Best Evidence Analyses and Commentary

2014 Evidence Based Guideline for Management of High Blood Pressure in Adults: An Overview
Mitchelle Rodriguez, PharmD; PGY1 General Practice Resident, Millcreek Community Hospital, Erie, PA

Since its publication in 2004, the primary resource for the management of hypertension has been the Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.1 This comprehensive document includes not only hypertension treatment guidelines, but also recommendations on diagnosis and classification of hypertension, management of “special situations” in hypertension, blood pressure devices, public health challenges, and description of common substances that may affect blood pressure.  The basis of the recommendations made for JNC 7 came from pooled data gathered from meta-analyses, randomized controlled trials, prospective studies, cross-sectional surveys, previous review/position statements and expert opinion.

Although JNC 7 has provided much needed guidance for the clinical management of hypertension, new data has become available leaving some of its content outdated and requiring an update, JNC 8. The U.S. National Heart, Lung, and Blood Institute (NHLBI) appointed JNC 8 panel members in 2008 and work began on developing updates to the previous version. In June 2013, the Institute announced that it would no longer participate in the development of any clinical guidelines, including the blood pressure guidelines leaving many clinicians disillusioned. The authors from the original JNC 8 panel chose to publish the recommendations independently in the form of the “2014 Guideline for Management of High Blood Pressure” published in the Journal of the American Medical Association on December 18, 2013.2

Unlike its predecessor, the 2014 guideline commonly referred to as JNC 8 is a hypertension management focused document. The recommendations and statements contained in this “evidence-based” guideline are as a result of data and expert opinions gathered from randomized controlled trials. Observational studies, systematic reviews, and meta-analyses were omitted. 

This new guideline contains a total of 9 “evidence-based” recommendations for the management of hypertension. These recommendations address 3 key concepts that the panelists identified as specifically leading to improved health outcomes. They include: initiation of antihypertensive pharmacologic therapy at specific blood pressure thresholds, treatment with antihypertensive pharmacologic therapy to a specified blood pressure goal and comparative benefits versus harms on specific health outcomes as a result of various antihypertensive drugs or drug classes.

The first and most notable difference from previous guidelines is the recommendation of targeting a systolic blood pressure (SBP) goal of <150 mmHg in patients aged 60 years or older. The data that supports this recommendation demonstrates a reduction in stroke, heart failure, and coronary heart disease when targeting this goal. Moreover, the panel states that no additional benefit is seen in patients over the age of 60 who target goal SBP of <140 mmHg compared to those who target SBP <160mmHg or <150mmHg.

With respect to diastolic blood pressure (DBP), JNC 8 recommends the initiation of pharmacotherapy in the general population <60 years when DBP is ≥ 90 mmHg and treatment to goal DBP <90 mmHg. This recommendation is supported by findings of decrease in cerebrovascular events, heart failure, and overall mortality in adults aged 30-69 with hypertension.  Additionally, the HOT trial reported no statistically significant difference in additional benefits by treating patients to a goal of either < 80mmHg or < 85mmHg compared to <90mmHg.3

Another key difference in the new guidelines is with respect to comorbidities such as diabetes and chronic kidney disease (CKD). In JNC 7, the recommended blood pressure goal for patients with CKD is <130/80 mmHg. However, JNC 8 recommends that patients age >18 years with CKD target a goal blood pressure of <140/90 mmHg. Ultimately, the panelists found that there was no evidence demonstrating a benefit in mortality, cardiovascular, or cerebrovascular health outcomes in adults <70 years with CKD that targeted lower blood pressure goal (<130/80 mmHg).  Evidence that the progression of kidney disease was not slowed when targeting a lower blood pressure goal of <130/80 mmHg compared with a goal of <140/90 mmHg solidified the overall expert opinion and recommendation to target blood pressure of <140/90 mmHg.

Similarly, in diabetic patients JNC 8 recommends to target a goal blood pressure of <140/90 mmHg. This new target is a deviation from JNC 7 and the American Diabetes Association (ADA) recommendations, 130/80 mmHg and 140/80 mmHg respectively. In this case, the recommendation made by the panelists was based on expert opinion. No randomized controlled trials were found to meet the inclusion criteria and demonstrate improved health outcomes in diabetics by targeting SBP goal of <140 mmHg compared to <150 mmHg.  As for the DBP goal, insufficient evidence was found to support the previous recommendation of <80 mmHg. The consensus from the panelists was that using a consistent blood pressure goal among the general population and diabetics would facilitate implementation of the guidelines.

When initiating pharmacotherapy, one major change to be aware of is the elimination of β-blockers as first line agents. The new guidelines recommend initiating antihypertensive treatment with one of the following: thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). The panel does not recommend the use of β-blockers in hypertension due to reported higher rate of cardiovascular events, more specifically stroke, in participants involved in a study comparing β-blockers and ARBs.4

While the blood pressure targets have been “loosened” when compared to previous recommendations, management of patients already controlled by the standards of JNC 7 should not be altered. Instead, these recommendations should be applied to uncontrolled and newly diagnosed patients.  Limitations, such as exclusion of “landmark” trials (UKPDS and ADVANCE), systemic reviews, meta-analyses and the limited scope of the document may deter some from implementing these new recommendations in practice. However, this guideline attempts to base its recommendations and expert opinions from strict evidence supplied by randomized controlled trials. Additionally, it addresses the assumption that by targeting lower blood pressure levels, patients may improve outcomes irrespective of the type of agent used. Unlike its predecessor, JNC 8 is able to provide “evidence- based” dosing regimens for studied antihypertensive medications. Overall, the recommendations made in JNC 8 are just that, it is up to clinicians to interpret and apply them in practice. A summary of recommendations from JNC 8 are listed in Figure 1.

 

References:

1.     Chobanian AV, Bakris GL, Black HR, et al.; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560-72.

2.     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; 311(5):507-520.

3.     Hansson L, Zanchetti A, Carruthers SG, et al; HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998;351(9118):1755-1762

4.     Dahlof B, Devereux RB, Kjeldsen SE, et al; LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359(9311):995-1003.


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