Making Sense of New Hypertension Management Guidelines
The medical community is seeking to put into context the updated evidence-based guidelines for managing hypertension in older adults, which were released by the Eighth Joint National Committee (JNC 8) earlier this year. The implications of the JNC 8 report have generated controversy, as a recent analysis by Navar-Boggan and colleagues from Duke Medicine estimated that as many as 13.5 million adults would no longer be considered to have poorly controlled blood pressure, and as many as 5.8 million adults would no longer be prescribed antihypertensive medication if the guidelines were rigidly applied. The analysis, which was published online ahead of print in JAMA, sought to quantify the effects of the nine recommendations put forth by the JNC 8.
In the JNC 8 report, only two of the nine recommendations are strongly supported by the evidence with a Grade A rating:
- In the general population between the ages of 30 and 59 years, initiate pharmacologic treatment to lower diastolic blood pressure (DBP) to less than 90 mm Hg. (There was no evidence to support a systolic blood pressure [SBP] goal in this age group, but the committee decided to set it to 140 mm Hg. It also extended these SBP and DBP goals to patients older than 60 years with either chronic kidney disease or diabetes.)
- In the general population aged 60 years or older without the aforementioned chronic conditions, initiate pharmacologic treatment to lower SBP and DBP to 150 mm Hg or less and 90 mm Hg or less, respectively.
A corollary note to the latter recommendation advises that if pharmacologic treatment for high BP results in lower achieved SBP (for example, <140 mm Hg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted.
The methodology of the Seventh Joint National Committee (JNC 7) provided consensus-based recommendations from an expert committee based upon a nonsystematic literature review that included a range of study designs. The JNC 8 restricted its methodology to systemic reviews of randomized controlled trials and used a standardized protocol for reviewing this evidence. The JNC 8 committee carefully notes that they are not challenging the JNC 7 definition of hypertension as 140/90 mm Hg; the JNC 8 guidelines simply go a step further to address the thresholds and goals for pharmacological treatment of hypertension, and whether different drugs and drug classes differ in benefits and harms. The summary of the JNC 8 report, including the new algorithm for determining appropriate drug therapy and the other recommendations, was published in February.
In a Duke press release, lead author Ann Marie Navar-Boggan said that one in four adults older than 60 years is currently being treated for hypertension and meeting the stricter targets set by previous guidelines. “These adults would be eligible for less intensive blood pressure medication under the new guidelines, particularly if they were experiencing side effects,” Navar-Boggan said. “But many experts fear that increasing blood pressure levels in these adults could be harmful.”
Wilbert S. Aronow, MD, cardiology division, New York Medical College, Valhalla, NY, is one of these skeptical physicians. Since these studies included only noninstitutionalized adults, the impact of applying these guidelines in the long-term care setting remains to be seen. “Elderly persons in the community and in the long-term care sector have the lowest rates of adequate blood pressure control and the highest incidence of cardiovascular events,” he said in an interview with Annals of Long-Term Care. “I am very much concerned that the higher systolic blood pressure goal recommended by JNC 8 will lead to a higher incidence of cardiovascular events and mortality.”
The authors of the JNC 8 report offered the take-away message that the benefit of treating lower blood pressure levels with antihypertensive drugs is not established, however, “these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.”
-Allison Musante, ELS
