JNC 8: Expert Panel Want BP Cuffs Loosened

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The long–awaited update to guidelines for the management of hypertension, from the panel appointed to the Eighth Joint National Committee (JNC 8), raises the recommended blood pressure threshold to determine the need for drug therapy in many patients.
For most hypertensive individuals aged 60 or older, pharmacologic treatment should be started when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher, with the goal of achieving readings below those cutoffs.
For younger hypertensive patients and for those with chronic kidney disease or diabetes –– regardless of age –– treatment should be initiated when the systolic pressure is 140 or higher or the diastolic pressure is 90 or higher
In the previous JNC 7 guidelines released in 2003, the target blood pressure was less than 140/90 mm Hg for most hypertensive patients and less than 130/80 mm Hg for patients with chronic kidney disease or diabetes.

For the initial choice of agent, the authors made the following recommendations:

For nonblack individuals, including those with diabetes, ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide–type diuretics can all be chosen for first–line treatment
For black individuals, including those with diabetes, calcium channel blockers and thiazide–type diuretics are recommended as first–line therapy
For patients with chronic kidney disease, regardless of race or diabetes status, initial or add–on therapy should include an ACE inhibitor or an ARB to improve renal outcomes.

What Isn’t Included

The current guidance had a narrow focus and did not cover several subjects included in the JNC 7 recommendations, including definitions of pre–hypertension and hypertension, measurement of blood pressure, patient evaluation, secondary hypertension, adherence to treatment regimens, resistant hypertension, and lifestyle interventions.
The authors didn’t completely sidestep lifestyle, however. The included treatment algorithm has an instruction to implement lifestyle interventions and maintain them throughout management of the patient before moving on to drug therapy. And the authors stated that they endorse the recently released lifestyle recommendations of the ACC and AHA.
For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. These lifestyle treatments have the potential to improve blood pressure control and even reduce medication needs.

JNC 8 at Last! Guidelines ease up on BP thresholds, drug choices

The Eighth Joint National Committee (JNC 8) has released its new guidelines on the management of adult hypertension, which contain two key departures from JNC 7 that will simplify care.

The expert writing group recommends a relaxing of the more aggressive JNC 7 target blood pressures and treatment–initiation thresholds in elderly patients and in patients under age 60 with diabetes and kidney disease.
JNC 8 also backs away from the recommendation that thiazide–type diuretics should be initial therapy in most patients, suggesting an ACE inhibitor, angiotensin–receptor blocker (ARB), calcium–channel blocker (CCB), or thiazide–type diuretic are reasonable choices.

Simple message rule

Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else.
Any of these four groups of drugs are good, just get people to goal. Monitor them, track them, remonitor them. That’s a very simple message.

Nine Recommendations

In patients 60 years or over, start treatment in blood pressures >150 mm Hg systolic or >90 mm Hg diastolic and treat to under those thresholds.
In patients <60 years, treatment initiation and goals should be 140/90 mm Hg, the same threshold used in patients >18 years with either chronic kidney disease (CKD) or diabetes.
In nonblack patients with hypertension, initial treatment can be a thiazide–type diuretic, CCB, ACE inhibitor, or ARB, while in the general black population, initial therapy should be a thiazide–type diuretic or CCB.
In patients >18 years with CKD, initial or add–on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

While the targets have been loosened, the new guidelines do not mean that physicians should ease up on treatment in a patient who is doing very well based on JNC 7 guidance.

“I do think there’s always a concern about people not following the recommended targets; however, we have to start somewhere, and our panel’s opinion is that we should start where the evidence leads us,” Dr Paul A James (University of Iowa, Iowa City) lead author on the new guidelines, said. “In one sense, you’re fooling people by saying, ‘Let’s pretend it’s 140 mm Hg so we have a little leeway,’ and that doesn’t feel exactly right.”