What are the JNC (Joint National Committee) guidelines for managing hypertension in adults with elevated blood pressure?

JNC Guidelines for Hypertension Management in Adults

Current Guideline Status

The Joint National Committee (JNC) series has been superseded by the 2017 ACC/AHA Hypertension Guideline, which represents the current standard of care and updates all prior JNC reports including JNC 7 (2003) and JNC 8 (2014). 1

Blood Pressure Classification (2017 ACC/AHA - Current Standard)

The current classification system differs substantially from historical JNC reports:

• Normal BP: <120/<80 mm Hg 1, 2
• Elevated BP: 120-129/<80 mm Hg 1, 2
• Stage 1 Hypertension: 130-139/80-89 mm Hg 1, 2
• Stage 2 Hypertension: ≥140/≥90 mm Hg 1, 2

This represents a significant departure from JNC 7, which defined hypertension as ≥140/90 mm Hg and included a "prehypertension" category at 120-139/80-89 mm Hg. 2, 3

Cardiovascular Risk Gradient

The relationship between BP and cardiovascular disease is continuous and progressive, with risk doubling for every 20 mm Hg systolic or 10 mm Hg diastolic increase starting at 115/75 mm Hg. 1, 2, 3

• At elevated BP (120-129/<80 mm Hg): hazard ratios for coronary heart disease and stroke are 1.1-1.5 times higher than normal BP 1, 2
• At Stage 1 hypertension (130-139/80-89 mm Hg): risk increases to 1.5-2.0 times baseline 1, 2

Treatment Initiation Strategy

Stage 1 Hypertension (130-139/80-89 mm Hg)

For low-risk patients (10-year ASCVD risk <10%): Start lifestyle modifications alone, with drug therapy only if BP remains ≥140/90 mm Hg after 3-6 months 2

For high-risk patients (10-year ASCVD risk ≥10%, known CVD, diabetes, or chronic kidney disease): Immediately initiate lifestyle modifications PLUS single antihypertensive agent 2

Stage 2 Hypertension (≥140/≥90 mm Hg)

Immediately initiate both nonpharmacologic therapy AND antihypertensive medications, typically starting with 2 agents of different classes. 2, 4

Blood Pressure Treatment Goals

The target BP for most patients is <130/80 mm Hg. 2, 4

• For patients ≥65 years: target systolic BP <130 mm Hg with no specific diastolic target 2
• For patients with diabetes or chronic kidney disease: <130/80 mm Hg 2, 4
• A minimum acceptable control threshold is <150/90 mm Hg for elderly patients with significant comorbidities 2

First-Line Pharmacologic Agents

For the general non-black population: Thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, or ARBs 4, 3

For black patients: Thiazide-type diuretic or CCB as initial therapy (ACE inhibitors are less effective as monotherapy in this population) 4

For patients with chronic kidney disease: ACE inhibitor or ARB should be included in the regimen, regardless of race 4

For resistant hypertension: Spironolactone is the preferred first-line agent if not contraindicated 2

Lifestyle Modifications (Essential at All Stages)

Weight reduction: Target BMI 18.5-24.9 kg/m² and waist circumference <102 cm for men, <88 cm for women 4

DASH eating plan: Diet rich in fruits, vegetables, low-fat dairy products, whole grains, and reduced saturated fat 4, 5

Sodium restriction: <2,400 mg per day, with further reduction to 1,500 mg/day desirable 4, 5

Physical activity: 30-60 minutes of moderate-intensity aerobic exercise 4-7 days per week 4, 5

Alcohol limitation: ≤2 drinks per day for men, ≤1 drink per day for women 4, 5

Smoking cessation: Mandatory for all patients 4

Diagnostic Confirmation Requirements

Hypertension diagnosis must be based on an average of ≥2 readings obtained on ≥2 separate occasions. 2, 6

Proper measurement technique requires:

• Patient seated quietly for ≥5 minutes with back supported
• Feet flat on floor, arm at heart level
• Proper cuff size on bare arm
• No conversation and empty bladder 2

Out-of-office BP monitoring (ambulatory or home BP monitoring) should be used to confirm diagnosis and detect white coat hypertension or masked hypertension before initiating treatment. 2

Follow-Up and Monitoring

Monthly follow-up is required for adults initiating new or adjusted antihypertensive therapy until BP control is achieved. 2

Systematic use of home BP monitoring is recommended as a useful adjunct to improve BP control. 2

Critical Pitfalls to Avoid

Combined use of ACE inhibitors and ARBs is contraindicated due to increased risk of hyperkalemia and acute kidney injury 4

Single-visit BP measurements overestimate hypertension prevalence compared to averages from ≥2 visits, yet this practice remains common 1

The decline in BP control rates from 72.2% in 2013-2014 to 64.8% in 2017-2018 suggests implementation gaps that must be addressed through team-based care and telehealth strategies 1, 2