JNC 8 as an Unfinished Road Map: Destinations Without Transportation (Part 1)

No more waiting for Godot. Unlike Samuel Beckett’s figure, this time he arrived under the mantle of JNC 8.¹ Was it worth the wait?

To answer that question, let’s review the 9 recommendations that make up the latest guidelines.

1. In persons 60 years and older, antihypertensive treatment should be initiated at a systolic pressure of 150 mm Hg and a diastolic of 90 mm Hg; the target for therapy is 150/90 mm Hg or less. If a person 60 years or older is already being treated and has a systolic blood pressure less than 140 mm Hg, no changes are necessary.

2. For those individuals younger than 60 years, treatment is initiated at a diastolic blood pressure of 90 mm Hg or greater. There are few data on adults younger than 30 years.

3. For those who are hypertensive and younger than 60 years, the systolic equivalent is 140 mm Hg.

4. If the population is one with CKD and older than 18 years, 140/90 mm Hg is the level to initiate therapy as well as the target for treatment. Higher-grade proteinuria (3 g/d or more excretion) no longer changes the target blood pressure goal.

5. If the population is one with diabetes and older than 18 years, 140/90 mm Hg again is the initiation level for antihypertensives and the target after therapy. The special lower target for diabetic patients (less than 130 systolic) no longer applies.

6. In non-black hypertensive populations, the medications of choice are a thiazide diuretic, a calcium channel blocker, and an ACE inhibitor/angiotensin receptor blocker (ACEI/ARB). The panel did not recommend beta-blockers; alpha-blockers; central alpha-agents; peripheral vasodilators, such as hydralazine; or aldosterone receptor antagonists as initial therapeutic options.

7. In a black population, the drugs recommended were a thiazide and a calcium channel blocker. The data were supported by the ALLHAT trial. A calcium channel blocker is preferred over an ACEI/ARB.

8. In the CKD hypertensive population 18 years and older, add-on medications should consist of an ACEI/ARB for kidney protection.

9. Titrate additional medications monthly to reach target. Do not combine an ACEI and an ARB. If 3 drugs do not suffice, add drugs from another class.

Hurrah for the simplicity of overlapping target blood pressures. No longer are there multiple targets for blood pressure treatment depending on the underlying characteristics of the population treated (diabetes, renal disease). The evidence-based message regarding the inferiority of beta-blockers for hypertension was finally enforced, just as it was in England (by N.I.C.E.).

More controversial is the decision regarding hypertensive patients 60 years and older. Other inferior drugs (based on evidence) such as hydralazine and central alpha-agents were identified and demoted.

Still, I expected much more. My predictions for content were not fulfilled. My next installment looks at what added material might have helped practitioners achieve those target pressures.

Reference
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guidelines for the management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013. Published online December 18, 2013.