What are the JNC (Joint National Committee) 8 guidelines for initiating antihypertensive therapy?

JNC 8 Hypertension Guidelines

Blood Pressure Treatment Thresholds and Goals

The JNC 8 guidelines recommend initiating antihypertensive therapy at ≥150/90 mmHg for patients aged ≥60 years (goal <150/90 mmHg), at ≥140/90 mmHg for adults <60 years (goal <140/90 mmHg), and at ≥140/90 mmHg for all patients with diabetes or chronic kidney disease regardless of age (goal <140/90 mmHg). 1, 2

Age-Based Targets:

• Patients ≥60 years: Initiate treatment at BP ≥150/90 mmHg with goal <150/90 mmHg 3, 1
• Patients <60 years: Initiate treatment at BP ≥140/90 mmHg with goal <140/90 mmHg (based on expert opinion for systolic goal due to insufficient evidence) 3, 2
• Patients 30-59 years: Strong evidence supports diastolic goal <90 mmHg 2

Comorbidity-Based Targets:

• Diabetes (all ages): Goal <140/90 mmHg (notably less aggressive than JNC 7's <130/80 mmHg target) 3, 1
• Chronic kidney disease (all ages): Goal <140/90 mmHg 3, 1

Critical point: JNC 8 intentionally made treatment thresholds and goals identical to avoid confusion—if BP reaches the treatment threshold, that same value becomes the goal 3

Initial Pharmacological Treatment Selection

General Non-Black Population (without CKD):

Initiate treatment with any one of four first-line drug classes: thiazide-type diuretic, calcium channel blocker (CCB), ACE inhibitor (ACEI), or angiotensin receptor blocker (ARB). 3, 1, 2

• No specific order of preference among these four classes 3
• Beta-blockers are NOT recommended as first-line therapy for uncomplicated hypertension 1

Black Patients (without CKD):

Initial treatment should be a thiazide-type diuretic OR calcium channel blocker (these are particularly effective in this population). 3, 1, 2

• Do not use ACEI or ARB as initial monotherapy in black patients without CKD 1

Patients with Chronic Kidney Disease (any race):

An ACEI or ARB must be included in the treatment regimen to improve kidney outcomes. 3, 1, 2

• This does not have to be the initial agent if BP control requires multiple drugs 3
• Exception: If a black patient with CKD achieves control with single-agent therapy AND has proteinuria, use ACEI or ARB as initial therapy 3

Dosing Strategies

JNC 8 provides three discretionary dosing approaches, leaving the final decision to clinician judgment: 3

1. Start one drug → titrate to maximum dose → add second drug
2. Start one drug → add second drug before reaching maximum dose of first drug
3. Begin with two drugs simultaneously (separate pills or single-pill combination)

For Stage 1 or Stage 2 hypertension, either one or two drugs can be initiated at physician discretion, as insufficient evidence exists to support a specific strategy. 3

Combination Therapy

Two-Drug Combinations:

Add a drug from a different class among: thiazide diuretic, CCB, ACEI, or ARB. 3

• Preferred combinations emerging from clinical experience: ACEI/ARB + CCB, ACEI/ARB + thiazide, or CCB + thiazide 3

Three-Drug Combinations:

The preferred triple therapy is CCB + thiazide diuretic + ACEI or ARB. 3, 1

Absolute Contraindication:

Never combine ACEI + ARB together due to increased risk of end-stage renal disease, stroke, and adverse events without additional benefit (based on ONTARGET and ALTITUDE trials). 3, 1

• Also avoid thiazide + beta-blocker combination when possible due to increased diabetes risk 3

Treatment Adjustment Timeline

Review and modify antihypertensive dose or add additional drugs every 2-4 weeks until BP is controlled. 3

Critical Management Principles

When BP Falls Below Target:

If pharmacological treatment results in BP lower than the recommended goal without serious adverse effects, continue the current regimen—do not discontinue medications simply because BP is below target. 3, 1

Multiple Drug Requirement:

Most patients will require two or more antihypertensive medications to achieve BP control. 3, 1

Key Differences from JNC 7

• Elderly patients (≥60 years): Goal relaxed from <140/90 to <150/90 mmHg 3
• Diabetic patients: Goal relaxed from <130/80 to <140/90 mmHg 3
• CKD patients: Goal relaxed from <130/80 to <140/90 mmHg 3
• Beta-blockers: No longer recommended as first-line for uncomplicated hypertension 1
• Treatment thresholds = treatment goals: Simplified to avoid confusion 3