Hypertension is one of the most important preventable contributors to disease and death in the United States, leading to myocardial infarction, stroke, and renal failure when it is not detected early and treated appropriately. The Eighth Joint National Committee (JNC 8) recently released evidence-based recommendations on treatment thresholds, goals, and medications in the management of hypertension in adults.
For persons 18 years or older with chronic kidney disease (CKD) or diabetes mellitus, the treatment threshold and target blood pressures are the same as those for the general population younger than 60 years (i.e., threshold systolic pressure of 140 mm Hg or threshold diastolic pressure of 90 mm Hg; target systolic pressure of less than 140 mm Hg; target diastolic pressure of less than 90 mm Hg). There is no evidence that treating patients with CKD to a lower blood pressure goal slows the progression of the disease. Similarly, there is no evidence from randomized controlled trials showing that treatment to a systolic pressure of less than 140 mm Hg improves health outcomes in adults with diabetes and hypertension.
jnc 7 guidelines for hypertension pdf download
In the general nonblack population, including those with diabetes, initial anti-hypertensive treatment should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB). In the general black population, including those with diabetes, initial treatment should include a thiazide diuretic or calcium channel blocker. If the target blood pressure is not reached within one month after initiating therapy, the dosage of the initial medication should be increased or a second medication should be added (thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB; do not combine an ACE inhibitor with an ARB). Blood pressure should be monitored and the treatment regimen adjusted until the target blood pressure is reached. A third drug should be added if necessary; however, if the target blood pressure cannot be achieved using only the drug classes listed above, antihypertensive drugs from other classes can be used (e.g., beta blockers, aldosterone antagonists). Referral to a physician with expertise in treating hypertension may be necessary for patients who do not reach the target blood pressure using these strategies.
Adults with CKD and hypertension should receive an ACE inhibitor or ARB as initial or add-on therapy, based on moderate evidence that these medications improve kidney-related outcomes in these patients.
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How Joint National Committee (JNC) 8 report is different from JNC 7? Firstly, the definitions of hypertension and pre-hypertension, which were well-defined in JNC 7 has not been addressed in JNC 8. Secondly, similar treatment goals have been defined for all hypertensive population and no distinction between uncomplicated hypertension and hypertension with comorbid conditions like diabetes or chronic kidney disease (CKD) has been made. Another difference was the choice of initial drug in patients without compelling indications. In contrast to JNC 7 where thiazides were recommended to be the initial choice in patients without compelling indications, no such recommendation has been made in JNC 8.[2]
Recommendation 9 (Grade E recommendation) addressed the broader issue of the treatment plan in a hypertensive patient according to which the main objective of hypertension treatment is to attain and maintain goal BP. As per this recommendation if goal BP is not reached within a month of treatment, the dose of the initial drug should be increased or a second drug from one of the classes in recommendation 6 should be added. The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, third drug from the list provided should be added and titrated. Recommendation says that an ACEI and an ARB should not be used together in the same patient. If goal BP is not reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP; antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.
processing.... Drugs & Diseases > Cardiology Hypertension Guidelines Updated: Nov 09, 2022 Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD more...
Share Email Print Feedback Close Facebook Twitter LinkedIn WhatsApp webmd.ads2.defineAd(id: 'ads-pos-421-sfp',pos: 421); Sections Hypertension Sections Hypertension Overview Practice Essentials
Background Pathophysiology Etiology Epidemiology Prognosis Patient Education Show All Presentation History
Physical Examination Hypertension and Cerebrovascular Disease Hypertensive Emergencies Hypertensive Heart Disease Hypertension in Pediatric Patients Hypertension in Pregnancy Primary Aldosteronism Show All DDx Workup Approach Considerations
Baseline Laboratory Evaluation Radiologic Studies Show All Treatment Approach Considerations
Nonpharmacologic Therapy Pharmacologic Therapy Management of Diabetes and Hypertension Management of Hypertensive Emergencies Management of Hypertension in Pregnancy Management of Hypertension in Pediatric Patients Management of Hypertension in the Elderly Management of Hypertension in Black Patients Management of Ocular Hypertension Management of Renovascular Hypertension Management of Resistant Hypertension Management of Pseudohypertension Management of Pheochromocytoma Management of Primary Hyperaldosteronism Interventions for Improving Blood Pressure Control Prevention Show All Guidelines Medication Medication Summary
Diuretics, Thiazide Diuretic, Potassium-Sparing Diuretics, Loop ACEIs ARBs Beta-Blockers, Beta-1 Selective Beta-Blockers, Alpha Activity Beta-Blockers, Intrinsic Sympathomimetic Vasodilators Calcium Channel Blockers Aldosterone Antagonists, Selective Alpha2-agonists, Central-acting Renin Inhibitors/Combos Alpha-Blockers, Antihypertensives Antihypertensives, Other Antihypertensive Combinations Show All Questions & Answers Media Gallery Tables References Guidelines Guidelines Summary Screening Guidelines on screening for hypertension have been issued by the following organizations:
The 2013 joint European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines recommend that ambulatory blood-pressure monitoring (ABPM) be incorporated into the assessment of cardiovascular risk factors and hypertension. [125, 126]
However, the 2017, the American College of Cardiology/American Heart Association (ACC/AHA) updated their guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults by eliminating the classification of prehypertension and dividing it into two levels [1, 2] :
A group was empaneled to write the Eighth Joint National Committee (JNC8) guideline, but this effort was discontinued by the National Heart, Lung, and Blood Institute (NHLBI). A paper was published in The Journal of the American Medical Association in 2014 that is generally referred to as 'JNC 8' but officially, there are no JNC 8 guidelines sanctioned by the NHLBI, nor has JNC 8 been endorsed by the AHA, ACC, or many other organizations that endorsed JNC7.
It should be noted that, aside from the ADA guidelines, existing guideline recommendations on target BP goals were developed prior to the Systolic Blood Pressure Intervention Trial (SPRINT) study, an NIH sponsored trial that demonstrated a 25% decrease in cardiovascular events or death with targeting a systolic BP less than 120 mm Hg versus 140 mm Hg in patients at increased cardiovascular risk. [133] These intriguing results suggest a benefit from more-intensive BP targets than are recommended in existing guidelines. However, the generalizability of the SPRINT results remain unclear. Importantly, the SPRINT trial excluded patients with diabetes mellitus or prior cerebrovascular accident. These populations have been studied previously in the ACCORD and SPS3 trials, respectively, which failed to demonstrate significant benefits to stringent BP targets of below 120-130 mm Hg. [90, 134]
A large meta-analysis of hypertension studies that tested systolic BP targets (including the SPRINT trial) demonstrated a reduction in cardiovascular outcomes and overall mortality with a systolic BP target below 130 mm Hg, although the magnitude of the benefit decreased with BP goals progressively below 150 mm Hg. [136] Future guidelines will likely incorporate the results of the SPRINT trial into target BP recommendations, which may result in lower target BPs, at least for patients with high cardiovascular risk but without diabetes or prior cerebrovascular accidents.
Many guidelines exist for the management of hypertension. Two of the most widely used recommendations are the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) [5] and annually updated guidelines from the American Diabetes Association (ADA). [71] 2ff7e9595c
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