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In December 2013, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), a group of experts appointed by the National Heart, Lung, and Blood Institute, released new guidelines on the treatment of high blood pressure, or hypertension, in adults.[1] The JNC is tasked with formulating hypertension treatment guidelines every several years. It first issued guidelines in 1976, and the last update — in 2003 — was known as the JNC 7...
In December 2013, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), a group of experts appointed by the National Heart, Lung, and Blood Institute, released new guidelines on the treatment of high blood pressure, or hypertension, in adults.[1] The JNC is tasked with formulating hypertension treatment guidelines every several years. It first issued guidelines in 1976, and the last update — in 2003 — was known as the JNC 7 guidelines.[2] This article summarizes and offers our position on the new JNC 8 guidelines.
Unlike previous JNC recommendations, the JNC 8 guidelines elicited quite a bit of controversy. Most of the contention centered on the increase in the recommended treatment goal for systolic blood pressure (SBP, the top number in a blood pressure measurement). For adults 60 years and older, the recommended SBP goal was raised from 140 to 150.
This seemingly minor change meant that an estimated 7.4 million Americans over 60 with SBP between 140 and 149 were no longer candidates for therapy with blood-pressure-lowering drugs.[3]
The change was criticized by some hypertension experts who claimed that the previous SBP goal offered stronger protection against cardiovascular and renal (kidney) disease in older adults.[4] And although the other recommendations in the new guidelines were adopted “almost unanimously”[5] by the JNC 8 panel of 17 experts, five members dissented from the new SBP goal recommendation and took to the pages of the Annals of Internal Medicine to explain their opposition.[6]
About hypertension
Hypertension is the most common chronic disease in the U.S., affecting an estimated 30 percent of the adult population.[7] Rates are much higher in people 65 and older (72 percent), adult diabetics (59 percent) and black adults (41 percent).
Studies consistently have shown that effective treatment of high blood pressure has multiple lifesaving benefits, including reduced risks of heart attack, stroke, aortic aneurysm and chronic kidney disease. One large 2009 analysis concluded that every 10-point reduction in SBP or 5-point reduction in diastolic blood pressure (the bottom number in a blood pressure measurement) cuts the risk of heart disease events (including heart attack) by 22 percent and the risk of stroke by 41 percent in patients ages 60-69.[8]
However, for patients who reach a certain blood pressure level, further reduction provides no additional benefit, though the risk of adverse events from taking more hypertension drugs persists.
Identifying the precise point at which this risk-benefit balance tilts against further treatment for different patient groups became the focus of the debate over the guidelines.
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The JNC 8 Recommendations[9]
*If the blood pressure goal is not reached within the first month of treatment, the guidelines recommend increasing the dose of the initial medication or adding a second — followed by a third if blood pressure is still uncontrolled — from one of the four described drug classes (thiazide diuretic, CCB, ACE inhibitor or ARB). The guidelines recommend using drugs from other classes only if patients cannot take or tolerate these four classes and recommend against the use of an ACE inhibitor and ARB together. Finally, the guidelines recommend referral of patients with persistently uncontrolled blood pressure to a hypertension specialist. |
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The JNC 8 controversy
In formulating their recommendations, the majority of the JNC 8 panelists opted to rely solely on evidence from randomized controlled trials — the gold standard for evaluating medical interventions — rather than on observational data that had formed a substantial part of the evidence used for the previous JNC-7 guidelines.[10] Others on the panel disagreed, arguing that observational studies, though less rigorous than randomized clinical trials, still yielded valuable information if interpreted correctly.[11]
In an Annals of Internal Medicine editorial[12] expressing disagreement with the majority, five JNC panelists argued that the evidence was insufficient to support the new SBP goal of less than 150 for patients 60 and older and cited several randomized trials and observational studies that they claimed demonstrated benefits of treatment to a goal of 140 or lower. The authors indicated support for a higher age cutoff of 80 years and older for the 150 SBP treatment goal, as they asserted that the evidence is much clearer that the risks of treatment to a lower goal outweigh the benefits in this older, frailer age group.[13]
Adverse effects from blood pressure medications
Concern about overtreatment and adverse events due to anti-hypertensive drugs was a major reason the majority of the JNC 8 panelists supported raising the SBP goal for patients 60 and older.
All anti-hypertensive drugs have the potential to reduce blood pressure to dangerously low levels. Blood pressure that is too low can damage vital organs such as the heart (resulting in a heart attack) and can also lead to other adverse events. For example, anti-hypertensive drugs have been tied to an increased fall risk, especially in elderly patients, likely as a result of overly low blood pressure.[14]
Specific anti-hypertensive drug classes have additional adverse effects, some severe. For example, the JNC 8 guidelines are the first to recommend against the simultaneous use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARBs).[15] Although these drugs are beneficial and lifesaving for some when taken individually, their simultaneous use leads to higher rates of kidney failure, dangerously high blood potassium levels and low blood pressure. Further, the combinations offer no additional benefits over drugs from each class taken alone.[16]
Adverse effects of other classes include dehydration, low blood sodium levels and gout (thiazide diuretics); dangerously low heart rate (calcium channel blockers [CCBs] and beta blockers); dry cough and harmful effects on the fetus in pregnant women (ACE inhibitors); and, alarmingly, an increased rate of heart attack and death with CCBs. (For more information on the side effects of each anti-hypertensive drug class, see the WorstPills.org article on high blood pressure.)[17]
Our impressions
Regarding the controversy over the change in the SBP treatment goal from under 140 to under 150 for people 60 and older, studies in adults 60-80 years of age are conflicting, and it is unclear to us, based on the current data, which treatment target should be pursued in this population. However, the evidence is clearer, and agreement among experts is greater, that patients ages 80 and older should be treated to a goal SBP of less than 150.[18]
On the initial choice of medication, we disagree slightly with JNC 8 and believe that a thiazide-type diuretic should generally be the initial therapy for both black and non-black hypertensive patients without CKD because of their superior ability to prevent acute heart failure events.[19] However, ACE inhibitors or ARBs could be acceptable alternatives for certain non-black patients and CCBs for certain black patients (for example, those with poorly controlled diabetes[20]).
In non-black patients, ACE inhibitors or ARBs should be second-line therapies if thiazide diuretics fail to bring patients’ blood pressure under control. In black patients, CCBs are superior to ACE inhibitors and ARBs[21] and should therefore be second-choice therapies if thiazide diuretics fail to adequately control blood pressure on their own. However, because of their potential to increase the risk of heart attacks and their relative lack of benefit on long-term outcomes, such as cardiovascular and kidney disease in non-black patients, we do not believe that CCBs should be used in non-black patients,[22] except in patients who have failed multiple other therapies. (For more information on CCBs, see WorstPills.org article.[23])
The above recommendations are limited to relatively healthy hypertensive patients with no other serious diseases. For hypertensive patients with chronic kidney disease, we agree with JNC 8 that either an ACE inhibitor or an ARB should always be used because of their proven protective kidney effects in these patients.
Though not covered by JNC 8, drug recommendations for hypertensive patients with congestive heart failure, coronary artery disease and other conditions vary considerably from those presented above.
What You Can Do
If you have been diagnosed with mildly elevated blood pressure (up to 160/100, defined as “Stage 1” hypertension by JNC 7[24]), you initially should try to control it with diet and exercise. A proper regimen includes a reduced-sodium diet, frequent exercise and, if you are overweight or obese, a healthy, gradual weight loss regimen.
Should this fail to bring blood pressure below goal levels, your doctor can start you on an anti-hypertensive medication regimen (ideally beginning with a thiazide diuretic), with as few drugs and at the lowest doses necessary to keep your blood pressure at goal.
Ultimately, all patients should be evaluated by their doctor for long-term cardiovascular risk in order to determine the optimal therapeutic goal and to monitor for hypertension complications.
References
[1] James PA, Oparil S, Carter BL, 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 (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. http://jama.jamanetwork.com/article.aspx?articleid=1791497. Accessed July 10, 2014.
[2] National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). http://www.nhlbi.nih.gov/health-pro/guidelines/current/hypertension-jnc-7/index.htm. Accessed July 31, 2014.
[3] Kolata G. Hypertension Guide May Affect 7.4 Million. The New York Times. December 19, 2013. http://www.nytimes.com/2013/12/20/health/hypertension-guide-may-affect-7-4-million.html?_r=0. Accessed July 11, 2014.
[4] Peterson ED, Gaziano JM, Greenland P. Recommendations for treating hypertension: what are the right goals and purposes? JAMA. 2014 Feb 5;311(5):474-6. http://jama.jamanetwork.com/article.aspx?articleid=1791422#jed130141r2. Accessed July 11, 2014.
[5] Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. 2014 Apr 1;160(7):499-503. http://annals.org/article.aspx?articleid=1813288. Accessed July 11, 2014.
[6] Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. April 1, 2014;160(7):499-503. http://annals.org/article.aspx?articleid=1813288. Accessed July 11, 2014.
[7] Centers for Disease Control and Prevention. Prevalence of Hypertension and Controlled Hypertension — United States, 2007–2010. MMWR Supplements. November 22, 2013;62(03):144-148. http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a24.htm. Accessed July 11, 2014.
[8] Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. May 19, 2009;338:b1665. http://www.bmj.com/cgi/pmidlookup?view=long&pmid=19454737. Accessed July 11, 2014.
[9] James PA, Oparil S, Carter BL, 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 (JNC 8). JAMA. February 5, 2014;311(5):507-520. http://jama.jamanetwork.com/article.aspx?articleid=1791497. Accessed July 10, 2014.
[10] Peterson ED, Gaziano JM, Greenland P. Recommendations for treating hypertension: what are the right goals and purposes? JAMA. February 5, 2014;311(5):474-476. http://jama.jamanetwork.com/article.aspx?articleid=1791422#jed130141r2. Accessed July 11, 2014.
[11] Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. April 1, 2014;160(7):499-503. http://annals.org/article.aspx?articleid=1813288. Accessed July 11, 2014.
[12] Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. April 1, 2014;160(7):499-503. http://annals.org/article.aspx?articleid=1813288. Accessed July 11, 2014.
[13] Ibid.
[14] Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. April 2014;174(4):588-95.
[15] James PA, Oparil S, Carter BL, 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 (JNC 8). JAMA. February 5, 2014;311(5):507-520. http://jama.jamanetwork.com/article.aspx?articleid=1791497. Accessed July 10, 2014.
[16] Public Citizen. Petition to the FDA for Black Box Warnings on ACE Inhibitors, ARBs, and Aliskiren. October 4, 2012. http://www.citizen.org/documents/20751.pdf. Accessed July 10, 2014.
[17] WorstPills.org. High Blood Pressure. /chapters/view/41. Accessed July 10, 2014.
[18] Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. April 1, 2014;160(7):499-503. http://annals.org/article.aspx?articleid=1813288. Accessed July 11, 2014.
[19] This is based on the superiority of thiazide diuretics over both ACE inhibitors and CCBs in preventing heart failure events in those without chronic heart failure, as demonstrated in the results, by racial subgroup, from the landmark ALLHAT study (Wright JT Jr, Dunn JK, Cutler JA, et al. ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005 Apr 6;293(13):1595-608. http://jama.jamanetwork.com/article.aspx?articleid=200638. Accessed July 30, 2014.)
[20] This is based on the findings from multiple trials that thiazide diuretics can increase the risk of new diabetes diagnoses and worsen blood sugar levels for those with diabetes, when compared with ACE inhibitors and CCBs. (JNC 8. Supplement to 2014 evidence-based guideline for the management of high blood pressure in adults: report by the panel appointed to the Eighth Joint National Committee (JNC 8), p. 111.) However, because thiazide diuretics were superior to these two classes of drugs in preventing heart failure events even in diabetic subjects in the ALLHAT trial, we still recommend thiazide diuretics as first-line therapy in well-controlled diabetic patients. Sources: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. January 2014;37 Suppl 1:S14-80. http://care.diabetesjournals.org/content/37/Supplement_1/S14.full. Accessed July 11, 2014. [p. 23]; American Association of Clinical Endocrinologists. Comprehensive Diabetes Management Algorithm 2013. Endocr. Pract. 2013;19(2):327-335. https://www.aace.com/files/aace_algorithm.pdf. Accessed July 11, 2014. [p.9]
[21] JNC 8. Supplement to 2014 evidence-based guideline for the management of high blood pressure in adults: report by the panel appointed to the Eighth Joint National Committee (JNC 8). P. 96, 98, 128, 129.
[22] WorstPills.org. High Blood Pressure. /chapters/view/41. Accessed July 10, 2014.
[23] WorstPills.org. Calcium Channel Blockers. /monographs/view/183. Accessed July 16, 2014.
[24] The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). August 2004 (Published December 2003). http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf. Accessed July 10, 2014. pp. 12.
