JNC 8: What&#039;s covered, what&#039;s not, and what else to consider

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Applied Evidence

JNC 8: What's covered, what's not, and what else to consider

J Fam Pract. 2014 October;63(10):574-577,581-582,584

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References

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4. Heidenreich PA, Trogdon JG, Khavjou OA, et al; American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933-944.

5. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31:2115-2127.

6. Ogihara T, Saruta T, Rakugi H, et al; Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56:196-202.

7. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-2571.

8. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. III. Reduction in stroke incidence among persons with high blood pressure. JAMA. 1982;247:633-638.

9. Hypertension-Stroke Cooperative Study Group. Effect of antihypertensive treatment on stroke recurrence. JAMA. 1974;229:409-418.

10. Medical Research Council Working Party. MRC trial of treatment of mild hypertension: principal results. Br Med J (Clin Res Ed). 1985;291:97-104.

11. The Australian therapeutic trial in mild hypertension. Report by the Management Committee. Lancet. 1980;1:1261-1267.

12. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213:1143-1152.

13. Curb JD, Pressel SL, Cutler JA, et al; Systolic Hypertension in the Elderly Program Cooperative Research Group. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. JAMA. 1996;276:1886-1892.

14. Tuomilehto J, Rastenyte D, Birkenhäger WH, et al; Systolic Hypertension in Europe Trial Investigators. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med. 1999;340:677-684.

15. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703-713.

16. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.

17. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S76-S99.

18. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-3264.

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22. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-2997.

23. Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421-2431.

24. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-e319.

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The new guidelines include 3 methods of dosing antihypertensive medications; all stress the importance of avoiding ACEI and ARB combinations. It is important to note that this goal does not apply to individuals who have CKD and are 70 years or older. This is due to insufficient evidence, as well as uncertainty about the accuracy of an estimated GFR in this patient population. JNC 8 recommends that treatment of BP in patients 70 or older be based on comorbidities, including albuminuria, among other patient-specific considerations.¹

Diabetes. JNC 8 recommends treating patients age 18 years or older who have diabetes and BP ≥140/90 mm Hg, as JNC 7 did.² This is based largely on expert opinion.

Studies suggest that adults with both hypertension and diabetes have a reduction in mortality and improved cardiovascular and cerebrovascular outcomes when systolic BP is <150 mm Hg,^13-15 but no strong data support a goal of <140/90 mm Hg. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) BP trial, for example, showed comparable outcomes in patients with systolic BP of 150 or 140 mm Hg.¹⁶ The use of expert opinion vs well-designed studies in this instance seems at odds with JNC 8’s general policy of placing greater emphasis on evidence.

CASE › On her second visit, Ms. S’s BP is 144/82 mm Hg and her cholesterol levels are within the normal range. Her fasting glucose level is 104 mg/dL and glycated hemoglobin (HbA1c) is 6%. At a repeat visit one month later, her BP is 146/76 mm Hg. Given these 2 acceptable readings (<150/90 mm Hg for individuals age 60 and older who do not have diabetes), you do not initiate antihypertensive treatment.

However, you explain to the patient that her fasting glucose and HbA1c are evidence of insulin resistance. Although a diagnosis of diabetes is not warranted, you arrange for Ms. S to meet with a diabetes nurse educator for help in improving her diet and following an exercise regimen.

Pharmacotherapy: JNC 8 offers wider latitude

Like its predecessor, JNC 8 stresses the importance of diet and exercise. (See “Controlling hypertension starts with lifestyle modification”¹⁷ in this article.) It diverges from JNC 7, however, in its recommendations for initiating treatment (ALGORITHM).¹ The earlier version recommended thiazide diuretics as first-line therapy but included multiple indications for initiating therapy with other drug classes. JNC 8 guidelines are less specific.

Starting therapy with a thiazide diuretic, angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or calcium channel blocker (CCB)—all of which have high-quality evidence of improved outcomes^18-20—is recommended for most patients, including those with diabetes. (Blacks and patients with CKD are exceptions.) The recommended doses of these medications, summarized in the TABLE,^1,21 are similar to those used in RCTs. Other types of drugs are not recommended, either because they were shown to be inferior to another class of antihypertensive or because there is insufficient evidence of their efficacy.

For most blacks... JNC 8 recommends thiazide diuretics and CCBs as first-line therapy—a recommendation that is evidence-based. The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)²² revealed that black patients taking thiazide diuretics had fewer cerebrovascular and cardiovascular events and a lower rate of HF compared with those taking ACEIs, whether or not they had diabetes. Diuretics were more effective than CCBs in preventing HF, but no difference in rates of cerebrovascular and cardiovascular events, kidney disease, or overall mortality was found.²²

For patients with CKD and proteinuria, regardless of race, JNC 8 calls for either an ACEI or an ARB as first-line agent to prevent progression to end-stage renal disease. This recommendation is based on expert consensus, and intended to prevent progression to end-stage renal disease.^1,23

The optimal first-line agent for patients who have CKD without proteinuria is less clear. For such patients, JNC 8 notes, any of the 4 recommended drug classes can be used for initial therapy.¹

Guidance on starting—and titrating—therapy

 JNC 7 guidelines featured a complex means of diagnosing and monitoring hypertension.² JNC 8 has simplified the recommendations, which call for patients to be reassessed within a month of initiating therapy.

The new guidelines include 3 distinct methods of dosing antihypertensive medications, none of which has demonstrated better outcomes than any other. All call for replacing one type of drug with another if the first trial is ineffective or results in adverse effects. And all stress the importance of avoiding ACEI and ARB combinations due to increases in serum creatinine and hyperkalemia and the need for monitoring. Note, however, that Method 3 is recommended for patients with more severe hypertension.¹