The JNC 8 Hypertension Guidelines: An In-

Depth Guide | Page 1

Pulished !nline: January 21, 2014
Michael R. Page, PharmD, RPh
Compared with previou hypertenion treatment guideline, the Joint !ational Committee
"J!C #$ guideline advie higher %lood preure goal and le ue o& everal type o&
antihypertenive medication.
Patient will %e a'ing a%out the new J!C # hypertenion guideline, which were pu%lihed
in the Journal o& the (merican Medical (ociation on Decem%er 1#, 201).
1
*he new guideline emphai+e control o& ytolic %lood preure ",-P$ and diatolic %lood
preure "D-P$ with age. and comor%idity.peci&ic treatment cuto&&. *he new guideline
alo introduce new recommendation deigned to promote a&er ue o& angiotenin converting
en+yme "(C/$ inhi%itor and angiotenin receptor %loc'er "(R-$.
0mportant change &rom the J!C 1 guideline
2
include the &ollowing2
3 0n patient 40 year or older who do not have dia%ete or chronic 'idney dieae, the goal
%lood preure level i now 5160780 mm 9g.
3 0n patient 1# to 68 year o& age without ma:or comor%iditie, and in patient 40 year or
older who have dia%ete, chronic 'idney dieae "C;D$, or %oth condition, the new goal
%lood preure level i 5140780 mm 9g.
3 <irt.line and later.line treatment hould now %e limited to 4 clae o& medication2
thia+ide.type diuretic, calcium channel %loc'er "CC-$, (C/ inhi%itor, and (R-.
3 ,econd. and third.line alternative included higher doe or com%ination o& (C/
inhi%itor, (R-, thia+ide.type diuretic, and CC-. ,everal medication are now deignated
a later.line alternative, including the &ollowing2 %eta.%loc'er, alpha%loc'er, alpha17%eta.
%loc'er "eg, carvedilo$, vaodilating %eta.%loc'er "eg, ne%ivolol$, central alpha27.adrenergic
agonit "eg, clonidine$, direct vaodilator "eg, hydrala+ine$, loop diruretic "eg,
&uroemide$, aldoterone antagoint "eg, pironolactone$, and peripherally acting adrenergic
antagonit "eg, reerpine$.
3 =hen initiating therapy, patient o& (&rican decent without C;D hould ue CC- and
thia+ide intead o& (C/ inhi%itor.
3 >e o& (C/ inhi%itor and (R- i recommended in all patient with C;D regardle o&
ethnic %ac'ground, either a &irt.line therapy or in addition to &irt.line therapy.
3 (C/ inhi%itor and (R- hould not %e ued in the ame patient imultaneouly.
3 CC- and thia+ide.type diuretic hould %e ued intead o& (C/ inhi%itor and (R- in
patient over the age o& 16 year with impaired 'idney &unction due to the ri' o&
hyper'alemia, increaed creatinine, and &urther renal impairment.
*he change to a more lenient ytolic %lood preure goal may %e con&uing to many patient
who are accutomed to the lower goal o& J!C 1, including the 5140780 mm 9g goal &or
mot patient and 51)07#0 mm 9g goal &or patient with hypertenion and ma:or
comor%iditie.
*he guideline were in&ormed %y reult o& 6 'ey trial2 the 9ypertenion Detection and
<ollow.up Program "9D<P$, the 9ypertenion.,tro'e Cooperative, the Medical Reearch
Council "MRC$ trial, the (utralian !ational -lood Preure "(!-P$ trial, and the ?eteran@
(dminitration "?($ Cooperative. 0n thee trial, patient %etween the age o& )0 and 48
year received medication to lower D-P to a level 580 mm 9g. Reult howed a reduction
in cere%rovacular event, heart &ailure, and overall mortality in patient treated to the D-P
target level.
*he data were o compelling that ome mem%er o& the J!C # panel wanted to 'eep D-P
580 mm 9g a the only goal among younger patient, citing inu&&icient evidence &or %ene&it
o& an ,-P goal lower than 140 mm 9g in patient under the age o& 40 year. 9owever, more
conervative panelit puhed to 'eep the target ,-P goal a well a the D-P goal.
0n younger patient without ma:or comor%iditie, elevated D-P i a more important
cardiovacular ri' &actor than i elevated ,-P. *he J!C # panelit are not the &irt guideline
author to recogni+e thi relationhip. *he J!C 1 guideline author alo ac'nowledged that
D-P control wa more important than ,-P control &or reducing cardiovacular ri' in
patient 540 year o& age. 9owever, in patient 40 year and older ,-P control remain the
mot important &actor.
Ather recent evidence ugget that the ,-P goal 5140 mm 9g recommended %y the J!C 1
guideline &or mot patient may have %een unnecearily low. *he J!C # guideline author
cite 2 trial that &ound no improvement in cardiovacular outcome with an ,-P target 5140
mm 9g compared with a target ,-P level 5140 mm 9g or 5160 mm 9g. Depite thi &inding,
the new guideline do not diallow treatment to a target ,-P 5140 mm 9g, %ut recommend
caution to enure that low ,-P level do not a&&ect Buality o& li&e or lead to advere event.
*he hi&t to a D-P.%aed goal may mean younger patient will %e precri%ed &ewer
medication i& diagnoed with hypertenionC thi may improve adherence and minimi+e
advere event aociated with low ,-P, uch a eDual dy&unction.
Patients "ith #idney Disease
(lthough 1 pot hoc analyi howed a poi%le advantage in 'idney outcome with the lower
target o& 1)07#0 mm 9g recommended %y J!C 1, 2 other primary analye did not upport
thi &inding. (dditionally, another ) trial did not how an advantage with the 51)07#0 mm
9g goal over the 5140780 mm 9g goal level &or patient with chronic 'idney dieae.
( a reult, the new guideline recommend that patient with chronic 'idney dieae receive
medication u&&icient to achieve the higher 5140780 mm 9g goal level. 9owever, in an
eDception to thi goal level, the guideline ugget that patient with chronic 'idney dieae
or al%uminuria 10 year or older hould receive treatment %aed on comor%iditie, &railty, and
other patient.peci&ic &actor.
/vidence wa inu&&icient to upport a goal %lood preure o& 5140780 mm 9g in patient
over the age o& 10 year with C;D or al%uminuria.
Patients "ith Diaetes
(dult with dia%ete and hypertenion have reduced mortality a well a improved
cardiovacular and cere%rovacular outcome with treatment to a goal ,-P 5160 mm 9g, %ut
no randomi+ed controlled trial upport a goal 5140780 mm 9g. Depite thi, the panel opted
&or a conervative recommendation in patient with dia%ete and hypertenion, opting &or a
goal level o& 5140780 mm 9g in adult patient with dia%ete and hypertenion rather than the
evidence%aed goal o& 5160780 mm 9g.
$ollo%-up
*he J!C # guideline author impli&ied a complicated recommendation &or &ollowup in
patient with hypertenion. *he J!C 1 panel recommended that a&ter an initial high %lood
preure reading, &ollowup with a con&irmatory %lood preure reading hould occur within 1
day to 2 month, depending on how high the initial reading wa and whether or not the
patient had 'idney dieae or end.organ damage a a reult o& hypertenion. >nder J!C #, in
all cae, goal %lood preure target hould %e reached within a month o& tarting treatment
either %y increaing the doe o& an initial drug or %y uing a com%ination o& medication.
Treat&ents
Ei'e the J!C 1 panel, the J!C # panel recommended thia+ide.type diuretic a initial therapy
&or mot patient. (lthough (C/ inhi%itor, (R-, and calcium channel %loc'er "CC-$ are
accepta%le alternative, thia+ide.type diuretic till have the %et evidence o& e&&icacy.
*he J!C # panel doe not recommend &irt.line therapy with %eta.%loc'er and alpha.
%loc'er due to 1 trial that howed a higher rate o& cardiovacular event with ue o& %eta.
%loc'er compared with ue o& an (R-, and another trial in which alpha.%loc'er reulted in
in&erior cardiovacular outcome compared with ue o& a diuretic. 0n addition, a lac' o&
evidence comparing the 4 &irt.line therapie with carvedilol, ne%ivolol, clonidine,
hydrala+ine, reerpine, &uroemide, pironolactone, and other imilar medication preclude
ue o& any medication other than (C/ inhi%itor, (R-, CC-, and thia+ide.type diuretic
in the vat ma:ority o& patient.
-e&ore receiving alpha.%loc'er, %eta%loc'er, or any o& everal micellaneou agent, under
the J!C # guideline, patient would receive a doage ad:utment and com%ination o& the 4
&irt.line therapie. *riple therapy with an (C/ inhi%itor7(R-, CC-, and thia+ide.type
diuretic would precede ue o& alpha.%loc'er, %eta.%loc'er, or any o& everal other agent.
*hee new guideline all %ut eliminate ue o& %eta.%loc'er "including ne%ivolol$, alpha.
%loc'er, loop diuretic, alpha 17%eta.%loc'er, central alpha27adrenergic agonit, direct
vaodilator, aldoterone antagonit, and peripherally acting adrenergic antagonit in
patient with newly diagnoed hypertenion. Caution i warranted in patient who are already
ta%le on thee therapie.
'pe(ial Therapeuti( Considerations
(C/ inhi%itor and (R- may not %e an ideal choice in patient o& (&rican decent. Reult
o& a u%group analyi in the (ntihypertenive and Eipid Eowering *reatment to Prevent
9eart (ttac' *rial "(EE9(*$ &ound that (C/ inhi%itor led to wore cardiovacular
outcome than thia+ide.type diuretic or CC- in patient with (&rican ancetry. Depite the
u%group analyi o& (EE9(*, reult o& the (&rican (merican ,tudy o& ;idney Dieae and
9ypertenion "((,;$ upport ue o& &irt.line or add.on (C/0 to improve 'idney.related
outcome in patient o& (&rican decent with hypertenion, C;D, and proteinuria.
( a reult, the J!C # panelit recommend that all patient with chronic 'idney dieae and
hypertenion, regardle o& ethnic %ac'ground, hould receive treatment with an (C/
inhi%itor or (R- to protect 'idney &unction, either a initial therapy or add.on therapy.
Ane eDception to the ue o& (C/ inhi%itor or (R- in protection o& 'idney &unction applie
to patient over the age o& 16 year. *he panel cited the potential &or (C/ inhi%itor and
(R- to increae erum creatinine and produce hyper'alemia. ( a reult, &or patient over
the age o& 16 year with decreaed renal &unction, thia+ide.type diuretic or CC- are an
accepta%le alternative to (C/0 or (R-. 0n addition, the panel eDprely prohi%it
imultaneou ue o& an (C/ inhi%itor and an (R- in the ame patient. *hi com%ination ha
not %een hown to improve outcome. Depite the &act that the 2 medication wor' at
di&&erent point in the renin.angiotenin.aldoterone ytem, other com%ination o&
medication are %etter option, and the imultaneou ue o& (C/0 and (R- i not upported
%y evidence.
)i*estyle Changes
( in J!C 1, the J!C # guideline alo recommend li&etyle change a an important
component o& therapy. Ei&etyle intervention include ue o& the Dietary (pproache to ,top
9ypertenion "D(,9$ eating plan, weight lo, reduction in odium inta'e to le than 2.4
gram per day, and at leat )0 minute o& aero%ic activity mot day o& the wee'.
0n addition, to delay development o& hypertenion, improve the %lood preureFlowering
e&&ect o& eDiting medication, and decreae cardiovacular ri', alcohol inta'e hould %e
limited to 2 drin' daily in men and 1 drin' daily in women. !ote that 1 drin' contitute 12
ounce o& %eer, 6 ounce o& wine, or 1.6 ounce o& #0.proo& liBuor. Guitting mo'ing alo
reduce cardiovacular ri'.
Con(lusion
*he J!C # guideline move away &rom the aumption that lower %lood preure level will
improve outcome regardle o& the type o& agent ued to achieve the lower level. 0ntead, the
J!C # guideline encourage ue o& agent with the %et evidence o& reducing cardiovacular
ri'. 0n addition, the guideline may lead to le ue o& antihypertenive medication in
younger patient, which will produce eBuivalent outcome in term o& cardiovacular event
with le potential &or advere event that limit adherence.
Michael R. Page, PharmD, RPh, i the clinical editor &or Pharmacy *ime. *hi tory &irt
appeared online in Pharmacy *ime on January 4, 2014.
+e*eren(es
1. Jame P(, Aparil ,, Carter -E, et al. 2014 evidence.%aed guideline &or the management
o& high %lood preure in adult2 report &rom the panel mem%er appointed to the eighth Joint
!ational Committee "J!C #$ Hpu%lihed online Decem%er 1#, 201)I. J(M(.
doi210.10017:ama.201).2#4421.
2. -rotman DJ, <rot ,D. *he J!C 1 hypertenion guideline. J(M(. 200)C280"10$21)1).
1)14C author reply 1)14.1)16.