One emerging concept in hypertension that is likely to find expression in JNC-8 is that combining drugs from different classes is a more effective means of lowering blood pressure than is maximizing the dose of a single drug. Another is that visit-to-visit variability in systolic BP is an important predictor of stroke risk independent of mean systolic BP, and calcium channel blockers produce less visit-to-visit variation than do other drug classes (Lancet 2010;375:895-915).
So, will JNC-8 back away from the time-honored recommendation to treat all patients with high blood pressure, including those who are elderly, to less than 140/90 mm Hg? Dr. Smith wouldn’t say.
"We have a dilemma here," he observed. "Do we do what makes sense intuitively in extrapolating from very strong, solid, observational data, or do we need to mount large randomized controlled trials, like the Institute of Medicine would say?"
He did note that an SBP goal of less than 140 mm Hg has been an important public health goal for several decades. "We’ve seen good things happen – we’ve seen a decline in stroke – during that time, even though we don’t have the supporting randomized controlled trials," Dr. Smith said.
JNC-8 is one of five major sets of National Heart, Lung, and Blood Institute–sponsored cardiovascular guidelines in the works. Dr. Smith predicted the obesity report, like JNC-8, will probably be released in the spring. Meanwhile, the Adult Treatment Panel 4 (ATP 4) cholesterol report, the risk assessment guidelines, and the lifestyle report are nearing completion.
"I would expect them to be out by summer," he said.
Dr. Smith reported having no financial conflicts.