• The long-awaited update to guidelines for the management of hypertension, from the panel appointed to the Eighth Joint National Committee (JNC 8), raises the recommended blood pressure threshold to determine the need for drug therapy in many patients.
• Point out that for most hypertensive individuals 60 or older, pharmacologic treatment should be started when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher, with the goal of achieving readings below those cutoffs.

The long-awaited update to guidelines for the management of hypertension — from the panel appointed to the Eighth Joint National Committee (JNC 8) — raises the recommended blood pressure threshold to determine the need for drug therapy in many patients.

For most hypertensive individuals 60 or older, pharmacologic treatment should be started when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher, with the goal of achieving readings below those cutoffs, according to the new recommendations.

For younger hypertensive patients and for those with chronic kidney disease ordiabetes — regardless of age — treatment should be initiated when the systolic pressure is 140 or higher or the diastolic pressure is 90 or higher, stated the guideline, which was published online in the Journal of the American Medical Association.

In the previous JNC 7 guidelines released in 2003, the target blood pressure was less than 140/90 mm Hg for most hypertensive patients and less than 130/80 mm Hg for patients with chronic kidney disease or diabetes.

The move to higher cutoffs for older patients and for patients with chronic kidney disease or diabetes — which was hinted at earlier this year at the American Society of Hypertension meeting — could have mixed effects, according to Eric Peterson, MD, MPH, of Duke University Medical Center.

“On the individual patient level, that makes our job easier …. We don’t have to push blood pressures quite as far down,” he told MedPage Today. “On the other hand, from a population level, I have some concerns that this less aggressive push will ultimately translate into higher blood pressures on America’s front and perhaps in the end, more cardiovascular events.”

There will be a natural tendency for blood pressure to go up, particularly for older individuals, he said, noting that there might be some pushback to loosening control of blood pressure among clinicians who have been treating patients with diabetes and chronic kidney disease.

But ultimately, Peterson said, the new guideline will have the positive effects of stimulating discussion about what is and is not known about treating hypertension and spurring further research.

Whose Guidelines Are These?

The panel behind the current recommendations — which was 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 originally commissioned by the National Heart, Lung and Blood Institute (NHLBI) in 2008. But in June, the NHLBI decided to hand over the responsibility of developing guidelines to the American College of Cardiology (ACC) and the American Heart Association (AHA). That process eventually led to the release of guidance for the prevention of atherosclerotic cardiovascular disease last month.

James, Oparil, and the other panelists sent the hypertension recommendations out for external review, but did not receive endorsements from any federal agencies or professional societies, including the ACC and AHA. They decided to proceed with publication independently “to bring the recommendations to the public in a timely manner while maintaining the integrity of the predefined process.”

“This report is therefore not an NHLBI-sanctioned report and does not reflect the views of NHLBI,” the authors wrote.

In an accompanying editorial, Peterson and two of his colleagues — all of whom serve as cardiology editors for JAMA — said the guideline is “a stand-alone document, and it remains unclear as to whether, or when, or by whom another consensus national hypertension guideline will again be formulated.”

“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,” they wrote.

The Recommendations

To develop the recommendations, the panelists reviewed evidence from randomized, controlled trials only, a difference compared with JNC 7, which included multiple types of studies. The guideline was focused on three specific questions regarding the blood pressure thresholds used to initiate treatment, blood pressure goals, and appropriate drugs.

For the initial choice of agent, the authors made the following recommendations:

• For nonblack individuals, including those with diabetes, ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics can all be chosen for first-line treatment.
• For black individuals, including those with diabetes, calcium channel blockers and thiazide-type diuretics are recommended as first-line therapy.
• For patients 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.

To provide some guidance on how clinicians should combine and adjust doses of the various drugs, the panelists included a treatment algorithm in the guideline while stressing the importance of clinical judgment.

“Although this guideline provides evidence-based recommendations for the management of high blood pressure and should meet the clinical needs of most patients, 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 authors wrote.

What Isn’t Included

The current guidance had a narrow focus and did not cover several subjects included in the JNC 7 recommendations, including definitions of pre-hypertension and hypertension, measurement of blood pressure, patient evaluation, secondary hypertension, adherence to treatment regimens, resistant hypertension, and lifestyle interventions.

The authors didn’t completely sidestep lifestyle, however. The included treatment algorithm has an instruction to implement lifestyle interventions and maintain them throughout management of the patient before moving on to drug therapy. And the authors stated that they endorse the recently released lifestyle recommendations of the ACC and AHA.

“For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized,” they wrote. “These lifestyle treatments have the potential to improve blood pressure control and even reduce medication needs.”

Are the Recommendations Valid?

Guidelines have grown in importance, becoming the basis for quality measures and coverage decisions, and Harold Sox, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., explored whether the new recommendations are trustworthy.

“Despite the efforts of the expert panel that developed the new guideline for management of hypertension, some aspects of the external review process may undermine public confidence,” he wrote in an accompanying editorial, pointing to the fact that the document was not published in draft form to elicit public comments, for example.

But,”the panel addressed them head-on by agreeing to share its record of the review process with anyone who asks,” he wrote. “Reading the critiques and responses, many readers will conclude that the panel was on solid ground in its interpretation of high-quality evidence about the limited but important set of questions that it chose to address.”

He said “the panel’s decision to open the review process to public scrutiny challenges other guidelines programs to follow suit.”

The external review process also received support in another editorial by Howard Bauchner, MD, editor-in-chief of JAMA, and two colleagues from the journal’s editorial staff.

“At JAMA there was broad unanimity among the external peer reviewers and internal editorial reviewers that the guideline was comprehensive, concise, and clear and that it appropriately acknowledged the areas of controversy,” they wrote.