Joint National Committee 8 report: How it differ from JNC 7.

Hypertension is the most prevalent condition seen in primary care. On one hand, hypertensive patients are always apprehensive if blood pressure (BP) treatment will reduce their disease burden; on the other hand, clinicians need guidelines for management of hypertension based upon the best available scientific evidence. In this regard, a guiding-report was long overdue. The last report on management guidelines of hypertension was released in 2003.[1] Recently, in February 2014, new guidelines were released by the expert committee.[2] These guidelines have been formulated by adopting an evidence-based approach and recommend treatment thresholds, goals, and medications in the management of hypertension in adults.

How Joint National Committee (JNC) 8 report is different from JNC 7? Firstly, the definitions of hypertension and pre-hypertension, which were well-defined in JNC 7 has not been addressed in JNC 8. Secondly, similar treatment goals have been defined for all hypertensive population and no distinction between uncomplicated hypertension and hypertension with comorbid conditions like diabetes or chronic kidney disease (CKD) has been made. Another difference was the choice of initial drug in patients without compelling indications. In contrast to JNC 7 where thiazides were recommended to be the initial choice in patients without compelling indications, no such recommendation has been made in JNC 8.[2]

One major difference was the methodology by which committee reached these recommendations. Initially, the critical questions and review criteria were defined by an expert panel with input from methodology team; followed by initial systematic review by methodologists restricted to randomized control trial (RCT) evidence. Subsequent review of RCT evidence and recommendations were made by the panel according to a standardized protocol.[2] This grossly differ from the methodology adopted by JNC 7 where methodology was based upon nonsystematic literature review by an expert committee including a range of study designs, and recommendations were made based on consensus.[1]

In all JNC 8 made nine recommendations. These recommendations were categorized from grades A to E and Grade N depending upon the strength of the recommendations. Grade A means “strongly recommended,” Grade B means “moderately recommended,” Grade C means “weakly recommended,” Grade D means “recommendation against” and Grade E means “expert opinion” (i.e., there is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends). Grade N means “no recommendation for or against.”

First five of the nine recommendations dealt with the question of threshold BP at which treatment should be started and the target BP, which is required to be achieved with treatment. Recommendation 1 (Grade A recommendation) states that in the general population aged ≥60 years, initiate pharmacologic treatment if BP is ≥150/90 mmHg and treat to a goal BP of <150/90 mmHg. Recommendation 2 states that in the general population <60 years, initiate pharmacologic treatment to lower BP at diastolic blood pressure (DBP) ≥90 mmHg and treat to a goal DBP <90 mmHg (For ages 30-59 years Grade A recommendation; for ages 18-29 years Grade E recommendation). Recommendation 3 (Grade E) states that in the general population <60 years, pharmacologic treatment should be initiated if systolic blood pressure (SBP) is ≥140 mmHg and treat to a goal SBP <140 mmHg. In the population aged ≥18 years with CKD or diabetes, treatment should be initiated if BP is ≥140/90 and treat to goal BP of <140/90 mmHg (recommendations 4 and 5, Grade E).

Recommendation 6-8 addressed the issue of choice of the drug to be given to hypertensive patients. As per recommendation 6 (Grade B recommendation), 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). In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB (recommendation 7, for general black population: Grade B recommendation; for black patients with diabetes: Grade C recommendation). As per recommendation 8 (Grade B recommendation), in all patients aged ≥18 years with CKD, regardless of race or diabetic status, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes.

Recommendation 9 (Grade E recommendation) addressed the broader issue of the treatment plan in a hypertensive patient according to which the main objective of hypertension treatment is to attain and maintain goal BP. As per this recommendation if goal BP is not reached within a month of treatment, the dose of the initial drug should be increased or a second drug from one of the classes in recommendation 6 should be added. 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, third drug from the list provided should be added and titrated. Recommendation says that an ACEI and an ARB should not be used together in the same patient. If goal BP is not 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.

As is clear from discussion, JNC 8 guidelines are evidence based, more simplified with clear-cut thresholds and target ranges, and will surely be handy at the hands of clinicians in managing hypertensive patients.