New hypertension guidelines raise BP thresholds

Panel members from the Eighth Joint National Committee recommend including higher BP cutoffs for older patients and for patients with chronic kidney disease or diabetes.

New hypertension guidelines raise BP thresholds
New hypertension guidelines raise BP thresholds

Updated hypertension treatment and management guidelines from the Eighth Joint National Committee (JNC 8) raise the recommended BP thresholds for determining whether drug therapy is necessary in many patients.

Among adults aged 60 years and older with hypertension, pharmacologic treatment should be initiated when systolic BP is 150 mm Hg or higher or if the diastolic BP is 90 mm Hg or higher, with the goal of reducing BP to below those cutoffs, the new recommendations specify.

For younger patients, or for those with chronic kidney disease or diabetes at any age, treatment initiation should begin with systolic readings of 140 or higher, or diastolic readings of 90 or higher, the guidelines state.

Published in the Journal of the American Medical Association, the first updates since 2003 raise the BP thresholds from the 140/90 mm Hg for most hypertensive patients and less than 130/80 mm Hg for those with chronic kidney disease or diabetes set forth in the JNC 7 guidelines.

The JNC 8 panel, co-chaired by Paul James, MD, of the University of Iowa in Iowa City, and Suzanne Oparil, MD, of the University of Alabama at Birmingham, was initially commissioned by the National Heart Lung and Blood Institute in 2008, but was later handed off to the American College of Cardiology and the American Heart Association.

Although the updated hypertension treatment guidelines were sent out for external review, the recommendations were published independently without endorsements from the ACC, AHA or any other federal agency, James and Oparil noted.

Eric D. Peterson, MD, MPH, of Duke University Medical Center and JAMA associate editor, and colleagues noted in an accompanying editorial that the new hypertension guidelines do not represent a national consensus and "it remains unclear as to whether, or when, or by whom," another such document will be formulated.

The JNC 8 panelists reviewed evidence from randomized controlled clinical trials to answer three questions: when treatment goals should be initiated, what BP goals are appropriate and which drugs should be used. 

ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers and thiazide-type diuretics should be chosen as first-line treatment options for nonblack patients with hypertension, including those with diabetes, the panelists recommended.

For black individuals, including those with diabetes, calcium channel blockers and thiazide-type diuretics are recommended as first-line therapy.

For those with chronic kidney disease, regardless of race or diabetes status, initial or add-on therapy should include an ACE inhibitor or an ARB to improve renal outcomes.

The updated recommendations also include a treatment algorithm to provide guidance for combining and adjusting doses of the various drugs. However, the panelists emphasized "these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient." 

The new JNC 8 guidelines do not include recommendations on several important issues covered in the JNC7, including definitions of pre-hypertension and hypertension, BP measurement, patient evaluation, secondary hypertension, adherence to treatment regimens, resistant hypertension and lifestyle interventions. The panel did note that it supports recently recommended lifestyle interventions from the AHA.

"There is an important need to create a national consensus group to draft an updated comprehensive practice guideline that would harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy," Peterson and colleagues wrote in their editorial.

References

  1. James P et al. JAMA. 2013; doi: 10.1001/jama.2013.284427.
  2. Peterson E et al. JAMA. 2013; doi: 10.1001/jama.2013.284430.
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