Being a hospitalist it is very hard to adjust the HTN meds during hospital stay because of several confounding factors affecting the readings. We constantly try to recommend primary care physicians and patients about the ambulatory monitoring to better help medication titration but not an easy task. Along with lifestyle modifications, treating sleep apnea is big deal too. I wish guidelines include patient education and ambulatory blood pressure monitoring as primary recommendation.
JNC 8 Has Finally Arrived
JNC 8 Has Finally Arrived
- Allan S. Brett, MD
This updated hypertension guideline focuses on drug treatment thresholds and drug choices.
- 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
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.
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.
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).
Editor Disclosures at Time of Publication
Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose