JNC 8 Guidelines for the Management of Hypertension in Adults When treating high blood pressure, how low should we try to go? This complete version of the updated guidelines for hypertension is written for the health care professional who wants to understand the science behind the new recommendations on high blood pressure. Epub 2014 Feb 26. , Tyramine levels go up when foods are at room temperature. Triple therapy with an ACEI/ARB, CCB, and thiazide-type diuretic would precede use of alpha-blockers, beta-blockers, or any of several other agents. Before The two classes of medication are both recommended as first-line treatments for high blood pressure: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). How Long Does It Take Lisinopril to Work? What is the difference between JNC 7 and JNC 8? Dr. Aryan (Anish Dhakal) Follow Advertisement A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Expert Opin Pharmacother. Our process of managing hypertension through intensive blood pressure control to achieve lower systolic blood pressure targets requires a concerted effort among healthcare providers at all levels. See permissionsforcopyrightquestions and/or permission requests. Disclaimer. In addition, a lack of evidence comparing the 4 first-line therapies with carvedilol, nebivolol, clonidine, hydralazine, reserpine, furosemide, spironolactone, and other similar medications precludes use of any medications other than ACEIs, ARBs, CCBs, and thiazide-type diuretics in the vast majority of patients. What are the latest JNC guidelines? In addition, the panel expressly prohibits simultaneous use of an ACEI and an ARB in the same patient. Debate continues about optimal blood pressure goals after publication of guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) in 2017 that set or permitted a treatment goal of less than 130 mm Hg, depending on the population.1. For those without cardiovascular disease and at lower risk, drug treatment is recommended if the average blood pressure is 140/90 mm Hg or higher. 1998 Mar 7;351(9104):689-90. doi: 10.1016/S0140-6736(05)78489-0. OTHER TRIALS THAT INFLUENCED THE GUIDELINES, Cleveland Clinic Center for Continuing Education. Of note, a minority of the JNC 8 panel disagreed with the new targets and provided evidence for keeping the systolic blood pressure target below 140 mm Hg for patients 60 and older.5 Further, the JNC 8 report was not endorsed by several important societies, ie, the AHA, ACC, National Heart, Lung, and Blood Institute, and American Society of Hypertension (ASH). These recommendations have a class I level of evidence (ie, strongest level) in the 2017 ACC/AHA guidelines.1. Generally, ACE inhibitors should remain the initial treatment of choice for hypertension. All rights reserved. Nevertheless, there seems to be agreement that intensive treatment generally leads to a reduction in cardiovascular events. Careers. This finding was based primarily on six randomized controlled trials (RCTs) comparing intensive vs. conservative blood pressure goals among older patients.712, Panel members concluded that the absence of evidence supporting a lower target was grounds to raise blood pressure goals. (SBP 120-139 mmHg), previously defined by JNC 7, 40 was 1.11 (95% confidence interval [CI] 0.97-1.27) when compared with normal BP (SBP < 120 mmHg). The information provided is for educational purposes only. PDF Hypertension - ACCP In 2014, panel members of the Eighth Joint National Committee published the results of their evidence review and deliberations about the prevention, detection, evaluation, and treatment of high blood pressure. About 50% of patients did not achieve the target systolic blood pressure (< 120 mm Hg) despite receiving an average of 2.8 antihypertensive medications in the intensive-treatment group and 1.8 in the standard-treatment group. In addition, the guidelines may lead to less use of antihypertensive medications in younger patients, which will produce equivalent outcomes in terms of cardiovascular events with less potential for adverse events that limit adherence. Current hypertension management recommendations from various organizations are listed in Table 1.15, Management of hypertension is key for improving health outcomes. Hypertension - Clinical Practice Guideline | AAFP Potassium-rich foods include: Fruits such as bananas, melons, avocadoes, and apricots. Screening Guidelines on screening for hypertension have been issued by the following organizations: United States Preventive Services Task Force (USPSTF) Joint National Committee (JNC). Federal government websites often end in .gov or .mil. This applies to black and non-black populations. In younger patients without major comorbidities, elevated DBP is a more important cardiovascular risk factor than is elevated SBP. The International Society of Hypertension (ISH) has published summary guidelines based on major international guidelines published between 2017 and 2020 on the control of hypertension. These can include pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia. We aim for that same target in patients without cardiovascular disease but who have an elevated estimated cardiovascular risk (> 10%) over the next 10 years. ACE (angiotensin-converting enzyme) inhibitors and angiotensin receptor blockers (ARBs) effectively lower blood pressure (BP) through inhibition of the renin-angiotensin system and are equally recommended as first-line medications in the treatment of hypertension. This was designed to reduce elevated blood pressure readings in the presence of a healthcare professional in a medical setting (ie, white coat hypertension). High Blood Pressure-A High Risk Problem for Public Healthcare. For many patients, this involves drug treatment. The etiology of elevated blood pressure is a complex process involving the interaction of genetics, demographics, comorbid disorders, and environmental influences. The Eighth Joint National Committee (JNC 8) recently released evidence-based recommendations on treatment thresholds, goals, and medications in the management of hypertension in adults. The downside is adverse effects. New US guidelines for the management of hypertension]. There is ample evidence that there are racial differences in the response to certain common classes of blood pressure medication. What is the difference between JNC 7 and JNC 8? Would you like email updates of new search results? This slight change should not have been enough to produce significant differences in clinical outcomes, a major limitation of this trial. Mar 31, 2023. For others, achieving a systolic blood pressure closer to 140 mm Hg, compared with 150 mm Hg, is reasonable given the available evidence, assuming that the adverse effects of medication are minimal. JNC VI guidelines Lancet. The trial was intended to last 5 years but was stopped early at a median of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group: 1.65% per year vs 2.19%, a 25% relative risk reduction (P < .001) or a 0.54% absolute risk reduction. The trial enrolled 9,361 participants at least 50 years of age with systolic blood pressure 130 mm Hg or higher and at least 1 additional risk factor for cardiovascular disease. For example, the cardiovascular benefit of intensive treatment is less clear in diabetic patients, and the risk of adverse events may be higher in older patients with chronic kidney disease. 2014 Oct;43(10 Pt 1):1048-55. doi: 10.1016/j.lpm.2014.03.031. An official website of the United States government. One exception to the use of ACEIs or ARBs in protection of kidney function applies to patients over the age of 75. Blood pressure targets should be applied in the appropriate clinical context and on a patient-by-patient basis. Standard treatment, with a systolic blood pressure goal of less than 140 mm Hg: it used polytherapy for patients whose systolic blood pressure was 160 mm Hg or higher. Braoveanu AM, erbnescu MS, Mlescu DN, Predescu OI, Cotoi BV. Why are ACE inhibitors used first line for hypertension? and transmitted securely. All Rights Reserved. Soon after, the much-anticipated report of the panel members appointed to the eighth JNC (JNC 8) was published.4 Previous JNC reports were written and published under the auspices of the National Heart, Lung, and Blood Institute, but while the JNC 8 report was being prepared, this government body announced it would no longer publish guidelines. In addition, SPRINT used automated office blood pressure measurements in which patients were seated alone and a device (Model 907, Omron Healthcare) took 3 blood pressure measurements at 1-minute intervals after 5 minutes of quiet rest. PDF JNC 8 Hypertension Guideline Algorithm - Umpqua Health Patients will be asking about the new JNC 8 hypertension guidelines, which were published in the Journal of the American Medical Association on December 18, 2013. As a result, the JNC 8 panelists recommend that all patients with chronic kidney disease and hypertension, regardless of ethnic background, should receive treatment with an ACEI or ARB to protect kidney function, either as initial therapy or add-on therapy. The availability of four first-line agents may seem more challenging, but it allows clinicians to incorporate their preferencesand those of their patientsinto the accepted practice recommendations. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). JNC 7 defined hypertension as 140/90 mm Hg or higher, and introduced the classification of prehypertension for patients with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg. Hypertension guidelines: Treat patients, not numbers All Rights Reserved. However, the process and methodology were controversial, especially as the panel excluded some important clinical trials from the analysis. Patients with high-normal blood pressure or hypertension are stratified into risk group A (no associated cardiovascular disease risk factors . The JNC 8 Hypertension Guidelines: An In-Depth Guide - AJMC According to JNC 7, the general BP goal is to lower systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg. Med Monatsschr Pharm. If an increase in dose or addition of a new drug does not reduce your blood pressure to your target goal, then your healthcare provider should add a third drug from one of the recommended classes. This is a class I (strong) recommendation for patients with known cardiovascular disease or a 10-year risk of a cardiovascular event of 10% or higher, with a B-R level of evidence for the systolic goal (ie, moderate-quality, based on systematic review of randomized controlled trials) and a C-EO level of evidence for the diastolic goal (ie, based on expert opinion). Adults with diabetes and hypertension have reduced mortality as well as improved cardiovascular and cerebrovascular outcomes with treatment to a goal SBP <150 mmHg, but no randomized controlled trials support a goal <140/90 mmHg. Weber MA, Schiffrin EL, White WB, et al. US Hypertension Management Guidelines: A Review of the Recent Past and Results were even better in the subset of patients who had diabetes.27 However, the decrease in blood pressure attributable to anti hypertensive therapy with ramipril was minimal (34 mm Hg systolic and 12 mm Hg diastolic). Copyright 2017 Elsevier Ltd. All rights reserved. sharing sensitive information, make sure youre on a federal Since MAOIs inhibit monoamine oxidase, they decrease the breakdown of tyramine from ingested food, thus increasing the level of tyramine in the body. MeSH The drugs of choice in treating patients with a hypertensive crisis and eclampsia or pre-eclampsia are hydralazine, labetalol, and nicardipine (5,6). This process has helped us to reach our treatment goals while limiting adverse effects of lower blood pressure targets. Diabetes Care. Epub 2018 Mar 5. 2022 Mar 22;3(2):353-361. doi: 10.1002/jha2.415. The goal of therapy for a hypertensive emergency is to lower the mean arterial pressure by no more than 25% within minutes to 1 hour and then stabilize BP at 160/100-110 mm Hg within the next 2 to 6 hours. The Eighth Joint National Committee (JNC 8) recently issued the most anticipated guideline in some time.1 The JNC 8 committee was initially appointed in 2008 by the National Heart, Lung, and Blood Institute. The JNC 8 guideline authors cite 2 trials that found no improvement in cardiovascular outcomes with an SBP target <140 mm Hg compared with a target SBP level <160 mm Hg or <150 mm Hg. Are we fostering a healthier population or merely tolerating higher blood pressure values? Many physicians are still taking blood pressure manually, which tends to give higher readings. In adults older than 60 years of age, treatment should begin if the systolic pressure is 150 mm Hg or higher and if the diastolic pressure is 90 mm Hg or higher. eCollection 2021. Curr Health Sci J. Changes between the 2022 and 2015/2017 Taiwan Hypertension Guidelines, new recommendations, and the "not to do" list are summarized in Tables 1A, Tables 1A . Also, 26% of this group (16.2 million) had high-normal blood pressure and were in risk groups A or B, a context in which vigorous lifestyle modification is recommended in the JNC-VI guidelines. Despite the subgroup analysis of ALLHAT, results of the African American Study of Kidney Disease and Hypertension (AASK) support use of first-line or add-on ACEIs to improve kidney-related outcomes in patients of African descent with hypertension, chronic kidney disease, and proteinuria. It advocated managing systolic hypertension in patients over age 50. Intensive treatment, with a systolic blood pressure goal of less than 120 mm Hg: the protocol called for polytherapy, even for participants who were 75 or older if their blood pressure was 140 mm Hg or higher. Other recent evidence suggests that the SBP goal <140 mmHg recommended by the JNC 7 guidelines for most patients may have been unnecessarily low. Treating numbers rather than patients may result in unbalanced patient care. We aim for a blood pressure goal below 130/80 mm Hg for all patients with cardiovascular disease, according to the AHA/ACC guidelines. The Hypertension Canada Guidelines are the nation's clinical practice guidelines for the management of hypertension. All told, about 3 million Americans could suffer a serious adverse effect under the intensive-treatment goals. JNC 8 Hypertension Guideline Algorithm Adult aged 18 years with HTN Implement lifestyle modifications Set BP goal, initiate BP-lowering medication based on algorithm General Population (no diabetes or CKD) Age 60 years Diabetes or CKD present Age < 60 years All Ages Diabetes present The JNC 8 panel does not recommend first-line therapy with beta-blockers and alpha-blockers due to 1 trial that showed a higher rate of cardiovascular events with use of beta-blockers compared with use of an ARB, and another trial in which alpha-blockers resulted in inferior cardiovascular outcomes compared with use of a diuretic. Systolic BP levels between 120 and 139 mm Hg and diastolic between . This review will also discuss the most recently available evidence that has an impact on the JNC 8 recommendations. Compared with placebo, the rate of composite events was significantly reduced in the rosuvastatin group (3.7% vs 4.8%, HR 0.76, P = .002)28 and the candesartan-hydrochlorothiazide-rosuvastatin group (3.6% vs 5.0%, HR 0.71; P = .005)29 but not in the candesartan-hydrochlorothiazide group (4.1% vs 4.4%; HR 0.93; P = .40).30, In addition, a subgroup analysis comparing active treatment vs placebo found a significant reduction in major cardiovascular events for treated patients whose baseline systolic blood pressure was in the upper third (> 143.5 mm Hg, mean 154.1 mm Hg), while treated patients in the lower middle and lower thirds had no significant reduction.30. Results showed a reduction in cerebrovascular events, heart failure, and overall mortality in patients treated to the DBP target level. Instead, the JNC 8 guidelines encourage use of agents with the best evidence of reducing cardiovascular risk. What are the latest JNC guidelines for hypertension? In this article, we summarize the evolution of hypertension guidelines and the evidence behind them. FOIA Stratifying the results according to the systolic blood pressure achieved ( 130 or < 130 mm Hg), the relative risks of mortality, coronary heart disease, cardiovascular disease, heart failure, and albuminuria were actually lower in the higher stratum than in the lower. JNC reports have served as a valuable source of guidelines, and JNC 8 is the most recently updated guideline for the prevention, diagnosis, and treatment of hypertension. The 2017 ACC/AHA guidelines lowered the definition of hypertension to 130/80 mm Hg or higher, thereby increasing the number of US adults with hypertension from 31.9% to 45.6%. 2006 May;12(4):303-9. doi: 10.18553/jmcp.2006.12.4.303. Acta Cardiol. These guidelines were published by the 8th Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, known as JNC 8. Hypertension: New Guidelines from the International Society of - AAFP Once You Start Blood Pressure Medication, Can You Stop? Finally, the various medical societies should collaborate on hypertension guideline development. SHEP Cooperative Research Group, Results of the pilot study for the Hypertension in the Very Elderly Trial, The Felodipine Event Reduction (FEVER) study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients, Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS), Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study, Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis, The HOPE study (Heart Outcomes Prevention Evaluation), Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. In 2015, the AHA, ACC, and ASH released a joint scientific statement outlining hypertension goals for specific patient populations7: < 150/90 mm Hg for those age 80 and older, < 140/90 mm Hg for those with coronary artery disease. Excessive tyramine can elevate blood pressure and cause a hypertensive crisis. JNC VI guidelines - PubMed The final recommendations are: JNC 8 recommends an increase in the initial drug dose or addition of a second drug from one of the recommended drug classes for your subgroup if you are not able to reach your blood pressure target within a month. The major findings (January 2018-March 2021) and their relevance to . In 2017, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organizations lowered the numbers for the diagnosis of hypertension (high blood pressure) to 130/80 millimeters of mercury (mm Hg) and higher for all adults. Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Treatment of MAOI hypertensive crisis with sublingual nifedipine. Which of the following indicates hypertensive crisis? These medicines were initially developed to treat high blood pressure, but they also relax the prostate and bladder neck, allowing urine to flow freely. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),2 published in 2003, specified treatment goals of: < 130/80 mm Hg for those with diabetes or chronic kidney disease. For example, beta-blockers have been shown to improve survival in patients with heart failure, so they are a good choice for the reduction of blood pressure in patients with congestive heart failure. The use of antihypertensive medications, however, was not a controlled variable in the trial, and practitioners chose the appropriate drugs for their patients. Unauthorized use of these marks is strictly prohibited. Clinical practice guidelines for the management of Results of 5 key trials--HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative--informed the changes in the new guidelines. These new guidelines all but eliminate use of beta-blockers (including nebivolol), alpha-blockers, loop diuretics, alpha1/beta-blockers, central alpha2-adrenergic agonists, direct vasodilators, aldosterone antagonists, and peripherally acting adrenergic antagonists in patients with newly diagnosed hypertension. HOPE 32830 explored the effect of blood pressure- and cholesterol-controlling drugs on the same primary end points but in patients at intermediate risk of major cardiovascular events. Investigators randomized the 12,705 patients to 4 treatment groups: Blood pressure control with candesartan (an ARB) plus hydrochlorothiazide (a thiazide diuretic), Cholesterol control with rosuvastatin (a statin). The ideal target blood pressure is not known, but a goal of less than 130/80 mm Hg may be reasonable. , Consume a low-sodium diet. Since publication of the 2017 ACC/AHA BP Guideline, several new findings have emerged which, taken together, can better inform the approach to the prevention, detection, and management of hypertension. [Epub ahead of print]. It examined intensive and standard blood pressure control targets in patients with type 2 diabetes at high risk of cardiovascular events, using primary outcome measures similar to those in SPRINT. Although ACEIs, ARBs, and calcium channel blockers (CCBs) are acceptable alternatives, thiazide-type diuretics still have the best evidence of efficacy. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. In clinical practice, one size does not always fit all, as special cases exist. High Blood Pressure Stage 1 = 130-139 or 80-89. 2017 ACC/AHA and JNC-8 hypertension guidelines - aanpcert.org The 2019 certification examinations use the 2017 ACC/AHA and JNC-8 guidelines to reference test items. 1997 Nov 15;350(9089):1413-4. doi: 10.1016/S0140-6736(05)64202-X. Lancet. ACEIs and ARBs may not be an ideal choice in patients of African descent. Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine. People older or younger than age 60 years People aged 18 years with chronic kidney disease People aged 18 years with diabetes Although 1 post-hoc analysis showed a possible advantage in kidney outcomes with the lower target of 130/80 mmHg recommended by JNC 7, 2 other primary analyses did not support this finding. By designating fewer categories, JNC 7 simplifies the classification of BP for adults. The JNC 8 guidelines contained nine recommendations surrounding the three critical questions.