COMMENTARY

JNC 8: The Pearls for Primary Care

Sandra Adamson Fryhofer, MD

Disclosures

February 21, 2014

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Hello. I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic: new adult hypertension management guidelines from the Eighth Joint National Committee, published in JAMA.[1] Here's why it matters.

High blood pressure is very common. It's the most common condition treated by primary care physicians. Left untreated, hypertension can lead to heart attack, stroke, kidney failure, and even death. Of the estimated 78 million adults in the United States who have it, only half have their blood pressure under adequate control. These new guidelines are well overdue. The last update was back in 2003.[2] There is one major difference from previous JNC recommendations: These new guidelines are evidence-based.

First, what's the threshold for starting medication, and what blood pressure goals should we aim for? It depends on age. For patients age 60 years and over -- a grade A recommendation -- both systolic and diastolic matter. Start medication to keep blood pressure below 150/90. This goal is a little more lenient than what we've been used to. Remember that the JNC 7 had set treatment thresholds for starting meds at 140/90. Although the evidence base is not there, the new committee's expert opinion says that blood pressures less than 140 after treatment are fine if well tolerated with no adverse effects. For younger patients, those 30-60 years, the body of evidence supports keeping diastolic under 90.

The evidence is not there to support a recommendation for a systolic goal in the under-60 age group. The evidence also does not even support a diastolic goal recommendation for those under 30 years of age. For this younger, under-60 crowd, the committee's expert opinion weighed in again and said to keep it less than 140/90.

Which meds are best for initial therapy? It depends on race. For non-black patients, choices for initial therapy include an angiotensin-converting-enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), a calcium channel blocker, or a thiazide diuretic. African American patients, even those with diabetes, should begin with a calcium channel blocker or a thiazide diuretic.

The same goals apply to those with diabetes and anyone with chronic kidney disease. However, there was moderate evidence for using ACE inhibitors or ARBs initially or as an add-on to protect the kidneys in those with chronic kidney disease.

Several editorials accompanied these new guidelines. One in particular focused on the process of translating practice guidelines into performance measures and potential unintended consequences of treatment guidelines that are too strict.[3]

For Medicine Matters, I'm Dr. Sandra Fryhofer.

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