JNC 8: Not So Great?

I am of two minds about this relaxation of the blood pressure goals. On the one hand, I acknowledge that the recommendations are evidence based, at least in the sense that no incontrovertible data exist to refute this more relaxed goal. There are simply not any credible studies out there that demonstrate better results when the systolic goal is 140 mm Hg rather than 150 mm Hg. It doesn’t mean that it might not be true—140 might really be better than 150—it simply means that the issue has not been studied in any clinical trial. So from a purist, evidence-based standpoint, I can accept that the new recommendation is perfectly valid from a scientific point of view.

But the part of me that values the art of medicine as well as the science is profoundly troubled by this lockstep scientific purity. What I am extremely concerned about is the possibility that the practice community will misinterpret the recommendations and take them as a mandate to loosen blood pressure control in those over age 60. If the target is just to get the systolic below 150 mm Hg, some may conclude that a pressure of 160 or even 165 is “close enough for government work,” to use the convenient phrase that dogs us federal employees. This would be a misinterpretation of the guidelines’ actual recommendation, but nonetheless, a very understandable and almost predictable one. Given that the practice community has never done a bang-up job of getting patients to the goals previously recommended, is it really the time to relax those guidelines and run the risk of even less blood pressure control?

I have to reluctantly conclude that the pseudo JNC 8 guidelines are not so great, at least for hypertensive patients over age 60. Although I cannot quibble with the strict scientific underpinning of the guidelines, they seem very likely to lead to a setback in hypertension control. We may see more heart attacks, strokes, heart failure, and renal failure if practitioners take the new guidelines as license to be less vigilant in treating elevated blood pressure. Treating elevated blood pressure is the low-hanging fruit for most primary care providers, and discouraging them from plucking that fruit from the tree is clearly a step in the wrong direction.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

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