 with benefits that often persist after therapy stops.¹¹ Therefore, early recognition may alter underlying risk trajectories rather than simply suppressing numbers. More practically, assigning a diagnosis reduces diagnostic and therapeutic inertia,¹⁴ and encourages follow-up, monitoring, and risk conversations—important considerations for a silent and highly prevalent condition. The American Heart Association’s (AHA’s) recent review provides a broader scientific context on early intervention and long-term outcomes.¹⁵

Wittmer et al also noted that the summary published in the guideline did not include detailed Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework¹⁶ evidence profiles with absolute risk estimates.¹ We appreciate the opportunity to clarify our methodology. Using the ADAPTE framework,¹⁷ we systematically evaluated major international hypertension guidelines published within the past decade for the quality and transparency of their evidence reviews, use of structured grading systems such as GRADE,¹⁶ clarity of recommendations, and recency of their evidence base.

Using this structured process, we selected 3 sources: the American College of Cardiology (ACC)-AHA, the World Health Organization (WHO), and the European Society of Cardiology (ESC).^18-20 Among these, the 2024 ESC guideline²⁰ provided the most up-to-date evidence tables, current to January 2024. Consistent with international standards for guideline adaptation, we relied on these high-quality syntheses rather than reproducing full systematic reviews to inform our judgments. We hope this clarifies the robustness of our evidence appraisal process.

Response to Boussageon. In his letter, Boussageon raised concerns about evidence interpretation.² As outlined above, the guideline followed the ADAPTE process,¹⁷ and therefore did not generate new evidence tables. Instead, it relied on the comprehensive GRADE-based syntheses of the ACC-AHA, WHO, and ESC guidelines.^18-20 This approach minimized the risk of selective citation because decisions were anchored in large, independently produced evidence reviews. All recommendations were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II reporting standards.²¹

The Heart Outcomes Prevention Evaluation–3 (HOPE-3) trial,²² which Boussageon highlighted, is fully consistent with our recommendations. HOPE-3 showed that individuals with BP of less than 140/90 mm Hg and low cardiovascular risk do not benefit from pharmacotherapy; precisely the group for whom we recommend lifestyle modification alone. HOPE-3 was included in the ACC-AHA evidence tables reviewed through ADAPTE, meaning it was incorporated into our deliberations even if not singled out in the final text. This trial was neither overlooked nor selectively interpreted.

We recognize the importance of trust in guideline development and emphasize that our evidence review was systematic, structured, and aligned with the conclusions reached.

Response to Allen. In Allen’s letter,³ we appreciated the focus on panel composition. Strong primary care representation is essential in guidelines designed for primary care use. We chose a broader definition of primary care that included family physicians, nurses, and pharmacists. Indeed, the Hypertension Canada guidelines included substantial primary care involvement in oversight and development, including family physicians, a nurse practitioner, community pharmacists, a methodologist, and hypertension specialists in the 2025 edition, and for well over 20 years.

Patient partners from Hypertension Canada contributed throughout development and created the patient support tool; an additional group of patient partners from the Heart and Stroke Foundation of Canada reviewed all recommendations. This multidisciplinary structure reflects best practice for conditions as common and system wide as hypertension. We agree that maintaining strong primary care and patient involvement must remain an ongoing priority.

We thank all correspondents for the care with which they examined the guideline. Their comments raise important issues about diagnosis, evidence synthesis, and terminology—issues that will help refine future iterations of Hypertension Canada’s clinical practice guideline. While some interpretations of the literature may differ, we share a common goal: to provide guidance that is evidence-based, practical, and centred on patients. We welcome continued dialogue as we collectively advance hypertension care in Canada.

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