Report from the panel members appointed to the Eighth Joint National Committee (JNC 8) 2014 evidence-based guidelines for the management of high blood pressure in adults Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; Cheryl DennisonHimmelfarb, RN, ANP, PhD; Joel Handler, MD; Daniel T. Lackland, DrPH; Michael L. LeFevre, MD, MSPH; Thomas D. MacKenzie, MD, MSPH; Olugbenga Ogedegbe, MD, MPH, MS; Sidney C. Smith Jr, MD; Laura P. Svetkey, MD, MHS; Sandra J. Taler, MD; Raymond R. Townsend, MD; Jackson T. Wright Jr, MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013. Questions guiding the JNC8 review This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management. They address thresholds, goals for pharmacologic treatment, and whether particular antihypertensive drugs or drug classes improve important health outcomes compared to others. 1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? 2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? 3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? The answers to these three questions are reflected in 9 recommendations JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013. Recommendations (1/3) Recommendation 1 BP thresholds Goals SBP ≥150 mm Hg or DBP ≥90 mm Hg SBP <150 mm Hg and DBP <90 mm Hg DBP ≥90 mm Hg DBP <90 mm Hg SBP ≥140 mm Hg SBP <140 mm Hg (Strong recommendation) General population ≥60 years Recommendation 2 (Strong recommendation) General population <60 years Recommendation 3 (Expert opinion) General population <60 years JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013. Recommendations (2/3) BP thresholds Goals SBP ≥140 mm Hg or DBP ≥90 mm Hg SBP <140 mm Hg and DBP <90 mm Hg SBP ≥140 mm Hg or DBP ≥90 mm Hg SBP <140 mm Hg and DBP <90 mm Hg Recommendation 4 (Expert opinion) Population with CKD ≥18 years CKD: chronic kidney disease Recommendation 5 (Expert opinion) Population with diabetes ≥18 years Initial treatment Recommendation 6 (Moderate recommendation) General nonblack population (with diabetes) Thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013. Recommendations (3/3) Recommendation 7 Initial treatments (Moderate recommendation) General (with diabetes) Thiazide-type diuretic, or calcium channel blocker (CCB) black population Recommendation 8 Initial or add-on treatments (Moderate recommendation) Angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) Population with CKD ≥18 years Recommendation 9 Non control strategies (Expert opinion) Goal BP not reached within a month of treatment Goal BP not reached with 2 drugs Increase the dose of the initial drug, or add a second drug (from the list provided) Add and titrate a third drug (from the list provided) Do not use an ACEI and an ARB together in the same patient JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013. Conclusions • This JNC8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from JNC 7 reasonable. • It offers clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies to achieve those goals. • However these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.