JNC 8 as an Unfinished Road Map: Destinations Without Transportation (Part 2)

In part 1 of this article, I reviewed the 9 hypertension recommendations offered by JNC 8.¹ I applauded some content, but the final product left me eager for more.

Target blood pressures were there all right, and simplified greatly, and newer hierarchies for initial antihypertensive choices were provided. But how about more on emerging means at our disposal to get to target in even the patients with the most severe disease?

When I attended the American Society of Hypertension Meeting in San Francisco in May 2013, I found the practical and novel innovations in blood pressure management astounding. There were multiple sessions on identifying and treating resistant hypertension. This entity was already well publicized in the literature but was all but absent from the JNC final draft. Why was resistant hypertension such a prominent part of a national meeting and essentially ignored in JNC 8?

The benefits and efficacy of spironolactone in this specific population were extolled in May. Although the data undergirding spironolactone for resistant hypertensives may not be of an order of magnitude worthy of the committee stamp of evidence-based approval, the niche for this drug is becoming secure.

In San Francisco, not only were beta blockers drubbed as initial therapy but atenolol was unmasked as an agent that may increase cardiovascular risks when used to treat hypertension compared with other antihypertensives and as an agent that increases, not decreases, central blood pressure. A 2-hour review of beta blockers focused on why they were becoming passé for blood pressure therapy. Other beta blockers, such as metoprolol, were seen as drugs that increase insulin resistance and lead to diabetes mellitus. Studies that have compared carvedilol to metoprolol favored carvedilol for just that reason.

Where should we stand on ambulatory blood pressure monitoring and renal denervation therapy? They were important content at the May sessions. They didn’t seem to make the JNC cut.

In fairness to the JNC committee, their commitment to evidence-based medicine is laudable. But in the meanwhile, wasn’t there enough preliminary data to make some recommendations that may not have been Grade A, but compelling nonetheless?

For this author, conspicuous by their absence in this regard were the following:

• Making the definition of resistant hypertension de rigueur and suggesting specific therapy. Why not recommend spironolactone in appropriate patients (those who will not get hyperkalemic)? It was said in San Francisco in May 2013 that resistance warrants more potent diuretic usage and that means chlorthalidone, not hydrochlorthiazide. Chlorthalidone has an evidence-based pedigree that cannot be disputed.

• The data are also in on atenolol in the context of hypertension. Even if we don’t throw the baby out with the proverbial “bath water,” atenolol is not an acceptable drug even for add-on therapy.

• In patients hypertensive and obese, should carvedilol receive the nod over other traditional beta blockers, like metoprolol?

• Can we finally put hydralazine and clonidine out of their misery?

• Some other valuable maneuvers for resistant hypertension, such as “stacking” diuretics (using a combination like chlorthalidone and spironolactone) and dosing long half-life medications in the p.m., are viable but are not mentioned.

If it takes a long time to see JNC 9 (or if ever), I am concerned that JNC 8 stopped short of blood pressure management for 2014 and beyond. I can see the target destinations on the JNC map, but I need a car and gas to get there.

References:

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.