Applied Evidence
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Is your patient on target? Optimizing diabetes management
As new evidence emerges and guidelines are frequently revised, optimizing diabetes treatment with an eye toward HbA1c, blood pressure, and lipid...
Tracy D. Mahvan, PharmD
Steven G. Mlodinow, MD
University of Wyoming, School of Pharmacy, Laramie (Dr. Mahvan); Salud Family Health Centers, Longmont, Colo (Dr. Mlodinow)
tbaher@uwyo.edu
The authors reported no potential conflict of interest relevant to this article.
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.
› 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
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