What are the JNC (Joint National Committee) 8 guidelines for managing hypertension?

JNC 8 Guidelines for Managing Hypertension

The JNC 8 guidelines recommend initiating antihypertensive treatment with a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB), with specific medication choices based on patient race and comorbidities. 1

Blood Pressure Targets

The JNC 8 guidelines established specific blood pressure targets based on age and comorbidities:

• Age ≥60 years: Target BP <150/90 mmHg 1
• Age <60 years: Target BP <140/90 mmHg 1
• Patients with diabetes or chronic kidney disease (CKD): Target BP <140/90 mmHg 1

These targets represent a departure from previous guidelines that recommended lower targets for patients with diabetes and CKD.

Initial Medication Selection

Medication selection should follow these evidence-based recommendations:

• Non-Black patients: Start with any of the four first-line agents:

  • Thiazide-type diuretic
  • Calcium channel blocker (CCB)
  • Angiotensin-converting enzyme inhibitor (ACEI)
  • Angiotensin receptor blocker (ARB) 1

• Black patients: Initial therapy should be either:

  • Thiazide-type diuretic
  • Calcium channel blocker (CCB) 1

• Patients with CKD: Include an ACEI or ARB in the treatment regimen 1

Treatment Approach

1. Initial therapy: Start with one medication at a moderate dose
2. Follow-up: Review and adjust medication every 2-4 weeks until blood pressure goal is achieved 1
3. Combination therapy: If blood pressure remains above target:
   • Add a second medication from a different class before maximizing the dose of the first medication
   • For patients with Stage 2 hypertension (BP ≥160/100 mmHg), consider initiating therapy with two medications simultaneously 1

Combination Therapy Recommendations

• Preferred combinations: Thiazide-type diuretic plus one of the other first-line agents (CCB, ACEI, or ARB) 1
• Avoid: Combining ACEIs and ARBs as this increases adverse events without additional benefit 1
• Triple therapy: If needed, use CCB + thiazide diuretic + ACEI/ARB 1

Lifestyle Modifications

Although not extensively detailed in the JNC 8 guidelines specifically, lifestyle modifications remain an important component of hypertension management:

• Reduce sodium intake toward 5 g of salt daily 2
• Regular physical activity
• Weight reduction for overweight or obese patients
• Moderation of alcohol consumption
• Consumption of a diet rich in fruits, vegetables, and low-fat dairy products 2

Special Considerations

• CKD patients: Should receive an ACEI or ARB as part of their regimen 1
• Black patients with CKD and proteinuria: An ACEI or ARB is recommended as initial therapy 1
• Orthostatic hypotension risk: Treat cautiously when initiating therapy with two medications 1

Common Pitfalls to Avoid

• Therapeutic inertia (failing to intensify treatment when needed)
• Inappropriate combination therapy
• Discontinuing effective therapy
• Overlooking race-specific recommendations 1
• Using β-blockers as first-line therapy for primary hypertension 1

The JNC 8 guidelines represent a significant shift toward evidence-based recommendations that focus on outcomes that matter most to patients: reducing morbidity and mortality from cardiovascular disease.