A new guideline for the management of hypertension developed by the Eighth Joint National Committee (JNC 8) has been published online in JAMA. The long-awaited update provides evidence-based recommendations for the management of high blood pressure (BP), with different BP goals and treatments recommended for patients based on age, race/ethnicity, kidney function and diabetes status. Most strikingly, it raises the recommended BP threshold to determine the need for drug therapy in many patients.

The committee found no evidence from randomised clinical trials for a clinical benefit of setting a systolic BP goal < 150 mmHg in the general population of 60 years and older. Thus, the guideline recommends a treatment goal of systolic BP < 150 mmHg and diastolic BP < 90 mmHg if antihypertensive treatment is initiated in this population. In patients who are already being treated for hypertension, and in whom a lower systolic BP has been achieved without adverse health effects, there is no need to adjust treatment.
A treatment goal of systolic BP < 140 mmHg and diastolic BP < 90 mmHg for patients younger than 60 years old is recommended, since there was no evidence available that prompted change of earlier recommendations. In JNC 7 of 2003, an even lower target of <130 mmHg was specified for patients with chronic kidney disease or diabetes. This lower target is now eliminated in JNC 8.

It is recommended that initial antihypertensive treatment in the general nonblack population should include thiazide-type diuretics, calcium-channel blockers, ACE inhibitors and angiotensin receptor blockers. The available evidence is outlined, which provides the rationale for this list, and why some other agents are not included in the choice of first-line therapy.
Separate recommendations are done for black patients with hypertension, since the black patient subgroup in the ALLHAT trial showed a different response to therapy for this subgroup.
The recommended step-wise therapeutic approach is outlined to obtain target BP. If addition of a third drug from the recommended classes does not enable a patient to reach goal BP, a drug from a non-recommended class may be prescribed. An ACE inhibitor and an ARB should not be used simultaneously. If target BP is still not achieved, a hypertension specialist should be consulted.

The guideline contains an algorithm to guide clinicians in hypertension management. It should be noted that this algorithm has not yet been validated with respect to patient outcomes.

Source

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. 2013 Dec 18. doi: 10.1001/jama.2013.284427. [Epub ahead of print]

Find the new guideline on Pubmed