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

JNC Hypertension Guidelines

Blood Pressure Classification and Diagnosis

The most current JNC-based approach defines hypertension as blood pressure ≥130/80 mmHg for most adults, with treatment initiation based on cardiovascular risk stratification. 1

Key Blood Pressure Categories

• Normal: <120/<80 mmHg 2, 1
• Elevated (Prehypertension in JNC 7): 120-129/<80 mmHg or 130-139/80-89 mmHg 2, 1
• Stage 1 Hypertension: 140-159/90-99 mmHg 2
• Stage 2 Hypertension: ≥160/≥100 mmHg (JNC 7 combined former stages 2 and 3) 2

Diagnostic Requirements

• Confirm diagnosis with multiple office measurements on at least 2 separate visits, using the average of 2 or more properly measured, seated readings 2
• Validate with out-of-office monitoring (home BP or 24-hour ambulatory monitoring) before initiating treatment 1
• Measure BP in both arms at first visit; use the higher reading for classification 1
• Check standing BP in elderly patients and those with diabetes to detect orthostatic hypotension 1

Treatment Thresholds and Goals

Blood Pressure Targets by Age

For adults <60 years: Target BP <140/90 mmHg, though more recent evidence supports <130/80 mmHg for high-risk patients 2, 3, 4

For adults ≥60 years: JNC 8 recommended <150/90 mmHg, but this was controversial and later guidelines returned to <130 mmHg systolic for most patients 2, 4

For adults ≥65 years: Target systolic BP <130 mmHg if well tolerated 1

Special Populations

• Diabetes: Target <140/90 mmHg (JNC 8) or <130/80 mmHg (more recent guidelines) 3, 4
• Chronic kidney disease: Target <140/90 mmHg, with ACE inhibitor or ARB mandatory regardless of race 3, 4

Lifestyle Modifications (First-Line for All Patients)

All patients with elevated BP or hypertension must implement lifestyle changes before or alongside medications. 2, 1

Evidence-Based Interventions

• Weight reduction: Achieve BMI 18.5-24.9 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 3, 5
• Dietary sodium restriction: Reduce to <2,400 mg/day, ideally 1,500 mg/day (65-100 mmol/day) 2, 3, 5
• DASH diet: Emphasize fruits, vegetables, low-fat dairy, whole grains, reduced saturated fat 2, 3
• Potassium supplementation: Increase dietary potassium intake 2, 1
• Physical activity: 30-60 minutes of moderate-intensity aerobic exercise 4-7 days per week 3, 5
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (maximum 14/week for men, 9/week for women) 1, 3
• Smoking cessation: Mandatory for all patients 3

Expected BP Reduction

• Each lifestyle modification produces additive BP-lowering effects of 5-20 mmHg systolic 2
• Lifestyle changes enhance pharmacologic therapy efficacy 6

Pharmacological Treatment

When to Initiate Drug Therapy

Start medications immediately for:

• Stage 1 hypertension (≥140/90 mmHg) with 10-year ASCVD risk ≥10% 2, 1
• Stage 2 hypertension (≥160/100 mmHg) regardless of risk 2
• BP ≥130/80 mmHg with established cardiovascular disease, diabetes, or chronic kidney disease 1, 6

First-Line Medication Classes

The three preferred first-line agents are thiazide/thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers. 1, 6, 4

General Non-Black Population

• Initiate with thiazide diuretic (hydrochlorothiazide, chlorthalidone), ACE inhibitor (enalapril), ARB (candesartan), or calcium channel blocker (amlodipine) 3, 6, 4

Black Population

• Initiate with thiazide diuretic or calcium channel blocker (more effective than ACE inhibitors/ARBs as monotherapy) 3, 4

Chronic Kidney Disease (Any Race)

• Must include ACE inhibitor or ARB in regimen to improve kidney outcomes, especially with proteinuria 3, 4

Combination Therapy Strategy

• Most patients require ≥2 medications to achieve BP control 2
• Start combination therapy for Stage 2 hypertension or BP >20/10 mmHg above goal 2
• Simplify regimens using single-pill combinations to improve adherence 1

Critical Pitfalls to Avoid

Medication Errors

Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia, acute kidney injury, and hypotension without additional benefit 1, 3

Beta-blockers are NOT first-line therapy for uncomplicated hypertension; reserve for specific indications (heart failure, post-MI, angina) 1

Measurement Errors

• Improper BP technique (wrong cuff size, unsupported arm, talking during measurement) leads to inaccurate readings and inappropriate treatment decisions 1, 3
• Failure to confirm diagnosis with out-of-office monitoring results in overtreatment of white-coat hypertension 3

Treatment Intensity Errors

• The JNC 8 recommendation for <150/90 mmHg in adults ≥60 years was controversial and associated with subsequent decline in BP control rates from 2013-2018 2
• Undertreating high-risk patients (those with diabetes, CKD, or established CVD) by using lenient targets increases cardiovascular events 2

Risk Stratification Approach

Treatment decisions must be based on total cardiovascular risk, not BP values alone. 2

High-Risk Patients Requiring Aggressive Treatment

• Established cardiovascular disease (prior MI, stroke, heart failure) 2, 1
• Diabetes mellitus 2, 1
• Chronic kidney disease 2, 1
• 10-year ASCVD risk ≥10% 2, 1

Risk Assessment Tools

• Calculate Framingham CHD risk score to demonstrate treatment benefits to patients 2
• Assess for target organ damage (left ventricular hypertrophy, retinopathy, proteinuria, elevated creatinine) 2

Resistant Hypertension

Resistant hypertension is defined as BP remaining above goal despite three optimally dosed medications including a diuretic. 1

Management Approach

• Verify medication adherence and proper BP measurement technique 1
• Screen for secondary causes (primary aldosteronism, renal artery stenosis, obstructive sleep apnea) 1
• Refer to hypertension specialist for uncontrolled BP despite optimal therapy 1
• Consider adding spironolactone as fourth-line agent 1

Treatment Adherence Strategies

Only 44% of US adults with hypertension achieve BP control <140/90 mmHg, primarily due to poor adherence. 6

Evidence-Based Adherence Interventions

• Simplify regimens to once-daily dosing with combination pills 1
• Provide clear written and oral instructions at each visit 1
• Implement home BP monitoring to engage patients in their care 1
• Address medication side effects promptly rather than accepting non-adherence 1
• Involve family members in treatment plans 1
• Allow patients to take medications at most convenient time to establish habitual patterns 1

Long-Term Management

Hypertension treatment must be maintained lifelong, even beyond age 85 if well tolerated. 1

• Reassess BP and medication regimen at regular intervals (every 1-3 months until controlled, then every 3-6 months) 2
• Continue lifestyle modifications indefinitely as they enhance medication efficacy 2, 6
• For frail elderly patients, consider more gradual BP lowering to avoid adverse effects 1