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JNC 8 Has Finally Arrived

Guideline Watch |
December 24, 2013

JNC 8 Has Finally Arrived

  1. Allan S. Brett, MD

This updated hypertension guideline focuses on drug treatment thresholds and drug choices.

  1. Allan S. Brett, MD

Sponsoring Organization: None; the authors were appointed to the Eighth Joint National Committee (JNC 8), which is not currently affiliated with any organization.

Target Population: Primary care providers and other clinicians who care for patients with hypertension

Background and Objective: To guide clinicians in managing hypertension in adults

Key Points

This guideline addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during treatment, and choice of antihypertensive agents. Recommendations are as follows:

  • For younger patients (age, <60), drug therapy should be considered for diastolic BP ≥90 mm Hg or systolic BP ≥140 mm Hg. The goal is <140/90 mm Hg, but only the diastolic thresholds are based on high-quality evidence.

  • For older patients (age, ≥60), drug therapy should be considered for diastolic BP ≥90 mm Hg or systolic BP ≥150 mm Hg; the goal is <150/90 mm Hg.

  • For patients with diabetes and patients with chronic kidney disease, the threshold to initiate drug therapy is 140/90 mm Hg; the goal is <140/90 mm Hg.

  • In nonblack patients, acceptable initial drug-class choices are thiazide-type diuretics, calcium-channel blockers (CCBs), angiotensin-converting–enzyme (ACE) inhibitors, and angiotensin-receptor blocker (ARBs).

  • In black patients, acceptable initial drug-class choices are thiazide-type diuretics or CCBs.

  • Patients with chronic kidney disease generally should receive ACE inhibitors or ARBs.

  • When patients require escalation of therapy, either maximizing doses of individual drugs sequentially or combining several drugs at submaximal doses is acceptable.

What's Changed

JNC 7, the predecessor of this guideline, was a comprehensive document that covered not only hypertension treatment, but also definitions of hypertension, issues in BP measurement, public health perspectives, lifestyle modification, and “special situations” in hypertension management. In contrast, JNC 8 focuses narrowly on drug treatment. Moreover, recommendations in JNC 7 were informed liberally by extrapolation from observational data and by expert opinion, as well as by data from randomized trials. In contrast, recommendations in JNC 8 mostly reflect randomized trial–level evidence, with explicit acknowledgement when a recommendation reflects only expert opinion. JNC 8 is very transparent about its guideline-writing process, which aspired to the Institute of Medicine's report on creation of trustworthy guidelines. Two specific differences regarding treatment are as follows:

  • JNC 7 recommended a treatment threshold of 140/90 mm Hg regardless of age, whereas JNC 8 raises the systolic threshold at age 60. In addition, JNC 7 recommended a lower treatment threshold (130/80 mm Hg) for patients with diabetes or chronic kidney disease, but JNC 8 does not.

  • In JNC 7, thiazide-type diuretics were recommended as initial drug therapy (unless compelling reasons dictated another drug class), with CCBs, ACE inhibitors, ARBs, and β-blockers as alternates. In JNC 8, the initial drug choice is broadened to four classes for nonblack patients and two classes for black patients. β-blockers are no longer recommended for initial therapy because they might afford less protection against stroke.

Comment

The Eighth Joint National Committee (JNC 8) is a fairly straightforward, evidence-based guideline that is limited in scope to drug therapy for hypertension (although the authors briefly acknowledge that the potential benefits of diet and exercise “cannot be overemphasized”); in my view, its recommendations are reasonable. However, the guideline might frustrate clinicians who are looking for more comprehensive guidance on the nuances of hypertension management. For example, how do we decide that a patient with labile blood pressure actually has a BP of 140/90 mm Hg, warranting treatment? (e.g., How many readings? In office or ambulatory?) Should we use hydrochlorothiazide or chlorthalidone? For patients with resistant hypertension, what is a reasonable checklist of things that we should consider before enlisting the help of a specialist?

It so happens that the American Society of Hypertension and International Society of Hypertension released their own new hypertension guideline during the same week JNC 8 was published. Their guideline is more comprehensive than JNC 8, and it addresses the rhetorical questions I posed above. It reads more like a review article than a guideline and does not explicitly discuss how it was created. Nevertheless, its treatment recommendations are similar to those of JNC 8, with one exception — it raises the systolic treatment threshold to 150 mm Hg only for patients older than 80 (not 60).

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

Citation(s):

Reader Comments (24)

a

hello, I think this article has a good summery

Dr abhishek parmar Medical Student, Internal Medicine, Vadodara gujrat India

disappointed by JNC 8...

KIPENGE Richie Physician, Internal Medicine, Lubumbashi's University Teaching Hospital

There is nothing extraorinary... Even if it's clear but i think it useful!

ARIEF WIBOWO Physician, Internal Medicine, SSMH memorial hospital ,Jakarta,Indomesia

A better guideline with new evidence, but not more comprehensive. Many things to treat vary hypertension not have new revision. Still need to watch the other guidelines.

miguel angel navarro romero Physician, Internal Medicine, private

there are more evidence not to use thiazide because this is known to produce more diabetics, the question is more stable the hypertension but we have more diabetics?

Ratneswar Bhattacharya.M.D. Physician, Internal Medicine, kolkata,India.

At what level BP to be brought down for better cardio-vascular protection.Is it just <140/90 or much less than that e.g.120/80or even less than that.How frequently drug increment tobe done.

harsha neramballi subba rao Physician, Internal Medicine, bhagwan mahaveer jain hospital,bangalore

involvement of trained social workers in detection and first line treatment might make huge difference in reducing the morbidity and mortality associated with hypertension,especially in our country with lot of rural people.

James Reed, M.D. Physician, Endocrinology, Morehoise of Medicine

This document is vague and raises more controversies than it settles

Ricardo Lama, MD Physician, Internal Medicine, Ecuador

This guidelines were done based on best available evidence and lessened the recommendations based on expert opinion.
I realized the recommendations are based on RCT o MA. There is a lot of room for doing from now on well designed randomized clinical trial that address many questions not resolved or recommended by JNC 8.

HAROLDO PINHEIRO Physician, Cardiology, University of ate of Par´, Brazil

Many cases requires the use of betablockers before any other madications. The guidelines gave no suggstions regarding their use as first choice

Pinheiro Haroldo, MD Physician, Cardiology, State University of Para, Brazil

Many resistent cases will never be under contol unless betablockers are prescribed. The guidelines do not offer a suggestion for the right time to wait with the first four options.

Purushottam Singh MD Internal Medicine Physician, Internal Medicine, Al Gharbia Hosp, Abu Dhabi, UAE

Still guidelines need to clarify about Labile HTN and when to start medication in such patients.
Otherwise JNC 8 is straight forward as far as medication plan is concerened

Narasimhachary.Nattamai.L Physician, Internal Medicine, Madurai,Tamilnadu,India

Yes,I find it difficult to bring down the B.P for my patients as per new jnc8th guidelines.I think this will be hajordous to my patients.This is my personal opinion.

Johanes nugroho MD Other Healthcare Professional, Cardiology, Surabaya

I think thats a good guideline based on data. In the real world have aggressive vs conservative physician and so this guideline can not to satisfy for all, but individual approach is a wise decision

Roni Oliven; internal medicine Physician, Geriatrics, israel

Sadly, still no specific geriatric guidlines, other than "over 60"… otherwise not bad… still, I always wondered why thiazide induced hyponatremia isn't a good enough reason to remove thiazides from "first choice" antihyperensive therapy

Dr.Arghya Chattopadhyay Physician, Internal Medicine, Kolkata ,India

It is very useful and straight forward guideline,though finer discussion were expected.

DINAKER MANJUNATH Physician, Internal Medicine, Sunshine Hospitals, Hyderabad, INDIA

JNC 8: Disappointing to say the least.
- No emphasis on home monitoring Vs ambulatory BP monitor.
- What about time-tested 'beta-blockers' and centrally acting agents?
- Which patients should be selected for 'renal sympathetic de-nervation?
- Any 'new' recommendations for 'pregnancy-induced-hypertension?
-What about BP control in patients with End-stage renal disease? Are alpha 1 blockers still used?

Yaseer Muhammad Tareq Khan

The long awaited hypertension guideline JNC 8 disappointed many of us

MARIO CAVAZOS Physician, Internal Medicine, Private medicine

I Think is a good guideline, short and clearly.

MANDEEP SHARMA Physician, Internal Medicine, govt

Initial therapy choice between ACE(i) and ARBs ...many trials failed to show cardiovascular benefits with ARBs as 1st choice despite having produced an equal blood pressure reduction as by ACE(i). Still JNC 8 included ARBs as first choice ..however they should ideally be used in ACE (i) intolerant patients. How about combination choices of CCBs and ACE(i)..No inputs from JNC 8 unlike 7. Comments plz.....

MANFREDO TURCIOS Physician, Internal Medicine, school hospital

the guideline (jn8) is not what we expect

MBBS MD Physician, Internal Medicine, R D GARDI MEDICAL COLLEGE UJAIN MP INDIA

NOTHTHING EXTRAORDINARY TO THIS GUIDE LINE

Giorgio Dobrilla, professor

useful article

MUHAMMAD IDREES

too straight forward. but way to diagnose and if a patient comes with BP 154/90, then how to follow patient and when to start treatment , all are shaded area. i am truly disappointed.
what are better guidlines which one can follow in managing patient

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