2 0 1 4 G u i d e l i n e fo r t h e

Management of High Blood

P re s s u re ( E i g h t h Jo i n t N a t i o n a l
C o m m i t t e e ) : Take-Home Messages
Umar Farooq, MD, MS*, Sunita G. Ray, MD

KEYWORDS
 JNC8  High blood pressure  Blood pressure goals  Blood pressure treatment

KEY POINTS
 For patients younger than 60 years, the goal blood pressure (BP) is less than 140/90 mm
Hg; for patients older than 60 years, the goal BP is less than 150/90 mm Hg.
 For patients with diabetes mellitus and patients with chronic kidney disease (CKD), the
goal BP is less than 140/90 mm Hg.
 In nonblack patients with or without diabetes, initial drug-class should include a thiazide-
type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhib-
itor, or angiotensin receptor blocker (ARB).
 In black patients with or without diabetes, initial drug-class should include a thiazide-type
diuretic or CCB.
 All patients with CKD should receive an ACE inhibitor or ARB as starting or add-on therapy
to improve renal outcomes.

High blood pressure (BP) is one of the most common conditions treated in primary
care settings worldwide. It is an important preventable condition that leads to
morbidity and mortality if not diagnosed timely and/or treated appropriately.1–3
The Eighth Joint National Committee (JNC 8) used rigorous evidence-based
systematic review of the literature using only randomized control trials (RCTs) to
develop evidence statements and recommendations for BP treatment.4 This
report summarizes the key recommendation made by JNC 8 for hypertension
management and also highlights important differences from the previous
recommendations.

Division of Nephrology, Penn State College of Medicine, Hershey Medical Center, 500 University
Drive, Hershey, PA 17033, USA
* Corresponding author. Division of Nephrology, Penn State College of Medicine, Hershey
Medical Center, 500 University Drive, Mail Code H040, Hershey, PA 17033.
E-mail address: ufarooq@hmc.psu.edu

Med Clin N Am - (2015) -–-

http://dx.doi.org/10.1016/j.mcna.2015.02.004 medical.theclinics.com
0025-7125/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
2 Farooq & Ray

In contrast to JNC 7 guidelines,5 the 2014 Hypertension Guidelines focus on 3

highest-ranked clinical questions related to hypertension management:
a. BP threshold at which pharmacologic therapy should be initiated
b. Specific BP goal to improve outcomes
c. Comparative benefit and harms on health outcomes using various antihypertensive
drug classes
Based on patient age, ethnicity, and comorbid conditions, the following are the
summarized recommendations from the JNC 8 for hypertension management.4

TREATMENT INITIALIZATION AND GOALS

General Population: Age 60 Years or Older
For the general population aged 60 years or older, it was recommended to start phar-
macologic treatment to lower systolic BP (SBP) less than 150 mm Hg and diastolic BP
(DBP) less than 90 mm Hg. Additionally, there was no need to adjust treatment if it
achieves lower than target SBP levels without being associated with any adverse ef-
fects or the quality of life.

General Population: Age Younger Than 60 Years

In this patient age group, pharmacologic treatment is recommended to lower DBP to
a goal of less than 90 mm Hg and SBP to a goal of less than 140 mm Hg. In age
groups of 30 to 59 years, it is even more important to control DBP to lower than
90 mm Hg.

General Population: Age 18 Years or Older with Diabetes or Chronic Kidney Disease
In this patient population, pharmacologic treatment is also recommended to lower
SBP to a goal of less than 140 mm Hg and DBP to a goal of less than 90 mm Hg.

TREATMENT DRUGS OF CHOICE

General Nonblack Population
For the general nonblack population with or without diabetes, recommended initial
drugs are the following: thiazide-type diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker
(ARB).

General Black Population

For the general black population with or without diabetes, initial antihypertensive treat-
ment should include a thiazide-type diuretic or CCB.

General Population: Age 18 Years or Older with Chronic Kidney Disease

Regardless of race or diabetes status, patients with chronic kidney disease (CKD) and
hypertension should have ACEI or ARB as initial or add-on treatment to improve kid-
ney functions.
As compared with JNC 7, the current guidelines suggest relaxation of aggressive
target BP thresholds in older patients and in patients younger than 60 with diabetes
and CKD. Another important consideration is that JNC 7 guidelines mainly defined
hypertension and prehypertension, whereas current guidelines focus more on thresh-
olds for pharmacologic treatment.
 Management of High Blood Pressure 3

The JNC 8 panel does not recommend thiazide-type diuretics as initial drug of
choice in most patients. In the general nonblack population, it recommends selection
among 4 specific classes of medication as initial drug of choice: ACEI, ARB, CCB, or
thiazide-type diuretic. For the black population, it recommends 2 medication classes
as initial drug of choice: thiazides or CCB.
The JNC 8 also recommends dosing of various antihypertensive medications
used in outcome trials and noted that the doses should be adequate to achieve
results similar to those seen in RCTs. Table 1 summarizes the recommended
doses.
It is important to note that b-blockers are no longer recommended for initial ther-
apy because they may offer less protection against stroke in one study6 and other
studies showed similar efficacy of a b-blocker compared with the other 4 recom-
mended classes of drugs. Caution should be used when applying recommenda-
tions to nonhypertensive patient populations with heart failure and coronary
artery disease, as the RCTs limited to this particular subpopulation were not
reviewed in JNC 8.
The investigators of JNC 8 noted paucity of good-quality or fair-quality RCT data
comparing the 4 recommended classes of drugs with other commonly used antihyper-
tensives. The JCN 8 panel does not recommend use of the following drug classes as

Table 1
Evidence-based dosing of medications

Target Dose in Randomized Controlled Trials

Antihypertensive Medication Initial Dose and Number of Doses per day
Angiotensin-converting enzyme inhibitors
Captopril 50 mg 150–200 mg twice a day
Enalapril 5 mg 20 mg in 1-2 doses per day
Lisinopril 10 mg 40 mg daily
Angiotensin receptor blockers
Eprosartan 400 mg 600–800 mg in 1-2 doses per day
Candesartan 4 mg 12–32 mg daily
Losartan 50 mg 100 mg in 1-2 doses per day
Valsartan 40–80 mg 160–320 mg daily
Irbesartan 75 mg 300 mg daily
Beta-blockers
Atenolol 25–50 mg 100 mg daily
Metoprolol 50 mg 100–200 mg in 1-2 doses per day
Calcium channel blockers
Amlodipine 2.5 mg 10 mg daily
Diltiazem extended release 120–180 mg 360 mg daily
Nitrendipine 10 mg 20 mg in 1-2 doses per day
Thiazide-type diuretics
Bendroflumethiazide 5 mg 10 mg daily
Chlorthalidone 12.5 mg 12.5–25 mg daily
Hydrochlorothiazide 12.5–25 mg 25–100 mg in 1-2 doses per day
Indapamide 1.25 mg 1.25–2.5 mg daily
4 Farooq & Ray

Table 2
Three suggested strategies to dose the blood pressure (BP) medications

Strategy A Maximize first medication before adding second and third from the list
(thiazide, calcium channel blocker [CCB], angiotensin-converting enzyme
inhibitor [ACEI], or angiotensin receptor blocker [ARB]). Avoid both ACEI and
ARB together. Titrate each drug to maximum recommended dose to achieve
goal BP before adding another medication.
Strategy B Add second medication before reaching maximum dose of first medication.
Titrate both drugs up to the maximum recommended doses to achieve goal
BP. If goal BP is not achieved with 2 drugs, select a third drug from the list
(thiazide, CCB, ACEI, or ARB). Titrate the third drug up to the maximum
recommended dose to achieve goal BP.
Strategy C Start with 2 medication classes separately or as fixed-dose combinations. Some
committee members recommend starting with 2 drugs when systolic BP
(SBP) is >160 mm Hg and/or diastolic BP (DBP) is >100 mm Hg, or if SBP
is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not
achieved with 2 drugs, select a third drug from the list (thiazide, CCB, ACEI, or
ARB). Titrate the third drug up to the maximum recommended dose to
achieve goal BP.

first-line therapy: dual a1-blocking 1 b-blocking agents (eg, carvedilol), direct vasodi-
lators (eg, hydralazine), central a2-adrenergic agonists (eg, clonidine), aldosterone
receptor antagonists (eg, spironolactone), adrenergic neuronal depleting agents
(reserpine), and loop diuretics (eg, furosemide).
Additionally, the JNC 8 panel also recommended 3 strategies to uptitrate the dose
of medications to achieve the sustained control of BP (Tables 2 and 3). This includes

Table 3
Strategies to dose and titrate antihypertensive drugs

A B C
Maximize first medication Add second medication before Start with 2 medication classes
before adding second. reaching maximum dose of separately or as fixed-dose
first medication. combinations.
If goal BP not achieved
 Reinforce compliance with medication and lifestyle.
 For strategies A and B, add and titrate thiazide-type diuretic or angiotensin-converting
enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) or calcium channel blocker
(CCB) (use medication class not previously selected and avoid combined use of ACEI and
ARB).
 For strategy C, titrate doses of initial medications to maximum.
If goal BP not achieved
 Reinforce compliance with medication and lifestyle.
 Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not
previously selected and avoid combined use of ACEI and ARB).
If goal BP not achieved
 Reinforce compliance with medication and lifestyle.
 Add additional medication class (eg, b-blocker, aldosterone antagonist, or others) and/or
refer to physician with expertise in hypertension management.
 Management of High Blood Pressure 5

Table 4
Summary recommendations from JNC 8

Patient Subgroup Target SBP (mm Hg) Target DBP (mm Hg)
Age 60 y <150 <90
Age <60 y <140 <90
Age >18 y with CKD <140 <90
Age >18 y with diabetes <140 <90

General population (nonblack)

 Thiazides, CCB, ACEI, or ARB initially
General population (black)
 Thiazides or CCB initially
Chronic kidney disease
 Treatment should include ACEI or ARB
Adjust therapy after 1 month if BP goal not achieved.
Do not use ACEI or ARB together.
If patients need >3 drugs, refer to hypertension specialist.

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker;

CCB, calcium channel blocker; CKD, chronic kidney disease; DBP, diastolic blood pressure; JNC 8,
Eighth Joint National Committee; SBP, systolic blood pressure.

either maximizing doses of individual drugs sequentially or combining several drug

classes at lower doses.

SUMMARY

The JNC 8 guidelines focus on the 3 highest-ranked clinical questions that include
BP thresholds for starting therapy, specific BP goals, and risks and benefits of
specific antihypertensive drugs (Table 4). Only RCT data were used and the JNC
8 panel did not include observational studies, systematic reviews, or meta-
analyses. The investigators also suggested that benefit of lowering BP to less
than 140/90 is not clear. Lifestyle modifications, such as healthy diet, regular exer-
cise, and weight control, were considered very important for all patients with hyper-
tension. These recommendations are not alternatives for clinical judgment, and
decisions about medical care must be individualized to each patient.

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6 Farooq & Ray

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