What are the JNC (Joint National Committee) 8 guidelines for managing hypertension in adults, particularly those with chronic kidney disease or diabetes?

JNC 8 Hypertension Guidelines

The JNC 8 guidelines recommend a blood pressure goal of <150/90 mmHg for adults ≥60 years old, <140/90 mmHg for adults <60 years old, and <140/90 mmHg for all patients with diabetes or chronic kidney disease, regardless of age. 1, 2

Blood Pressure Treatment Targets

General Population

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

Patients with Diabetes

• All ages with diabetes: Target BP <140/90 mmHg 3, 1
• This represents a less stringent target compared to JNC 7, which recommended <130/80 mmHg 3, 4
• The change was based on the ACCORD trial showing no additional benefit of lowering SBP <130 mmHg 3

Patients with Chronic Kidney Disease (CKD)

• All ages with CKD: Target BP <140/90 mmHg 3, 1
• No differentiation by proteinuria level in JNC 8 recommendations 3
• This differs from earlier guidelines that recommended <130/80 mmHg for CKD patients 3, 4

First-Line Pharmacological Treatment

General Non-Black Population

Initiate treatment with any of four drug classes: 1, 2

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

Black Patients (Without CKD)

Initial therapy should be: 3, 1, 2

• Thiazide-type diuretic, OR
• Calcium channel blocker
• Do not use ACEI or ARB as first-line in this population due to reduced effectiveness 3

Patients with CKD

An ACEI or ARB should be included in the regimen: 3, 1, 2

• Does not need to be the initial agent unless BP is controlled with a single drug and proteinuria is present 3
• Applies to all patients with CKD regardless of race 3

Key Simplifications from JNC 7

Treatment thresholds equal treatment goals to avoid confusion 3, 5

• If you start treatment at 150/90 mmHg in a patient ≥60 years, the goal is also <150/90 mmHg 3

Fewer drug class recommendations based on comorbidities: 3, 5

• Treatment goals are largely similar whether patients have "complicated" versus "uncomplicated" hypertension 3
• Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension 1

Critical Pitfalls to Avoid

Never combine ACEI + ARB in the same patient—this provides no additional benefit and increases harm 1, 5

Do not stop medications simply because BP falls below target if the patient tolerates them well without adverse effects 3, 1

In black patients with CKD: If BP is controlled with a single agent, use ACEI or ARB as initial therapy only if proteinuria is present 3

ACEI and ARB are absolutely contraindicated in pregnancy 1

Important Controversy

The relaxed BP goal of <150/90 mmHg for adults ≥60 years generated significant controversy within the JNC 8 panel itself: 3, 5, 6

• A minority group argued this less stringent target could increase CVD prevalence in the USA 3
• The minority recommended the higher BP target only for those >80 years, aligning with most international guidelines 3
• Multiple other guidelines (ESH/ESC, Canadian, NICE) define "elderly" as ≥80 years, not ≥60 years 3

Comparison with Newer Evidence

Note: Subsequent guidelines (2017 ACC/AHA) recommend more intensive BP targets (<130/80 mmHg for most adults), particularly after the SPRINT trial 3. However, JNC 8 remains the most recent Joint National Committee guideline and represents the evidence-based approach as of 2014 2.