The JNC 8 Hypertension Guidelines: An In-Depth Guide

JANUARY 05, 2014
Michael R. Page, PharmD, RPh
Compared with previous hypertension treatment guidelines, the JNC 8 guidelines advise higher blood pressure goals and less use of several types of antihypertensive medications.

Patients will be asking about the new Joint National Committee (JNC 8) hypertension guidelines, which were published in the Journal of the American Medical Association on December 18.
The new guidelines emphasize control of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with age- and comorbidity-specific treatment cutoffs. The new guidelines also introduce new recommendations designed to promote safer use of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

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Important changes from the JNC 7 guidelines include the following:
  • In patients 60 years of age or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mmHg
  • In patients 18 to 59 years of age without major comorbidities, and in patients 60 years of age or older who have diabetes, chronic kidney disease, or both conditions, the new goal blood pressure level is <140/90 mmHg
  • First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACEIs, and ARBs
  • Second- and third-line alternatives included higher doses or combinations of ACEIs, ARBs, thiazide-type diuretics, and CCBs
  • Several medications are now designated as later-line alternatives, including the following:
    • Beta-blockers
    • Alpha-blockers
    • Alpha1/beta-blockers (eg, carvedilol)
    • Vasodilating beta-blockers (eg, nebivolol)
    • Central alpha2-adrenergic agonists (eg, clonidine)
    • Direct vasodilators (eg, hydralazine)
    • Loop diuretics (eg, furosemide)
    • Aldosterone antagonists (eg, spironolactone)
    • Peripherally acting adrenergic antagonists (eg, reserpine)
  • When initiating therapy, patients of African descent without chronic kidney disease should use CCBs and thiazides instead of ACEIs
  • Use of ACEIs and ARBs is recommended in all patients with chronic kidney disease regardless of ethnic background, either as first-line therapy or in addition to first-line therapy
  • ACEIs and ARBs should not be used in the same patient simultaneously
  • CCBs and thiazide-type diuretics should be used instead of ACEIs and ARBs in patients over the age of 75 with impaired kidney function due to the risk of hyperkalemia, increased creatinine, and further renal impairment
The change to a more lenient systolic blood pressure goal may be confusing to many patients who are accustomed to the lower goals of JNC 7, including the <140/90 mmHg goal for most patients and <130/80 mmHg goal for patients with hypertension and major comorbidities.
Results of 5 key trials--HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative--informed the changes in the new guidelines. In these trials, patients between the ages of 30 and 69 received medication to lower DBP to a level <90 mmHg. Results showed a reduction in cerebrovascular events, heart failure, and overall mortality in patients treated to the DBP target level.
The data were so compelling that some members of the JNC 8 panel wanted to keep DBP <90 mmHg as the only goal among younger patients, citing insufficient evidence for benefits of an SBP goal lower than 140 mmHg in patients under the age of 60. However, more conservative panelists pushed to keep the target SBP goal as well as the DBP goal.
In younger patients without major comorbidities, elevated DBP is a more important cardiovascular risk factor than is elevated SBP. The JNC 8 panelists are not the first guideline authors to recognize this relationship. The JNC 7 guideline authors also acknowledged that DBP control was more important than SBP control for reducing cardiovascular risk in patients <60 years of age. However, in patients 60 years of age and older SBP control remains the most important factor.
Other recent evidence suggests that the SBP goal <140 mmHg recommended by the JNC 7 guidelines for most patients may have been unnecessarily low. The JNC 8 guideline authors cite 2 trials that found no improvement in cardiovascular outcomes with an SBP target <140 mmHg compared with a target SBP level <160 mmHg or <150 mmHg. Despite this finding, the new guidelines do not disallow treatment to a target SBP <140 mmHg, but recommend caution to ensure that low SBP levels do not affect quality of life or lead to adverse events.
The shift to a DBP-based goal may lead to use of fewer medications in younger patients with a new diagnosis of hypertension and may improve adherence and minimize adverse events associated with low SBP, such as sexual dysfunction.