A new guideline for the management of high BP in adults, developed by the Eighth Joint National Committee and containing nine recommendations and a treatment algorithm, has been published online in JAMA.
The guideline provides evidence-based recommendations for the management of high BP, with different BP goals and treatments recommended for patients based on age, race/ethnicity, kidney function and diabetes status.
Most notably, the Eighth Joint National Committee (JNC 8) loosened the recommended goal for systolic BP in older adults.
Target goals changed in some patients
The committee aimed to base recommendations on evidence from randomized clinical trials and found no evidence that setting a systolic BP goal <150 mm Hg in the general population aged at least 60 years provided any additional clinical benefit. Therefore, the guideline recommends that if treatment of high BP is to be started in this population, the treatment goal should be systolic BP <150 mm Hg and diastolic BP <90 mm Hg.
However, if a patient in that population is already being treated for high BP and has achieved a lower systolic BP, such as <140 mm Hg, treatment need not be adjusted if no adverse effects on health or quality of life are observed, according to the guideline.
The committee found no evidence for a systolic BP goal in patients younger than 60 years with hypertension or for a diastolic BP goal in patients younger than 30 years with hypertension. The guideline advises treating patients younger than 60 years with hypertension to a goal of systolic BP <140 mm Hg and diastolic BP <90 mm Hg.
“In the absence of any [randomized controlled trials] that compared the current [systolic] BP standard of 140 mm Hg with another higher or lower standard in this age group, there was no compelling reason to change current recommendations,” Paul A. James, MD, of the University of Iowa, and colleagues wrote in the guideline. Further, they wrote, participants in studies showing clinical benefits to achieving diastolic BP <90 mm Hg also usually achieved systolic BP <140 mm Hg, and there was no way to determine whether the clinical benefit was a result of improved diastolic BP, improved systolic BP or both.
The recommended treatment goal for patients aged at least 18 years with chronic kidney disease (CKD) and diabetes is systolic BP <140 mm Hg and diastolic BP <90 mm Hg. The committee noted insufficient evidence of BP treatment goals for patients aged at least 70 years with CKD; for this group, “antihypertensive treatment should be individualized, taking into consideration factors such as frailty, comorbidities and albuminuria.” The common recommendation of a systolic BP goal <130 mm Hg in patients with diabetes and hypertension is not supported by results from high-quality randomized clinical trials, according to the committee.
Four drug classes recommended
Initial antihypertensive treatment in the general nonblack population, including those with diabetes, is supported, based on moderate evidence. The treatment plan should include:
- Thiazide-type diuretics.
- Calcium channel blockers.
- ACE inhibitors.
- Angiotensin receptor blockers.
Beta-blockers are not recommended for initial treatment because one study showed that use was associated with a higher rate of stroke compared with use of angiotensin receptor blockers (ARBs). Alpha-blockers are not recommended for initial treatment because one study showed that patients who used them had worse cerebrovascular, HF and other CV outcomes compared with those who used diuretics.
The following classes of drugs are not recommended for first-line therapy because of a lack of good clinical evidence comparing them with the four recommended classes: dual alpha1- and beta-blocking agents, vasodilating beta-blockers, central alpha2-adregenic agonists, direct vasodilators, aldosterone receptor antagonists, peripherally acting adrenergic antagonists and loop diuretics.
For black patients with hypertension, including those with diabetes, the committee recommended first-line therapy with a thiazide-type diuretic or a calcium channel blocker (CCB). This recommendation is based on an analysis of the black patient subgroup of the ALLHAT trial, in which diuretics were more effective at improving cerebrovascular, HF and other CV outcomes in that subpopulation than ACE inhibitors, and those using ACE inhibitors had a 51% higher rate of stroke than those using CCBs, whereas clinical outcomes for those using diuretics and those using CCBs were similar.
For adults with CKD and hypertension, regardless of race or diabetes status, “initial (or add-on) antihypertensive treatment should include an ACE [inhibitor] or [angiotensin receptor blocker] to improve kidney outcomes,” the committee wrote.
Finally, if goal BP is not achieved 1 month after initial therapy, the dose should be increased or a second drug from one of the four recommended classes should be added. A third drug should be added if adding the second drug does not enable the patient to reach goal BP, but ACE inhibitors and ARBs should not be used in the same patient, according to the guideline.
If three drugs from the recommended classes do not enable the patient to reach goal BP or the patient is contraindicated for any of those drugs, a drug from a nonrecommended class may be prescribed. If goal BP still cannot be attained or the patient’s case is considerably complex, a referral to a hypertension specialist is recommended.
The guideline contains an algorithm for hypertension management. However, the committee noted that the algorithm “has not been validated with respect to achieving patient outcomes.”
A break from JNC 7
In a related editorial, Eric D. Peterson, MD, MPH, of Duke University Medical Center, J. Michael Gaziano, MD, of Brigham and Women’s Hospital, and Philip Greenland, MD, of Northwestern University Feinberg School of Medicine, said the new guideline differs from JNC 7, which was released in 2003. The new guideline raises target systolic BP goals in patients aged at least 60 years from <140 mm Hg to <150 mm Hg and eliminates the JNC 7 recommendation of a target systolic BP of <130 mm Hg for those with diabetes and kidney disease.
According to the editorialists, despite the JNC 7 target goal of systolic BP <140 mm Hg, only about half of US patients with hypertension have achieved that goal, and the JNC 8 recommendation of a target goal of systolic BP <150 mm Hg in those aged at least 60 years could mean that only about half of that population attains that mark. “Whether this change will have adverse consequences for population health is unclear, but it should be recalled that in the SHEP study, a 5-year lowering of average [systolic BP] from 155 mm Hg to 143 mm Hg resulted in a 32% reduction in cardiovascular events,” they wrote.
Additionally, they wrote, the JNC 8 guideline focus on BP target levels differs in stark contrast to the American College of Cardiology/American Heart Association guidelines on cholesterol management, which eschew specifying target levels in favor of focusing on treating those at greatest risk with more aggressive therapy. “Such divergent philosophies may cause confusion among clinicians and patients alike,” they wrote.
For more information:
James PA. JAMA. 2013;doi:10.1001/jama.2013.284427.
Peterson ED. JAMA. 2013;doi:10.1001/jama.2013.284430.
Disclosure: See the full text of the guideline for the committee members’ relevant financial disclosures. Peterson, Gaziano and Greenland report no relevant financial disclosures.