JNC 8 - hypertension management may never be the same

- Jennifer Middleton, MD, MPH

The Eighth Joint National Committee (JNC 8) released its "2014 Evidence-Based Guideline For the Management of High Blood Pressure in Adults" last week.  It's been 10 years since JNC 7, and I suspect that many family docs, like myself, have been eagerly awaiting its release.

In JNC 8, a group of experts from multiple fields, including Family Medicine, sifted through the enormous evidence base regarding hypertension treatment.  Where no or low-quality evidence exists, they stated as such and made an expert recommendation.  I appreciate their transparency in indicating these instances.

The committee sought to answer these 3 questions (directly quoted from the article):

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

And made the following recommendations (summarized by myself):

1. For adults aged 60 and older, treat blood pressure (BP) to a goal of less than 150/90.  
2. For adults 18-59, treat BP to a goal of less than 140/90.  This includes patients with diabetes and/or chronic kidney disease (CKD).
3. Initiate treatment with a thiazide diuretic, an ACE inhibitor, an ARB, or a calcium channel blocker (CCB). This includes patients with diabetes.
4. No, there were no beta blockers on that last list.  Exhaust those other classes before adding a beta blocker.  JNC 8 backs this up with solid references; here's one to whet your appetite.
5. For African-American patients, consider initiating treatment with a thiazide or a CCB.  This includes patients with diabetes.
6. Patients with CKD should be on an ACE inhibitor or ARB, regardless of race or co-morbid diseases.

It's unclear, as of yet, how widely these recommendations will be adopted.  Will the American Academy of Family Physicians endorse them?  How about the American Heart Association and/or the American College of Cardiologists?  They will likely want time to examine JNC 8 before stamping a seal of approval upon it, along with the AAFP, who thoughtfully posted an overview of the guidelines along with their plan to review them last week.

I encourage you to check out the article for yourself and draw your own conclusions.  Should JNC 8 be the new standard of care?