What are the initial management recommendations for hypertension according to the Joint National Committee 8 (JNC 8) guidelines?

JNC 8 Initial Management Recommendations for Hypertension

The JNC 8 guidelines recommend initiating antihypertensive therapy at different blood pressure thresholds based on age and comorbidities, with simplified treatment goals: <150/90 mm Hg for adults ≥60 years without diabetes or CKD, and <140/90 mm Hg for adults <60 years and all adults with diabetes or CKD. 1

Blood Pressure Treatment Thresholds and Goals

Age-Based Targets

• Adults ≥60 years (general population): Initiate treatment at BP ≥150/90 mm Hg with a goal of <150/90 mm Hg 2, 1
• Adults 30-59 years: Initiate treatment at diastolic BP ≥90 mm Hg with a diastolic goal of <90 mm Hg 1
• Adults <60 years: Goal BP <140/90 mm Hg based on expert opinion (insufficient evidence for systolic goal in this age group) 2, 1

Comorbidity-Based Targets

• Diabetes (all ages): Goal BP <140/90 mm Hg (relaxed from JNC 7's <130/80 mm Hg target) 2, 1
• Chronic kidney disease (all ages): Goal BP <140/90 mm Hg regardless of age 2, 1

Initial Pharmacological Management

Non-Black Patients (General Population)

First-line therapy includes any of the following four drug classes: 1

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

Black Patients (Including Those with Diabetes)

Initial therapy should consist of: 2, 1

• Thiazide-type diuretic, OR
• Calcium channel blocker

Rationale: These agents demonstrate particular effectiveness in the black population compared to ACEI/ARB monotherapy 2, 3

Patients with Chronic Kidney Disease

All patients with CKD should receive an ACEI or ARB (though this need not be the initial agent unless BP is controlled with a single agent and proteinuria is present) 2, 1

Key Simplifications from JNC 7

Unified Treatment Approach

• Treatment thresholds equal treatment goals to avoid confusion (unlike JNC 7 where these differed) 2
• Fewer drug class recommendations based on comorbidities: Treatment goals are largely similar whether patients have "complicated" versus "uncomplicated" hypertension 2

Medication Continuation Principle

If pharmacological treatment achieves BP lower than the recommended target without adverse effects, continue the therapy—do not discontinue medications simply because BP is below target 2

Important Caveats and Controversies

The Age ≥60 Years Controversy

• The relaxed BP goal of <150/90 mm Hg for adults ≥60 years generated significant controversy, with a minority of JNC 8 panel members dissenting and warning this could reduce treatment intensity 2
• This recommendation was based on strong evidence from randomized controlled trials but has been criticized particularly for potentially adverse effects on elderly black patients and women (who comprise a larger proportion of this demographic) 2
• Subsequent guidelines (2017 ACC/AHA) reverted to lower targets (<130/80 mm Hg), and the decline in hypertension control rates from 2013-2014 to 2017-2018 may be partially attributable to JNC 8's relaxed goals 2

Critical Distinction: JNC 8 is Not NHLBI-Endorsed

The JNC 8 panel report was published independently and is NOT endorsed by the National Heart, Lung, and Blood Institute (NHLBI), which withdrew from guideline development before publication 2

Black Patients with CKD Exception

In the rare instance that a black patient with CKD achieves BP control with a single agent, an ACEI or ARB should be the initial therapy if proteinuria is present 2

Combination Therapy Prohibition

Do not combine two RAS blockers (ACEI + ARB) as this combination is not recommended 2