JNC 8: What&#039;s covered, what&#039;s not, and what else to consider

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Applied Evidence

JNC 8: What's covered, what's not, and what else to consider

J Fam Pract. 2014 October;63(10):574-577,581-582,584

Tracy D. Mahvan, PharmD

Steven G. Mlodinow, MD

JNC 8 guidelines offer greater discretion in drug choice and modest relaxation of some BP targets. This review summarizes the recommendations and provides guidance on 2 patient populations that aren’t addressed.

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References

1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-520.

2. Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.

3. Roger VL, Go AS, Lloyd-Jones DM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.

4. Heidenreich PA, Trogdon JG, Khavjou OA, et al; American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933-944.

5. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31:2115-2127.

6. Ogihara T, Saruta T, Rakugi H, et al; Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56:196-202.

7. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-2571.

8. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. III. Reduction in stroke incidence among persons with high blood pressure. JAMA. 1982;247:633-638.

9. Hypertension-Stroke Cooperative Study Group. Effect of antihypertensive treatment on stroke recurrence. JAMA. 1974;229:409-418.

10. Medical Research Council Working Party. MRC trial of treatment of mild hypertension: principal results. Br Med J (Clin Res Ed). 1985;291:97-104.

11. The Australian therapeutic trial in mild hypertension. Report by the Management Committee. Lancet. 1980;1:1261-1267.

12. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213:1143-1152.

13. Curb JD, Pressel SL, Cutler JA, et al; Systolic Hypertension in the Elderly Program Cooperative Research Group. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. JAMA. 1996;276:1886-1892.

14. Tuomilehto J, Rastenyte D, Birkenhäger WH, et al; Systolic Hypertension in Europe Trial Investigators. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med. 1999;340:677-684.

15. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703-713.

16. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.

17. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S76-S99.

18. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-3264.

19. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-2571.

20. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213:1143-1152.

21. Mann JFE. Choice of drug therapy in primary (essential) hypertension: recommendations. UpToDate Web site. Available at: http://www.uptodate.com/contents/choice-of-drug-therapy-in-primary-essential-hypertension-recommendations. Accessed March 3, 2014.

22. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-2997.

23. Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421-2431.

24. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-e319.

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PRACTICE RECOMMENDATIONS

› Initiate pharmacologic treatment for patients  60 years or older with systolic blood pressure (BP) ≥150 mm Hg and/or diastolic BP ≥90 mm Hg. A
› Start antihypertensive treatment for systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg in patients who are younger than 60 or have chronic kidney disease or diabetes. C
› Select either a thiazide diuretic or a calcium channel blocker as first-line therapy for African Americans, whether or not they have diabetes. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Carla S is a 64-year old African American whom you’re seeing for the first time. Her health has been excellent over the last 10 years, she reports, with one caveat: She has “borderline hypertension,” but has never been treated for it and denies any symptoms. Her blood pressure (BP) today is 154/82 mm Hg. A physical exam is unremarkable. Blood tests reveal a normal blood count and normal renal function, and a nonfasting glucose level of 145 mg/dL. You ask Ms. S to return in a week for a repeat BP and fasting lab work.

Hypertension is the most common condition seen by physicians in primary care,¹ and a major risk factor for cardiovascular disease (CVD) and the morbidity and mortality associated with it. US treatment costs are an estimated $131 billion per year.^2-4 With this in mind, the Joint National Committee on Hypertension (JNC) released its eighth report (JNC 8) in December 2013¹—the first update in a decade.

In many ways, JNC 8 guidelines are simpler than those of JNC 7,² with more evidence-based recommendations and less reliance on expert opinion. The JNC has eliminated definitions such as stage 1, 2, and 3 hypertension, and focuses on outcomes instead. At the heart of the recommendations are 3 key questions:

1. At what BP should treatment be initiated to improve outcomes?
2. What should the target BP be for those undergoing treatment?
3. Which medications are best?

Answers to the first 2 questions, of course, go hand in hand. In other words, if the threshold for treatment is a systolic BP ≥140 mm Hg (more on that in a moment), then the target of treatment is a systolic BP of <140 mm Hg. In answer to the third question, JNC 8 offers guidance but gives physicians greater discretion in determining which type of drug to use when initiating treatment.¹

In the text, algorithm, and table that follow, we present an overview of JNC 8. We also discuss the optimal treatment of hypertension in patients with heart failure (HF) and coronary artery disease (CAD)—populations JNC 8 does not address.

Age-based recommendations are a bit less stringent

JNC 8 does not address the optimal treatment  of hypertension in patients with heart failure and coronary artery disease, but the ACC/AHA guidelines we report on here can help.60 years and older. Unlike JNC 7, which recommended initiating treatment for otherwise healthy patients of all ages with a BP ≥140/90 mm Hg,² JNC 8 clearly delineates its recommendations by age. It calls for treating patients ages 60 or older with systolic BP ≥150 mm Hg and/or diastolic BP ≥90.¹

The change is evidence-based: Moderate- to high-quality randomized controlled trials (RCTs) have found a reduced incidence of stroke, HF, and coronary heart disease when BP was treated to <150/90, but no additional benefit from a systolic BP target of <140 mm Hg for patients in this age group.^5,6 Notably, JNC 8 does not recommend a change in medication for patients 60 years or older for whom the more stringent target is being maintained without adverse effects.¹

18 to 59 years. For adults younger than 60, JNC 8 recommends treating systolic BP ≥140 and diastolic BP ≥90 mm Hg.¹ The systolic BP guideline is based on expert opinion, however, as there is no high-quality evidence for a systolic threshold in this age group. This is largely because most patients younger than 60 who have systolic BP ≥140 also have diastolic BP ≥90, making it difficult to study the treatment of systolic BP alone. High-quality trials have shown improved health outcomes when patients ages 30 to 59 years were treated for diastolic BP ≥90, however.^7-12 For patients younger than 30, the recommendation for treatment of diastolic pressure is based on expert consensus, as no sufficiently high-quality evidence exists.

Targets for patients with CKD and diabetes

Chronic kidney disease (CKD). JNC 8 recommends treating patients ages 18 to 69 years who have CKD and BP ≥140/90 mm Hg. JNC 7’s more stringent recommendation—treating such patients with BP ≥130/80 mm Hg²—was relaxed because there is little evidence of a lower mortality rate or cardiovascular or cerebrovascular benefits as a result of tighter control. In patients younger than 70, CKD is defined as an estimated (or measured) glomerular filtration rate (GFR) <60 mL/min/1.73 m² or albuminuria (>30 mg of albumin per g of creatinine).¹