JNC Guidelines for Hypertension Management
The 2017 ACC/AHA guideline defines hypertension as blood pressure ≥130/80 mmHg and recommends treatment to a target of <130/80 mmHg for most adults to reduce morbidity and mortality. 1
Blood Pressure Classification
The most recent JNC guidelines (now published as ACC/AHA guidelines) classify blood pressure as follows:
| BP Category | Systolic BP | Diastolic BP |
|---|---|---|
| Normal | <120 mmHg | and <80 mmHg |
| Elevated | 120-129 mmHg | and <80 mmHg |
| Hypertension Stage 1 | 130-139 mmHg | or 80-89 mmHg |
| Hypertension Stage 2 | ≥140 mmHg | or ≥90 mmHg |
This represents a significant change from the JNC 7 classification, which defined hypertension as ≥140/90 mmHg and included a "prehypertension" category (120-139/80-89 mmHg) 1.
Treatment Thresholds and Goals
When to Initiate Pharmacotherapy:
- For primary prevention with low ASCVD risk (<10%): Initiate at BP ≥140/90 mmHg
- For primary prevention with high ASCVD risk (≥10%): Initiate at BP ≥130/80 mmHg
- For secondary prevention or with comorbidities (diabetes, CKD): Initiate at BP ≥130/80 mmHg
BP Treatment Goals:
- Most adults: <130/80 mmHg
- Older adults (≥65 years): SBP <130 mmHg (with consideration of patient factors)
First-Line Pharmacotherapy Options
The guidelines recommend four primary classes of medications for initial therapy 2:
- Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
- ACE inhibitors (e.g., lisinopril, enalapril)
- Angiotensin II receptor blockers (ARBs) (e.g., losartan, valsartan)
- Calcium channel blockers (CCBs) (e.g., amlodipine)
Population-Specific Recommendations:
- Non-Black patients: Can start with any of the four recommended classes
- Black patients: Should preferentially start with either a thiazide diuretic or CCB
- Patients with CKD: ACE inhibitor or ARB recommended, especially with proteinuria
Treatment Strategies
Dosing Approach:
- For Stage 1 hypertension: Start with a single agent, titrate to maximum dose, then add a second drug if needed
- For Stage 2 hypertension (≥140/90 mmHg): Consider initiating with two medications from different classes
Monitoring and Adjustment:
- Review and adjust medications every 2-4 weeks until BP is controlled
- If goal is not achieved with two drugs at maximum doses, add a third agent from a different class
- For triple therapy, the combination of CCB + thiazide diuretic + ACEI/ARB is recommended 2
Lifestyle Modifications
Lifestyle modifications are recommended for all patients with elevated BP or hypertension 3:
- DASH diet: Rich in fruits, vegetables, whole grains, and low-fat dairy; low in saturated fat and sodium
- Sodium restriction: <2,300 mg/day, ideally 1,500 mg/day
- Weight reduction: Aim for BMI <25 kg/m²
- Physical activity: 150 minutes of moderate-intensity aerobic activity per week
- Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women
Special Considerations
- Avoid combining ACEIs and ARBs as this increases adverse events without additional benefit 2
- Beta-blockers are not recommended as first-line therapy for primary hypertension unless there are specific indications (e.g., heart failure, post-MI) 2
- Resistant hypertension (BP remains ≥130/80 mmHg despite optimal doses of three medications including a diuretic) may require addition of spironolactone or other agents
Historical Context
The evolution of JNC guidelines shows progressively lower BP targets over time:
- JNC 7 (2003): Goal <140/90 mmHg for most; <130/80 mmHg for diabetes and CKD 1
- JNC 8 Panel (2014): Goal <150/90 mmHg for adults ≥60 years; <140/90 mmHg for others 4
- ACC/AHA (2017): Goal <130/80 mmHg for most adults 1
This shift reflects growing evidence that lower BP targets reduce cardiovascular events and mortality, particularly from the SPRINT trial which demonstrated benefits of intensive BP control.