Commentary

JNC 8: Not So Great?

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Today I’d like to talk a bit about the new national hypertension guidelines you may have heard about recently. We all have been waiting a long time for the latest set of guidelines to come out. A fair number of people have been quite disappointed with what they finally saw after the inordinately long wait. But are they really right to be unhappy? There are several important perspectives that we need to consider here. Let’s first review how we got to the present point.

The previous set of official recommendations for hypertension management was published way back in 2003. So the practice community has waited very patiently for an updated set of guidelines. The previous guidelines were known as JNC 7, referring to the seventh iteration of recommendations emanating from a group of big-time hypertension experts known as the Joint National Committee (JNC). All the JNC reports have been sponsored by the National Institutes of Health (NIH), and hence, had a high degree of visibility and credibility. However, many practitioners felt that cost considerations mitigating in favor of inexpensive drugs, such as thiazide diuretics, unfairly colored and distorted the JNC 7 recommendations.

In the interest of full disclosure, I should point out that I was one of the many Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) investigators who produced an influential study result that indeed seemed to favor diuretics over the newer and more expensive antihypertensive therapies. So JNC 7 was received with some suspicion that saving money might have taken precedence over optimal therapeutic management.

Many new studies relevant to hypertension goals and preferred antihypertensive therapies have come out in the years since JNC 7 first appeared. So there was a lot of anticipation that these more recent studies would inform and modify some of the existing JNC recommendations. This sort of speculation was all very fair and reasonable. But then something quite unanticipated happened. The JNC 8 experts met and discussed recommendations, but no guidelines emerged. Literally, years went by, and the recommendations that were expected as JNC 8 instead became known as JNC Wait and then JNC Late.

Then the NIH decided that it didn’t want to be in the guideline-issuing business any longer. The NIH outsourced its lipid guidelines, which had previously been known as the NCEP (National Cholesterol Education Panel) recommendations, to a joint committee of the American Heart Association and the American College of Cardiology. The hypertension experts who had met as the JNC 8 group were similarly cut loose from formal NIH sponsorship. This action was not because the NIH was unhappy with their work, but rather because the NIH had simply decided that it no longer wanted to sponsor any clinical recommendations of any sort.

So what to do? Having finally reached consensus after years of meetings, the JNC 8 experts found themselves without an official sponsor. So they decided to take a page from rock star Prince’s playbook, and they published their recommendations as “the Panel Members Appointed to the Eighth Joint National Committee.” This move was a bit awkward, to say the least, but it was certainly preferable to leaving the fruits of their extensive labors unavailable to the practice community.

Apart from all these distractions, what has generated the most controversy has been the actual guidelines for the management of patients with hypertension who are aged 60 years or older. This is a pretty sizable chunk of the total population with hypertension, since the prevalence of elevated blood pressure increases dramatically with age. And this is also the population whose consequences of inadequately controlled hypertension are the most severe. The majority of strokes occur in those over the age of 60, as do most of the myocardial infarctions and cases of new-onset heart failure.

This group truly has a lot at stake when it comes to hypertension control or lack thereof. And I have to tell you, it’s a group I identify with. I saw 60 in the rearview mirror several years back, and I’ve been on antihypertensive therapy since my late thirties. Consequently, I am following this discussion very closely for both professional and personal reasons.

The JNC 8 authors recommended against initiating antihypertensive therapy in patients over the age of 60 unless their blood pressure was over 150/90 mm Hg, which represents a loosening of the earlier recommendations to start drug treatment at the lower systolic level of 140 mm Hg. Also, the new goal for antihypertensive therapy in this age group is simply to achieve a systolic pressure of ≤ 150 mm Hg, instead of the previous goal of under 140 mm Hg.

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