A Review of the JNC 8 Blood Pressure Guideline

Hypertension is a major independent risk factor for coronary artery disease, stroke, heart failure, and renal failure. One of every 3 American adults—or approximately 67 million adults (31%) —has hypertension (HTN). 1 A person over the age of 55 years has a 90% lifetime risk of developing HTN. 2 Hypertension accounts for 18% of cardiovascular disease deaths in Western countries. 3 High blood pressure (BP) costs the nation 47. 5 billion each year. 4In 2014, the Eighth Joint National Committee (JNC 8) published the evidence-based guideline for the management of high BP in adults. This new guideline was characterized by a systematic review of the literature with an emphasis on randomized, controlled clinical trials. The guideline attempted to answer 3 key questions. 5The committee provided 9 graded recommendations to answer the 3 key questions. Grading was performed on the basis of the strength of the available evidence used to make the recommendation: grade A is indicative of strong evidence, grade B of moderate evidence, grade C of weak evidence, and grade E of expert opinion (in lieu of sufficient evidence). Below are the 9 recommendations. 5Recommendation 1. The guideline recommends the initiation of drug therapy in order to lower a systolic BP (SBP) of ≥150 mmHg or a diastolic BP (DBP) of ≥90 mmHg for the general population at 60 years of age or older (Grade A). A corollary recommendation is that patients whose achieved SBP on pharmacologic therapy is lower than the new guideline recommendation can be continued at that level of therapy, if well tolerated (Grade E). Recommendation 2. The target DBP to start pharmacologic therapy for subjects younger than 60 years of age is ≥90 mmHg. On the basis of available evidence, the recommendation for patients aged 30 to 59 years is strong (Grade A). For those between the ages of 18 and 29, the recommendation is on the basis of expert opinion (Grade E). Recommendation 3. The target SBP to start pharmacologic therapy for subjects younger than 60 years of age is ≥140 mmHg (Grade E). Recommendation 4. In the population aged 18 years or older with chronic kidney disease, initiate pharmacologic treatment to lower BP at SBP ≥140 mmHg or DBP ≥90 mmHg and treat to a goal of SBP 60 yr), in whom issues such as cardiovascular risk, frailty, side effects, cost, and patient preference affect therapy more acutely.