ACC GUIDELINES PART2
Integrating New Cardiovascular Guidelines in Primary Care Practice
Part 2 Hypertension and Joint National Committee 8
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I have a personal disclosure. My first job after medical school was clinic director in the only rural site of the Hypertension Detection and Follow-up Program (HDFP). HDFP was one of the first multicenter clinical trials sponsored by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH).  That experience influenced my entire career; I worked with a physician’s assistant and two nurse practitioners using a protocol of screening and “stepped care” in the community of Evans County, GA. The protocol was developed by NHLBI’s National High Blood Pressure Education Program whose Joint National Committee (JNC) developed the first national clinical practice guideline for a chronic disease. It has been the model for the cooperation of public health, clinical investigators, and community practitioners and has, even by the most conservative estimates, saved the lives of thousands of Americans from “the silent killer.” I have had a lifelong “love affair” with the National Institutes of Health and there is no medical institution in the world for which I have greater respect. The fact that the development of this 8th version of the JNC guideline, although funded by NHLBI, is not published at their website, in my opinion, says something. The NHLBI guideline website continues to show the JNC7 report as the current guideline for primary care on hypertension. 
The eighth JNC report was first released online in late December, 2013 and published in the Journal of the American Medical Association (JAMA) in February, 2014.  A “minority report” representing the views of five members of the JNC was released online in January, 2014 and published in the Annals of Internal Medicine in April, 2014.  I believe the publication of a minority report is unprecedented in the history of the JNC.
The recommendations of JNC8 are as follows:
Recommendation 1: In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A)
Corollary Recommendation: In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)
Recommendation 2: In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E)
Recommendation 3: In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E)
Recommendation 4: In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
Recommendation 5: In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
Recommendation 6: In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B)
Recommendation 7: In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)
Recommendation 8: In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)
Recommendation 9: The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E)
Many of the JNC8 recommendations are significant changes from JNC7. Recommendation 1 has received the most publicity; it relaxes the goal of SBP control over age 60 from 140 to 150 in the absence of diagnosed diabetes (DM) or chronic kidney disease (CKD). The consensus statement of the JNC8 committee is that there is insufficient evidence that the benefits of tighter control over age 60 outweigh the risk of adverse effects. The minority report argues that there is already compelling evidence of benefit to keep the goal at less than 140 as recommended in JNC7. In my practice I aim for the JNC7 goal for older adults as the JNC8 corollary allows.
For hypertensives with DM or CKD, the SBP goal has been relaxed from 130 to 140 and the DBP goal from 80 to 90. JNC8 is at least somewhat comforting that when our patients are not achieving JNC7 goals we will not be held liable for negligence.
Recommendations 6-8 on the choice of pharmacotherapy also show major change from JNC7. The JNC7 recommends initial treatment of all hypertensives without “compelling indication” with a thiazide diuretic if a trial of lifestyle modification has not achieved goal BP. JNC8 (which does not even address non-pharmacologic therapy) removes beta blockers from first line therapies for primary care. For black people JNC8 recommends using CCB rather than ACEI or ARB even if the individual is diabetic. I am following the American Diabetes Association Standards of Medical Care for Diabetes 2014 which still recommends ACEI or ARB for all hypertensives with diabetes. 
Most of us in the practitioner community have neither the training nor the time and resources to evaluate all the evidence pertaining to the treatment of hypertension. The positive aspect of JNC8 for us is that the treatment goals for which they found compelling evidence of benefit are easier for ourselves and our patients to achieve. I still believe that the evidence-based clinical practice guideline process is the best source of standards for our practice and that openly sharing the differences of opinion which are generated by this process is helpful to us in primary care even if it complicates our lives for now.
Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA
Published July 15, 2014
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975 and completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. Dr. Sneiderman was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences and maintains certification by the American Board of Family Medicine. He has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snow sports since 2005.
- Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group. JAMA. 1979 Dec 7;242(23):2562-2571. http://jama.jamanetwork.com/article.aspx?articleid=367742
- The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
- 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 Feb 5;311(5):507-520. http://jama.jamanetwork.com/article.aspx?articleid=1791497
- Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. 2014 Apr 1;160(7):499-503. http://annals.org/article.aspx?articleid=1813288
- American Diabetes Association. Standards of Medical Care in Diabetes 2014. Diabetes Care. 2014 Jan; 37(Supplement 1):S14-S80. http://care.diabetesjournals.org/content/37/Supplement_1/S14.full#sec-167