Hypertension: Eighth Joint National Committee (JNC 8) Recommendations

Updated 23/11/2023 5:44 PM - Dr. Linda Park

Hypertension, a prevalent condition in primary care, significantly contributes to the risk of myocardial infarction, cerebrovascular accidents, renal failure, and mortality. The JNC 8, published in JAMA in December 2013, introduced pivotal changes in hypertension management, distinguishing it from its predecessor, JNC 7.

Key Changes and Nuances:

1. Scope and Applicability (JNC 8 Nuances 1-2):
   
   
   
   • The recommendations are tailored for individuals aged 18 years or older with hypertension.
   
   
   • Retains the 140/90 definition from JNC 7, emphasizing that these guidelines specifically target hypertensive populations.
   
   
2. Data Basis and Scope (JNC 8 Nuances 3):
   
   
   
   • JNC 8 relies exclusively on data from randomized controlled trials (RCTs), diverging from the varied study designs employed by JNC 7, which included observational studies, systematic reviews, or meta-analyses.
   
   
   • Acknowledges its limitations, deeming itself "not a comprehensive guideline" and excluding considerations of adherence and medication costs.
   
   
3. Uniform Treatment Goals (JNC 8 Nuances 4):
   
   
   
   • Advocates for uniform treatment goals across hypertensive populations, diverging from JNC 7, which had goals defined by co-morbid conditions.
   
   
4. Recommended Drug Classes (JNC 8 Nuances 5):
   
   
   
   • Recommends four drug classes for initial and add-on therapy: thiazide-type diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs).
   
   
5. Treatment Goals for Different Age Groups (JNC 8 Nuances 6-7):
   
   
   
   • Initiates pharmacologic treatment for individuals aged 60 or older at SBP of 150 mm Hg or higher and DBP of 90 mm Hg or higher.
   
   
   • Individuals younger than 60 commence treatment at DBP of 90 mm Hg or higher.
   
   
   • Establishes specific treatment goals for each group.
   
   
6. Population-Specific Recommendations (JNC 8 Nuances 8-9):
   
   
   
   • Tailors pharmacologic interventions for populations with chronic kidney disease (CKD) or diabetes.
   
   
7. Preference for Specific Drug Classes (JNC 8 Nuance 10):
   
   
   
   • Introduces a preference for thiazide-type diuretics, CCBs, ACEIs, or ARBs as first-line agents for non-black populations.
   
   
   • Recommends thiazide-type diuretics or CCBs for the black population.
   
   
8. Primary Objective of Hypertension Treatment (JNC 8 Nuance 11):
   
   
   
   • Underscores the primary objective: attaining and maintaining goal blood pressure.
   
   
9. Stepwise Approach and Medication Adjustments (JNC 8 Nuances 12):
   
   
   
   • Recommends a stepwise approach, adjusting medication regimens as needed.
   
   
10. Discouragement of ACEI and ARB Combination (JNC 8 Nuance 13):
    
    
    
    • Discourages combining ACEIs and ARBs in the same patient.
    
    

Specific Recommendations and Supporting Evidence:

Recommendation 1:

In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at systolic blood pressure (SBP) of 150 mm Hg or higher or diastolic blood pressure (DBP) of 90 mm Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. (SOR = A)

In this age group, initiating pharmacologic treatment at the specified blood pressure thresholds has shown a significant reduction in the risk of stroke, heart failure, and coronary heart disease. Setting a goal SBP lower than 140 mm Hg provides no additional benefit compared to an SBP of 140 to 160 or 140 to 149. It is noteworthy that, if pharmacologic treatment results in a lower achieved SBP (e.g., <140 mm Hg) without adverse effects on health or quality of life, adjustment of treatment may not be necessary. This approach contributes to a comprehensive strategy aimed at minimizing cardiovascular risks in the elderly population.

Recommendation 2:

In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal DBP of lower than 90 mm Hg. (SOR = A, for ages 30 - 59 years, SOR = E for ages 18 - 29 years)

For individuals under 60 years of age, the initiation of pharmacologic treatment is recommended when diastolic blood pressure (DBP) reaches or exceeds 90 mm Hg. The goal is to maintain DBP below 90 mm Hg. Notably, the evidence supports the absence of incremental benefits in treating patients to a lower goal of <80 or <85 mm Hg compared to the goal of <90 mm Hg. This nuanced approach is tailored to different age brackets, ensuring an effective and evidence-based strategy for blood pressure management.

Recommendation 3:

In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to a goal SBP of lower than 140 mm Hg. (SOR = E)

For individuals under 60 years of age, specifically targeting systolic blood pressure (SBP) at 140 mm Hg or higher for initiation of pharmacologic treatment is recommended. The expert opinion of the panel guides the treatment approach, acknowledging the lack of substantial evidence from quality randomized controlled trials (RCTs) to support a specific SBP target for this age group. The overarching goal is to treat at a threshold of >140 mm Hg with a treatment goal of <140 mm Hg, aligning with a comprehensive approach to hypertension management.

Recommendation 4:

In the population aged 18 years or older with CKD, initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher or DBP of 90 mm Hg or higher and treat to goal SBP of lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (SOR = E)

The focus of this recommendation is on individuals aged 18 to 70 years with chronic kidney disease (CKD), emphasizing the initiation of pharmacologic treatment when systolic blood pressure (SBP) reaches 140 mm Hg or higher, or diastolic blood pressure (DBP) reaches 90 mm Hg or higher. The goal is to treat to an SBP lower than 140 mm Hg and a DBP lower than 90 mm Hg. Importantly, this is a departure from JNC 7, which suggested a lower BP goal of <130/80 mm Hg. The nuanced approach addresses age-specific considerations and the presence of albuminuria.

Recommendation 5:

In the population aged 18 years or older with diabetes, initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher or DBP of 90 mm Hg or higher and treat to a goal SBP of lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (SOR = E)

For individuals aged 18 years or older with diabetes, the initiation of pharmacologic treatment is recommended when systolic blood pressure (SBP) is 140 mm Hg or higher or diastolic blood pressure (DBP) is 90 mm Hg or higher. The treatment goal is to maintain SBP and DBP below 140 mm Hg and 90 mm Hg, respectively. Notably, JNC 8 found no randomized controlled trials (RCTs) addressing whether treatment to an SBP goal of <140 improves health outcomes compared with a higher goal (e.g., <150 mm Hg). This recommendation aligns with a consistent blood pressure goal in the general population and emphasizes evidence-based adjustments.

Recommendation 6:

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (SOR = B)

This recommendation underscores the importance of tailoring initial antihypertensive treatment for the general nonblack population, incorporating thiazide-type diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs). Each of these four drug classes is deemed to yield comparable beneficial effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes. The nuanced approach considers evidence-based differences in heart failure outcomes, providing valuable guidance for clinicians in the selection of antihypertensive agents.

Recommendation 7:

In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (SOR = B for the general black population; SOR = C for black patients with diabetes)

Tailoring antihypertensive treatment for the general black population, this recommendation suggests the inclusion of a thiazide-type diuretic or calcium channel blocker (CCB) in the initial regimen. This preference is supported by evidence from the ALLHAT study, indicating a greater effect of thiazides compared to ACEIs in improving cerebrovascular, heart failure, and combined cardiovascular outcomes in black patients. Additionally, initial therapy with CCBs among black patients in the ALLHAT study was associated with a 51% relative risk reduction for stroke when compared to ACEI.

Recommendation 8:

In the population aged 18 years or older with CKD and hypertension, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.

For individuals aged 18 years or older with chronic kidney disease (CKD) and hypertension, the recommendation emphasizes the inclusion of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in the initial or add-on antihypertensive treatment regimen. The focus is on improving kidney outcomes, and this recommendation applies to all CKD patients with hypertension, irrespective of race or diabetes status. Notably, the guidance acknowledges potential conflicts and relies on expert opinion to provide nuanced recommendations based on the presence or absence of proteinuria.

Recommendation 9:

The primary objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of therapy, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using the drugs in recommendation six because of a contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.

Summary

The primary objective of hypertension treatment, as outlined in this recommendation, is to achieve and sustain goal blood pressure (BP). The stepwise approach involves dose adjustments, addition of a second drug from the recommended classes, and continuous assessment of BP. If goal BP is not attained with two drugs, the recommendation allows for the addition and titration of a third drug from the specified classes. Importantly, combining angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in the same patient is discouraged. In cases where goal BP cannot be achieved with the recommended drugs due to contraindications or the necessity for more than three drugs, alternative antihypertensive classes can be considered. The recommendation acknowledges the potential need for referral to a hypertension specialist in challenging cases or for the management of complex patients requiring additional clinical consultation.

These detailed recommendations, underpinned by evidence and expert opinions, provide a comprehensive guide for clinicians in addressing hypertension across diverse patient populations. The stepwise approach and consideration of individual factors contribute to a nuanced and effective strategy for hypertension management. Clinicians are encouraged to refer to the complete JNC 8 guidelines for an in-depth understanding of each recommendation and associated evidence.