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Evidence-Based Diabetes Management January 2014

The JNC 8 Hypertension Guidelines: An In-Depth Guide

Michael R. Page, PharmD, RPh
Compared with previous hypertension treatment guidelines, the Joint National Committee (JNC 8) guidelines advise higher blood pressure goals and less use of several types of antihypertensive medications.

Patients will be asking about the new JNC 8 hypertension guidelines, which were published in the Journal of the American Medical Association on December 18, 2013.1

The new guidelines emphasize control of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with age- and comorbidity-specific treatment cutoffs. The new guidelines also introduce new recommendations designed to promote safer use of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).

Important changes from the JNC 7 guidelines2 include the following:

• In patients 60 years or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mm Hg.

• In patients 18 to 59 years of age without major comorbidities, and in patients 60 years or older who have diabetes, chronic kidney disease (CKD), or both conditions, the new goal blood pressure level is <140/90 mm Hg.

• First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs.

• Second- and third-line alternatives included higher doses or combinations of ACE inhibitors, ARBs, thiazide-type diuretics, and CCBs. Several medications are now designated as later-line alternatives, including the following: beta-blockers, alphablockers, alpha1/beta-blockers (eg, carvedilo), vasodilating beta-blockers (eg, nebivolol), central alpha2/-adrenergic agonists (eg, clonidine), direct vasodilators (eg, hydralazine), loop diruretics (eg, furosemide), aldosterone antagoinsts (eg, spironolactone), and peripherally acting adrenergic antagonists (eg, reserpine).

• When initiating therapy, patients of African descent without CKD should use CCBs and thiazides instead of ACE inhibitors.

• Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of ethnic background, either as first-line therapy or in addition to first-line therapy.

• ACE inhibitors and ARBs should not be used in the same patient simultaneously.

• CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in patients over the age of 75 years with impaired kidney function due to the risk of hyperkalemia, increased creatinine, and further renal impairment.

The change to a more lenient systolic blood pressure goal may be confusing to many patients who are accustomed to the lower goals of JNC 7, including the <140/90 mm Hg goal for most patients and <130/80 mm Hg goal for patients with hypertension and major comorbidities.

The guidelines were informed by results of 5 key trials: the Hypertension Detection and Follow-up Program (HDFP), the Hypertension-Stroke Cooperative, the Medical Research Council (MRC) trial, the Australian National Blood Pressure (ANBP) trial, and the Veterans’ Administration (VA) Cooperative. In these trials, patients between the ages of 30 and 69 years received medication to lower DBP to a level <90 mm Hg. Results showed a reduction in cerebrovascular events, heart failure, and overall mortality in patients treated to the DBP target level.

The data were  so compelling that some members of the JNC 8 panel wanted to keep DBP <90 mm Hg as the only goal among younger patients, citing insufficient evidence for benefits of an SBP goal lower than 140 mm Hg in patients under the age of 60 years. However, more conservative panelists pushed to keep the target SBP goal as well as the DBP goal.

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