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

JNC Guidelines for Hypertension Treatment

Blood Pressure Treatment Goals

The JNC-8 guidelines recommend a blood pressure goal of <150/90 mmHg for patients over 60 years old, <140/90 mmHg for adults under 60, and <140/90 mmHg for all patients with diabetes or chronic kidney disease, representing a significant liberalization from JNC-7 targets. 1

Age-Based Targets:

• Adults ≥60 years: <150/90 mmHg 1
• Adults <60 years: <140/90 mmHg 1
• Diabetes (all ages): <140/90 mmHg (relaxed from JNC-7's <130/80 mmHg) 1
• Chronic kidney disease (all ages): <140/90 mmHg (relaxed from JNC-7's <130/80 mmHg) 1

Important caveat: If a patient achieves blood pressure below these targets without adverse effects on their current regimen, continue the medications—do not discontinue therapy simply because BP is below goal. 2

First-Line Pharmacological Treatment

For the general non-Black population without CKD, initiate treatment with any of four drug classes: thiazide-type diuretic, calcium channel blocker (CCB), ACE inhibitor (ACEI), or angiotensin receptor blocker (ARB). 1

General Population Algorithm:

• Stage 1 or Stage 2 hypertension: Begin with one or two agents at physician's discretion (JNC-8 does not mandate a specific approach) 1
• No preferential ordering among the four drug classes for initial therapy 1
• Beta-blockers are NOT recommended as first-line therapy for uncomplicated hypertension 1

Race-Specific Recommendations:

• Black patients (without CKD): Initiate with thiazide-type diuretic OR calcium channel blocker 1
• White patients: Any of the four classes (thiazide, CCB, ACEI, or ARB) 1

Chronic Kidney Disease:

• All CKD patients with hypertension: Must include an ACEI or ARB in their regimen (though not necessarily as initial agent unless single-drug control is achieved with proteinuria) 1, 2
• CKD with proteinuria: ACEI or ARB should be first-line 2

Combination Therapy Progression

Most patients require two or more medications to achieve blood pressure control. 3

Two-Drug Combinations:

• Add a second agent from a different class among: thiazide diuretic, CCB, ACEI, or ARB 1
• Preferred combinations: Thiazide + ACEI/ARB, Thiazide + CCB, or CCB + ACEI/ARB 1

Three-Drug Combinations:

• Preferred triple therapy: CCB + Thiazide + ACEI or ARB 1
• Never combine ACEI + ARB + direct renin inhibitor together—this increases adverse events without benefit 2

Initiating with Two Drugs:

• Consider starting with two agents if blood pressure is >20/10 mmHg above goal 3
• One agent should typically be a thiazide-type diuretic 3

Key Differences from JNC-7

JNC-8 represents a significant departure from JNC-7 by raising blood pressure targets in elderly patients and those with diabetes/CKD, and by removing the preferential status of thiazide diuretics. 1

Major Changes:

• Elderly (>60 years): Target raised from <140/90 to <150/90 mmHg 1
• Diabetes: Target raised from <130/80 to <140/90 mmHg 1
• CKD: Target raised from <130/80 to <140/90 mmHg 1
• Drug selection: No longer preferentially recommends thiazides first; all four classes are equal choices 1
• Treatment thresholds equal treatment goals to avoid confusion 1

JNC-7 Historical Context:

• JNC-7 (2003) recommended thiazide-type diuretics as preferred initial therapy for most patients 3
• JNC-7 defined "prehypertension" as 120-139/80-89 mmHg, recommending lifestyle modifications 3
• JNC-7 emphasized that systolic BP >140 mmHg in patients >50 years is more important than diastolic BP 3

Compelling Indications for Specific Drug Classes

Certain comorbidities mandate specific antihypertensive classes regardless of blood pressure level. 3

• Post-myocardial infarction: Beta-blockers and ACEI 1
• Heart failure: ACEI, ARB, beta-blockers, or diuretics 1
• Angina pectoris: Beta-blockers 1
• Diabetic nephropathy: ACEI or ARB 2
• Kidney transplant recipients: Dihydropyridine CCB as first-line 2

Critical Pitfalls to Avoid

• Do not use beta-blockers as first-line therapy for uncomplicated hypertension in JNC-8 guidelines 1
• Never combine ACEI + ARB in the same patient—no additional benefit and increased harm 2
• Avoid inadequate diuretic dosing (leads to poor control) or excessive dosing (causes volume contraction and worsening renal function) 2
• Do not stop medications simply because BP falls below target if well-tolerated 2
• ACEI and ARB are absolutely contraindicated in pregnancy 2

Methodology and Controversy

JNC-8 based recommendations exclusively on randomized controlled trials with >100 patients and >1 year follow-up, disregarding 99% of hypertension literature including epidemiological studies. 1

• The guidelines were developed independently and are not endorsed by the National Heart, Lung, and Blood Institute despite initial formation by NHLBI 1
• Critics argue the limited evidence base does not justify changing JNC-7 recommendations, particularly the liberalized targets 1
• Concern exists that raising BP targets may negatively impact cardiovascular outcomes given existing gaps between treatment goals and achieved control 1