Monday, December 23, 2013

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):

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?