The Joint Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC) released the long-awaited eighth report1, which was made available online in December of 2013 and published in JAMA this February. The multidisciplinary JNC 8 panel experts diligently adhered to Institute of Medicine standards for the development of trustworthy guidelines. Systematic review was performed, and only randomized controlled trials were included for analysis. Because the panel performed their own analysis on original studies, previous guidelines, systematic reviews meta-analyses and observational studies were not included in their analysis. They graded the strength of their recommendation based upon the level of available evidence, risks of treatment, as well as the magnitude and likelihood of benefit.
Geriatricians will immediately note an adjustment of BP targets. For patients 60 and over, the JNC advised the initiation of pharmacologic treatment at a systolic BP of 150 mmHg or higher, or a diastolic BP of 90 or higher. The recommended treatment target is to get below 150/90.
For those patients 60 or older in whom treatment successfully is maintaining blood pressure under 140/90 and being well tolerated, the recommendation is not to readjust the medication regimen because of the higher target.
BP targets, which were formerly <130/80 in JNC 7 for adults with diabetics or chronic kidney disease are now less aggressive at <140/90, regardless of age.
The recommended antihypertensive drug classes for initial treatment were broadened to include thiazide diuretics, ACE inhibitors, Angiotensin II Receptor Blockers (ARBs), or calcium channel blockers. For African-American patients, initial therapy was recommended to be with thiazides or calcium channel blockers.
It should be noted that the JNC 8 multidisciplinary panel was not unanimous concerning the decision to adjust the target for patients 60 and over2. In a report published in this month’s Annals of Internal Medicine this minority of JNC experts explain their reason for dissent. Essentially it is their opinion that the Systolic Hypertension in the Elderly Program (SHEP trial) and the Hypertension in the Very Elderly Trial (HYVET) support the original systolic BP goal of <140. They admit that two other Japanese trials, which influenced the overall change, did not demonstrate the 140 mm Hg threshold, but believe that these trials were underpowered, and may not have generalizability to other ethnic populations in the US.
As always, it must be kept in mind that even national guidelines are not a substitute for clinical judgment.
Doctors and practitioners who have been in practice for a few decades may recall when it was considered appropriate to avoid being rigidly adherent to blood pressure targets for older patients for fear of medication side effects and polypharmacy.
It should be remembered that the relaxing of these treatment thresholds was not so much driven by evidence of harm, but more from a lack of strong individual trials demonstrating clear evidence of benefit for aggressive targets.
There is a legitimate concern that relaxing thresholds will shift the entire population curve of hypertensive control in the wrong direction. Also, one should keep in mind that the new JNC 8 guidelines are not in accord with recent European, Canadian and UK specific guidelines.
Data from the National Health and Nutrition Survey (NHANES) 2011-2012 show that the percentage of elders achieving the previous target BP goal has improved, but is still 50.5 percent of patients, even with the use of multiple medications. For those who have a cadre of older patients in whom they have not been able to get to <140/90, these long-awaited guidelines may be greeted with a bit of a relief, particularly for those frail patient s at risk for falls or medication side effects, such as orthostatic hypotension.
Another interesting but anticipated change was the removal of beta blockers from the list of initial drug therapies. Of course, each physician must decide on a therapeutic course of action appropriate for a patient’s particular medical situation and preferences.
Since it is beyond the scope of this newsletter to represent the depth and breadth of the new guidelines or the reasoning behind the changes, I strongly encourage all physicians and practitioners to review the JAMA article. It is a quicker read than JNC 7 was and has fewer specific recommendations and less complicated thresholds. An understanding of the evidence base and logic behind the guideline development can be helpful when discussing treatment options with patients and families. For some patients, and perhaps physicians, it may be tempting to conclude that practice guidelines swing back and forth arbitrarily and that the so-called experts do not really know what to do. After reviewing these guidelines, I do not share that opinion but rather feel that the experts endeavored to limit recommendations to those supported by sizeable prospective trials.
The final point of discomfort for us may have to do with the struggle to conform to performance thresholds set by insurance companies and other payers. No doubt these measures eventually will manifest a readjustment their targets. For some payers, there may be an uncomfortable gap while we wait for their performance guidelines to catch up with the current state of the evidence. Perhaps one can take some solace in the likelihood that it will be quite a few years before we see JNC 9.
I think that the new JNC 8 Report is not saying that treating hypertension is any less efficacious than previously. It will be important for us to continue to stress the importance of continuing to addressing this silent killer. Few things in modern preventive medicine are more established than the benefits of blood pressure treatment. Many at least partially attribute the recent decline in stroke death in the US to improved blood pressure treatment. Ultimately, we must figure out how to work together with patients and families to figure out the best regimen. Now perhaps we have a little more leeway as far as balancing pursuit of targets and risk of medication side effect in our older patients who may not tolerate aggressive regimens.
1 James, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC8). Journal of the American Medical Association February 5, 2014; 311(5):507-520
2 Wright, JT et al, Evidence supporting a Systolic Blood Pressure Goal of Less than 150 mmHg in Patients Aged 60 Years or Older: The Minority View, Annals of Internal Medicine, April 1, 2014, 160(7):499-503.