The JNC 8 Hypertension H ypertension Guidelines: An An In-Depth Guide http://www.aj!.!o/journals/e"iden!e-#ased-dia#etesana$eent/%&'(/january-%&'(/the-jn!-8-hypertension-$uidelines-anin-depth-$uide/)-%*sthash.+,$A#n.dpu Michael R. Page, PharmD, RPh Compared Compared with previous hypertension treatment treatment guidelines, the Joint National Committee Committee (JNC 8) guidelines advise advise higher blood pressure pressure goals and less use of several types of antihypertensive medications. Patients will be asing about the new JNC 8 hypertension guidelines, which were published in the Journal of the !merican "edical !ssociation on #ecember $8, %&$'.$ he new guidelines emphasie emphasie control of systolic systolic blood pressure pressure (*+P) and diastolic blood pressure pressure (#+P) with age and comorbidity speci-c treatment cutos. he new guidelines also introduce new recommendations recommendations designed to promote promote safer use of angiotensin converting enyme (!C/) inhibitors and angiotensin receptor blocers (!0+s). 1mportant changes from the JNC 2 guidelines% include the following3 4 1n patients 5& years or older who do not have diabetes or chronic idney disease, the goal blood pressure level is now 6$7&9& mm :g. 4 1n patients $8 to 79 years of age without ma;or comorbidities, and in patients 5& years or older who have diabetes, chronic idney disease (C<#), or both conditions, the new goal blood pressure pressure level is 6$=&9& mm :g. 4 >irstline and laterline treatments should now be limited to = classes of medications3 thiaidetype diuretics, calcium channel blocers (CC+s), !C/ inhibitors, and !0+s. 4 *econd and thirdline alternatives included higher doses or combinations of !C/ inhibitors, !0+s, thiaidetype diuretics, and CC+s. *everal medications are now designated as laterline laterline alternatives, including the following3 betablocers, alphablocers, alpha$betablocers alpha$betablocers (eg, carvedilo), vasodilating betablocers (eg, nebivolol), central alpha%adrenergic alpha%adrenergic agonists (eg, clonidine), direct vasodilators (eg, hydralaine), loop diruretics (eg, furosemide), aldosterone antagoinsts (eg, spironolactone), and peripherally acting adrenergic antagonists (eg, reserpine). reserpine). 4 ?hen initiating therapy, patients of !frican descent without C<#
should use CC+s and thiaides instead of !C/ inhibitors. 4 @se of !C/ inhibitors and !0+s is recommended in all patients with C<# regardless of ethnic bacground, either as -rstline therapy or in addition to -rstline therapy. 4 !C/ inhibitors and !0+s should not be used in the same patient simultaneously. 4 CC+s and thiaidetype diuretics should be used instead of !C/ inhibitors and !0+s in patients over the age of 27 years with impaired idney function due to the ris of hyperalemia, increased creatinine, and further renal impairment. he change to a more lenient systolic blood pressure goal may be confusing to many patients who are accustomed to the lower goals of JNC 2, including the 6$=&9& mm :g goal for most patients and 6$'&8& mm :g goal for patients with hypertension and ma;or comorbidities. he guidelines were informed by results of 7 ey trials3 the :ypertension #etection and >ollowup Program (:#>P), the :ypertension*troe Cooperative, the "edical 0esearch Council ("0C) trial, the !ustralian National +lood Pressure (!N+P) trial, and the AeteransB !dministration (A!) Cooperative. 1n these trials, patients between the ages of '& and 59 years received medication to lower #+P to a level 69& mm :g. 0esults showed a reduction in cerebrovascular events, heart failure, and overall mortality in patients treated to the #+P target level. he data were so compelling that some members of the JNC 8 panel wanted to eep #+P 69& mm :g as the only goal among younger patients, citing insucient evidence for bene-ts of an *+P goal lower than $=& mm :g in patients under the age of 5& years. :owever, more conservative panelists pushed to eep the target *+P goal as well as the #+P goal. 1n younger patients without ma;or comorbidities, elevated #+P is a more important cardiovascular ris factor than is elevated *+P. he JNC 8 panelists are not the -rst guideline authors to recognie this relationship. he JNC 2 guideline authors also acnowledged that #+P control was more important than *+P control for reducing cardiovascular ris in patients 65& years of age. :owever, in patients 5& years and older *+P control remains the most important factor. Dther recent evidence suggests that the *+P goal 6$=& mm :g recommended by the JNC 2 guidelines for most patients may have been unnecessarily low. he JNC 8 guideline authors cite % trials that
found no improvement in cardiovascular outcomes with an *+P target 6$=& mm :g compared with a target *+P level 6$5& mm :g or 6$7& mm :g. #espite this -nding, the new guidelines do not disallow treatment to a target *+P 6$=& mm :g, but recommend caution to ensure that low *+P levels do not aect Euality of life or lead to adverse events. he shift to a #+Pbased goal may mean younger patients will be prescribed fewer medications if diagnosed with hypertensionF this may improve adherence and minimie adverse events associated with low *+P, such as seGual dysfunction. Patients With Kidney Disease !lthough $ post hoc analysis showed a possible advantage in idney outcomes with the lower target of $'&8& mm :g recommended by JNC 2, % other primary analyses did not support this -nding. !dditionally, another ' trials did not show an advantage with the 6$'&8& mm :g goal over the 6$=&9& mm :g goal level for patients with chronic idney disease. !s a result, the new guidelines recommend that patients with chronic idney disease receive medication sucient to achieve the higher 6$=&9& mm :g goal level. :owever, in an eGception to this goal level, the guidelines suggest that patients with chronic idney disease or albuminuria 2& years or older should receive treatment based on comorbidities, frailty, and other patientspeci-c factors. /vidence was insucient to support a goal blood pressure of 6$=&9& mm :g in patients over the age of 2& years with C<# or albuminuria. Patients With Diabetes !dults with diabetes and hypertension have reduced mortality as well as improved cardiovascular and cerebrovascular outcomes with treatment to a goal *+P 6$7& mm :g, but no randomied controlled trials support a goal 6$=&9& mm :g. #espite this, the panel opted for a conservative recommendation in patients with diabetes and hypertension, opting for a goal level of 6$=&9& mm :g in adult patients with diabetes and hypertension rather than the evidencebased goal of 6$7&9& mm :g. Follow-up he JNC 8 guideline authors simpli-ed a complicated recommendation for followup in patients with hypertension. he JNC 2 panel recommended that after an initial high blood pressure reading, followup with a con-rmatory blood pressure reading should
occur within 2 days to % months, depending on how high the initial reading was and whether or not the patient had idney disease or endorgan damage as a result of hypertension. @nder JNC 8, in all cases, goal blood pressure targets should be reached within a month of starting treatment either by increasing the dose of an initial drug or by using a combination of medications. Treatments Hie the JNC 2 panel, the JNC 8 panel recommended thiaidetype diuretics as initial therapy for most patients. !lthough !C/ inhibitors, !0+s, and calcium channel blocers (CC+s) are acceptable alternatives, thiaidetype diuretics still have the best evidence of ecacy. he JNC 8 panel does not recommend -rstline therapy with beta blocers and alphablocers due to $ trial that showed a higher rate of cardiovascular events with use of betablocers compared with use of an !0+, and another trial in which alphablocers resulted in inferior cardiovascular outcomes compared with use of a diuretic. 1n addition, a lac of evidence comparing the = -rstline therapies with carvedilol, nebivolol, clonidine, hydralaine, reserpine, furosemide, spironolactone, and other similar medications precludes use of any medications other than !C/ inhibitors, !0+s, CC+s, and thiaide type diuretics in the vast ma;ority of patients. +efore receiving alphablocers, betablocers, or any of several miscellaneous agents, under the JNC 8 guidelines, patients would receive a dosage ad;ustment and combinations of the = -rstline therapies. riple therapy with an !C/ inhibitor!0+, CC+, and thiaidetype diuretic would precede use of alphablocers, beta blocers, or any of several other agents. hese new guidelines all but eliminate use of betablocers (including nebivolol), alphablocers, loop diuretics, alpha $beta blocers, central alpha%adrenergic agonists, direct vasodilators, aldosterone antagonists, and peripherally acting adrenergic antagonists in patients with newly diagnosed hypertension. Caution is warranted in patients who are already stable on these therapies. pecial Therapeutic !onsiderations !C/ inhibitors and !0+s may not be an ideal choice in patients of !frican descent. 0esults of a subgroup analysis in the !ntihypertensive and Hipid Howering reatment to Prevent :eart !ttac rial (!HH:!) found that !C/ inhibitors led to worse cardiovascular outcomes than thiaidetype diuretics or CC+s in patients with !frican ancestry. #espite the subgroup analysis of !HH:!, results of the !frican !merican *tudy of
:ypertension (!!*<) support use of -rstline or addon !C/1s to improve idneyrelated outcomes in patients of !frican descent with hypertension, C<#, and proteinuria. !s a result, the JNC 8 panelists recommend that all patients with chronic idney disease and hypertension, regardless of ethnic bacground, should receive treatment with an !C/ inhibitor or !0+ to protect idney function, either as initial therapy or addon therapy. Dne eGception to the use of !C/ inhibitors or !0+s in protection of idney function applies to patients over the age of 27 years. he panel cited the potential for !C/ inhibitors and !0+s to increase serum creatinine and produce hyperalemia. !s a result, for patients over the age of 27 years with decreased renal function, thiaide type diuretics or CC+s are an acceptable alternative to !C/1s or !0+s. 1n addition, the panel eGpressly prohibits simultaneous use of an !C/ inhibitor and an !0+ in the same patient. his combination has not been shown to improve outcomes. #espite the fact that the % medications wor at dierent points in the reninangiotensin aldosterone system, other combinations of medications are better options, and the simultaneous use of !C/1s and !0+s is not supported by evidence. "i#estyle !hanges !s in JNC 2, the JNC 8 guidelines also recommend lifestyle changes as an important component of therapy. Hifestyle interventions include use of the #ietary !pproaches to *top :ypertension (#!*:) eating plan, weight loss, reduction in sodium intae to less than %.= grams per day, and at least '& minutes of aerobic activity most days of the wee. 1n addition, to delay development of hypertension, improve the blood pressureIlowering eect of eGisting medication, and decrease cardiovascular ris, alcohol intae should be limited to % drins daily in men and $ drin daily in women. Note that $ drin constitutes $% ounces of beer, 7 ounces of wine, or $.7 ounces of 8&proof liEuor. uitting smoing also reduces cardiovascular ris. !onclusion he JNC 8 guidelines move away from the assumption that lower blood pressure levels will improve outcomes regardless of the type of agent used to achieve the lower level. 1nstead, the JNC 8 guidelines encourage use of agents with the best evidence of reducing cardiovascular ris. 1n addition, the guidelines may lead to less use of antihypertensive medications in younger patients, which will produce eEuivalent outcomes in terms of cardiovascular events
with less potential for adverse events that limit adherence.
