Blood Pressure Management Guidelines to Be Loosened

The update to the guidelines for the management of hypertension raises the blood pressure threshold that determines the need for drug therapy in many patients.

The recommendations by the expert panel appointed to the Eighth Joint National Committee (JNC 8) suggest that for most hypertensive individuals 60 years of age or older, pharmacologic treatment should be started when the systolic pressure is 150 mm Hg or higher or diastolic pressure is 90 mm Hg or higher, with the goal of achieving readings below those cutoffs. For younger hypertensive patients and for those with chronic kidney disease or diabetes (regardless of age) treatment should be initiated when the systolic pressure is 140 or higher or the diastolic pressure is 90 or higher.

To develop the recommendations, the panelists reviewed evidence from randomized, controlled trials only, unlike JNC 7, which included multiple types of studies. The guideline was focused on three specific questions; the blood pressure thresholds used to initiate treatment, blood pressure goals, and appropriate drugs. For the initial choice of agent, the authors recommended that for nonblack individuals, including those with diabetes, ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics could all be chosen for first-line treatment.

For black individuals, including those with diabetes, calcium channel blockers and thiazide-type diuretics are recommended as first-line therapy. For patients with chronic kidney disease, regardless of race or diabetes status, initial or add-on therapy should include an ACE inhibitor or an ARB to improve renal outcomes. To provide some guidance on how clinicians should combine and adjust doses of various drugs, the panelists included a treatment algorithm, while stressing the importance of clinical judgment. The guideline was published online on December 18, 2013, in the Journal of the American Medical Association (JAMA).

“Although this guideline provides evidence-based recommendations for the management of high blood pressure and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient,” stated panel co-chairs Paul James, MD, of the University of Iowa (Iowa City, USA) and Suzanne Oparil, MD, of the University of Alabama (Birmingham, USA), and colleagues.

The current guidance had a narrow focus and did not cover several subjects included in the JNC 7 recommendations, such as definitions of pre-hypertension and hypertension, measurement of blood pressure, patient evaluation, secondary hypertension, adherence to treatment regimens, resistant hypertension, and lifestyle interventions.

Related Links:
Eighth Joint National Committee