Hyper Tension: the JNC 8 Controversy

If I were not in practice, I might have time to carefully read the entire Eighth Joint National Committee Report on the management of high blood pressure in adults, the other competing guidelines, and the numerous criticisms and critiques of these guidelines. I’ve read the summaries and a few of the critiques. What I’ve learned is that there is intense argument about the science, the analysis, the politics, and conflicts of interest in the writing of these guidelines.

If experts who spend their careers studying hypertension cannot agree on the best management for hypertension, where does that leave practicing clinicians? 

Understand that the evidence and guidelines will never be perfect. It’s so easy to forget that medicine is a science and an art. Physicians should do what excellent physicians have always done: exercise prudence. Strive to balance the scientific evidence and expert opinion with one’s own experience, never forgetting to include the patient in the conversation about what should be done. 

A recent issue of JAMA provides a nice, 13 page summary of JNC 8.¹ For those looking for a summary of the summary, see the box on page 511 where 9 recommendations are stated. Only 2 of the 9 recommendations are Grade A (high certainty based on evidence that net benefit is substantial):

1. for patients > 60 years old, initiate pharmacologic treatment for blood pressure >150/90.
2. for patients aged 30-59,  initiate pharmacologic treatment for diastolic blood pressure > 90.

Finally, don’t forget the importance of a healthy diet, exercise, and weight loss. Paying greater attention to these things may decrease the need for medications- and the need for a JNC 9!

–Dean Gianakos MD FACP

Reference:

1. James, PA, et al. 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults.  JAMA.  2014; 311(5):507-520.