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High blood pressure (hypertension) is the leading cause of death globally and the most important modifiable risk factor for cardiovascular disease. The recent release of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults from the panel members appointed to the Eighth Joint National Committee (JNC 8) represents a much needed update for the management of ideal blood pressure in a variety of individuals based on age (18 years or older) and underlying medical condition (diabetes, chronic kidney disease [CKD], etc.).
What are the Important Questions?
#1 – When should a blood pressure medication be started?
#2 – Should blood pressure be treated and lowered to a specific target?
#3 – What is the best blood pressure medication?
It was determined that the threshold for starting a blood pressure medication (Question #1) and the specific target for an ideal blood pressure (Question #2) should be the same.
What are the Recommendations?
When to Start a Blood Pressure Medication and the Specific Treatment Target
1. 60 years old or older:
start treatment at a systolic (“top” number) or diastolic (“bottom” number) blood pressure of ≥150 / ≥90 mm Hg
treat to a blood pressure of <150 / <90 mm Hg
2. Younger than 60 years old:
start treatment at a systolic (“top” number) or diastolic (“bottom” number) blood pressure of ≥140 / ≥90 mm Hg
treat to a blood pressure of <140 / <90 mm Hg
3. 18 years old or older with diabetes or chronic kidney disease (CKD):
start treatment at a systolic (“top” number) or diastolic (“bottom” number) blood pressure of ≥140 / ≥90 mm Hg
treat to a blood pressure of <140 / <90 mm Hg
Preferred Initial Blood Pressure Medications (see medication list below*)
4. General non-black population:
a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB)
combining both an ACEI and ARB is discouraged
5. General black population:
a thiazide-type diuretic or calcium channel blocker (CCB)
6. 18 years or older with chronic kidney disease (CKD) or diabetes:
an ACEI or ARB to improve kidney function
*Thiazide-type diuretics
Chlorthalidone
Hydrochlorothiazide
Bendroflumethiazide
Indapamide
*Calcium channel blockers (CCBs)
Amlodipine
Nifedipine
Diltiazem extended release
Nitrendipine
*ACE inhibitors (ACEIs)
Benazepril
Lisinopril
Enalapril
Captopril
*Angiotensin receptor blockers (ARBs)
Losartan
Valsartan
Irbesartan
Candesartan
Eprosartan
Long-term Goal of High Blood Pressure Management
7. The purpose of high blood pressure treatment is to attain and maintain an ideal blood pressure:
if ideal blood pressure is not reached within a month of treatment, the dose of the initial medication should be increased to the maximum dose and/or a second medication class should be added
if ideal blood pressure cannot be reached with 2 medications at maximal doses, a third medication class should be added
if ideal blood pressure cannot be reached using more than 3 different classes of medications at maximal doses, then a referral to a hypertension specialist may be indicated
What is the Controversy?
The most controversial recommendations were loosening the threshold for starting a blood pressure medication in those aged 60 years and older to a systolic blood pressure (“top” number) of ≥150 mm Hg, instead of ≥140 mm Hg, and ≥140 mm Hg for those with diabetes and chronic kidney disease (CKD), instead of ≥130 mm Hg, as per previous recommendations. Multiple studies since these new recommendations have suggested worse outcomes in both cases, which is obviously concerning. Additionally, a recent study in people with type 2 diabetes showed that they are less likely to suffer from heart attacks, strokes, or early death when they take blood pressure medications—even if they don’t have high blood pressure!
Unfortunately, there is a lack of high-quality medical evidence for ideal blood pressure goals in those aged 60 years and older and many people disagree with the new recommendations. People argue that this small increase in ideal blood pressure goals may potentially increase cardiovascular disease rates in older people and result in a greater healthcare burden. However, the authors of the 2014 guidelines firmly believe, based on the current evidence, setting a goal blood pressure of <140 mm Hg in this age group provides no additional benefit and recent evidence suggests that implementation of the 2014 guidelines would be cost-effective and save lives.
What You Need To Know
1. If you are 60 years old or older without diabetes or chronic kidney disease (CKD), then your ideal blood pressure should be <150 / <90 mm Hg with or without blood pressure medications.
2. If you are under the age of 60 years or have diabetes or chronic kidney disease (CKD), then your ideal blood pressure should be <140 / <90 mm Hg with or without blood pressure medications.
3. Should you need high blood pressure medications, your physician will decide which medication(s) are right for you.
4. Timely medical management of an ideal blood pressure and follow-up within six weeks is needed to prevent risk of cardiovascular events or death.
Decisions about ideal blood pressure management should carefully consider and incorporate all the characteristics and circumstances of each individual person. For all people with high blood pressure, the benefits of a healthy diet, regular exercise, weight control, and avoidance of tobacco products cannot be overemphasized. Take control of your health!
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