Slightly higher BP in older adults is acceptable….
On December 18, 2013, the Journal of the American Medical Association (JAMA) published new hypertension guidelines which come out of the report of panel members appointed to the eighth joint national commission (JNC 8). Hypertension, which can lead to CVA, MI, and kidney failure, has become more common in the ten years since JNC 7.
The new guidelines focus on what the panel considered their three primary questions:
- In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
- In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
- In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?
There are a total of 9 recommendations in the guidelines that aim to answer these questions. New changes include the goals of pharmacologic management. In adults >60 years old, when systolic blood pressure (SBP) is >150 or diastolic blood pressure is >90, then medication therapy should be initiated with a goal of SBP <150 and DBP <90; however, if current therapy lowers SBP to <140 and it is well-tolerated, then therapy does not need to be adjusted. This change comes in light of trial data showing that reducing BP to <150/90 improves health outcomes and not that having someone’s BP at <140/90 is wrong if it tolerated well.
In patients <60 or >18 years old with diabetes or chronic kidney disease, pharmacologic management should be initiated if SBP is >140 or DBP is >90 and goals should be to reduce BP to <140/90. The recommendation for drug selection has been separated by race: in the general non-black population the initial drug choice recommendation is: thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB); and in the general black population the initial antihypertensive drug choice should be either a thiazide-type diuretic or CCB. In addition, it is recommended that an ACE I or ARB should be the initial or add-on antihypertensive choice persons >18 years with CKD to improve kidney outcomes.
Finally, JNC 8 states that attaining and maintaining BP goals are important and if goals are not met within 1 month of pharmacotherapy treatment, then the dosage of the initial drug choice should be increased or a second drug (thiazide-type diuretic, CCB, ACEI, or ARB) should be added on. And if goals cannot be met with a 2 drug regimen, then a 3rd drug should be added. It is clearly stated that an ACE I and ARB should not be used together in the same patient and that antihypertensive medications from other classes should only be considered when the above listed are contraindicated for some reason or BP goals cannot be met.
JNC 8 limited their evidence review to RCT’s for development of these guidelines since this type of trial tends to have the least amount of bias. They also only used trials that contained >100 patients and were conducted for >1 year. In order to “pass” recommendations and supporting evidence, the panel attempted to attain 100% agreement amongst panel members but 2/3 majority was deemed acceptable except when evidence was based on expert opinion, then 75% majority agreement was required for approval. The National Heart, Lung and Blood Institute (NHLBI), however, did not participate in the development of these guidelines as they previously have. In June 2013, NHLBI announced that they would no longer participate in the development of clinical guidelines and that they would partner with and reassign the responsibility of guideline development to specialty organizations such as the American College of Cardiology and the American Heart Association.
The full guidelines are expected to be published in January 2014.
- JNC 8 recommends new BP goals for persons >60: <150/90.
- Under certain conditions, JNC 8 recommends new BP goals for persons >18 with CKD or diabetes: <140/90.
- Initial therapy for non-black population should consist of either thiazide-type diuretic, CCB, ACEI, or ARB; and in the black population should either be a thiazide diuretic or CCB.
JAMA, December 2013
James, P. et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. Published online December 18, 2013