The Clinical Core of the JNC 8 Hypertension Guidelines

The latest Joint National Committee guidelines (JNC 8) are based on 27 large clinical trials concerning hypertension management. These trials are often discussed in isolation, but their data have never been aggregated into a single source.

Now, Pharmacy Times is providing the rationale behind the JNC 8 recommendations in the context of these clinical trials.

Why does the JNC 8 recommend a more relaxed blood pressure (BP) goal for patients older than 60 years?

Many health care professionals are baffled by the JNC 8 recommendation to relax BP goals in older patients, but the reasoning behind it was derived from several clinical trials, including:

• JATOS: In patients aged 65 to 85 years, intensive treatment to a goal systolic blood pressure (SBP) <140 mm Hg (BP 136/75 mm Hg) produced no better cardiovascular outcomes than treatment to a goal SBP ≥140 mm Hg and <150 mm Hg (BP 146/78 mm Hg).

Why does the JNC 8 recommend BP reduction therapy starting at a diastolic blood pressure (DBP) >90 mm Hg and treating to <90 mm Hg in patients younger than 60 years?

The JNC 8 panel officially stated that this recommendation was based on expert opinion, but several studies it cited provide rationale for this practice. For instance:

• In VA Cooperative, one of the earliest trials in hypertension, relatively young patients (median age of 48 to 49 years) who achieved DBP <90 mm Hg were less likely to experience morbid events.

Why does the JNC 8 recommend antihypertensive treatment starting at 140/90 mm Hg and treating to <140/90 mm Hg in adult patients with chronic kidney disease?

This recommendation is based on findings from the Collaborative, Collaborative 2, REIN-2, MDRD, RENAAL, and AASK trials:

• Collaborative, Collaborative 2, and RENAAL showed benefits of ACEIs and angiotensin II receptor blockers (ARBs) in slowing nephropathy in patients with diabetes and kidney damage.

Why does JNC 8 recommend antihypertensive treatment starting at a BP of 140/90 mm Hg and treating to <140/90 mm Hg in adult patients with diabetes?

This recommendation was based on results from SHEP, Syst-Eur, UKPDS, and ACCORD:

• In SHEP, patients aged 60 years or older who achieved an average BP of 143/68 mm Hg had lower stroke rates than those who achieved an average BP of 155/72 mm Hg. The cardiovascular event rate reduction was 51 per 1000 person-years in all patients, and 101 per 1000 person-years in patients with type 2 diabetes.

Why does JNC 8 recommend combinations of thiazides, CCBs, and ACEIs or ARBs (but not both together) as the mainline strategy for BP reduction?

Thiazide-type diuretics still have the best evidence of efficacy in patients with hypertension. In fact, thiazides were the basis of therapy in HYVET (indapamide), ANBP (chlorothiazide), MRC (bendrofluazide), SHEP (chlorthalidone), VA Cooperative (hydrochlorothiazide), Hypertension-Stroke Cooperative (methyclothiazide), ADVANCE (indapamide), and an arm of ALLHAT (chlorthalidone).

Why doesn’t the JNC 8 recommend the use of ACEIs as first-line treatment in patients of African descent, favoring thiazides and CCBs instead?

A subgroup analysis of ALLHAT found that patients of African descent had a 40% higher rate of stroke when treated with ACEIs than similar patients treated with CCBs or thiazides. It is important to remember that patients of African descent can still benefit from ACEIs if they have diabetes with proteinuria, as shown in the AASK trial. However, ACEIs in this population may be better as an add-on agent than as a first-line therapy.

To see all of the clinical trials and further commentary, see the original article from Pharmacy Times by clicking here.