Jnc 8

2014 Evidence-Based Guideline for
the Management of High Blood
Pressure in Adults
Report From the Panel Members Appointed
to the Eighth Joint National Committee (JNC 8)
Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD;
Cheryl Dennison-Himmelfarb, 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

• Hypertension is the most common condition seen in primary care and leads to
myocardial infarction, stroke, renal failure, and death if not detected early and
treated appropriately.
• Patients want to be assured that blood pressure (BP) treatment will reduce their
disease burden, while clinicians want guidance on hypertension management using
the best scientific evidence.
• This report takes a rigorous, evidence-based approach to recommend treatment
thresholds, goals, and medications in the management of hypertension in adults.
• Evidence was drawn from randomized controlled trials, which represent the gold
standard for determining efficacy and effectiveness.
• Evidence quality and recommendations were graded based on their effect on
important outcomes.

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?

Recommendation 1
• In the general population aged 60 years or older, initiate
pharmacologic treatment to lower BP at systolic blood pressure (SBP)
of 150 mm Hg or higher or diastolic blood pressure (DBP) of 90 mm
Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal
DBP lower than 90 mm Hg.
• Strong Recommendation – Grade A
• Corollary Recommendation
• In the general population aged 60 years or older, if pharmacologic
treatment for high BP results in lower achieved SBP (for example,
<140 mm Hg) and treatment is not associated with adverse effects
on health or quality of life, treatment does not need to be adjusted.
Expert Opinion – Grade E

• There is moderate to high quality evidence from
RCTs that in the general population aged 60 years
or older, treating high BP to a goal of lower than
150/90 mm Hg reduces stroke, heart failure, and
coronary heart disease (CHD).
• There is also evidence (albeit low quality) that
setting a goal SBP of lower than 140 mm Hg in this
age group provides no additional benefit compared
with a higher goal SBP of 140 to 160 mm Hg or 140
to 149 mm Hg

• The corollary to recommendation 1 reflects that
there are many treated hypertensive patients aged
60 years or older in whom SBP is currently lower
than 140 mm Hg, based on implementation of
previous guideline recommendations. The panel’s
opinion is that in these patients, it is not necessary
to adjust medication to allow BP to increase

Recommendation 2
• In the general population younger than 60 years,
initiate pharmacologic treatment to lower BP at DBP
of 90 mm Hg or higher and treat to a goal DBP of
lower than 90 mm Hg.
For ages 30 through 59 years, Strong
Recommendation – Grade A For ages 18 through
29 years, Expert Opinion – Grade E

• Initiation of antihypertensive treatment at a DBP threshold of
90 mm Hg or higher and treatment to a DBP goal of lower
than 90 mm Hg reduces cerebrovascular events, heart
failure, and overall mortality
• In further support for a DBP goal of lower than 90 mm Hg,
the panel found evidence that there is no benefit in treating
patients to a goal of either 80 mm Hg or lower or 85 mm Hg
or lower compared with 90 mm Hg or lower based on the
HOT trial, in which patients were randomized to these 3
goals without statistically significant differences between
treatment groups in the primary or secondary outcomes

• In adults younger than 30 years, there are no good-
or fair quality RCTs that assessed the benefits of
treating elevated DBP on health outcomes.
• In the absence of such evidence, it is the panel’s
opinion that in adults younger than 30 years, the
DBP threshold and goal should be the same as in
adults 30 through 59 years of age

Recommendation 3
• In the general population younger than 60 years,
initiate pharmacologic treatment to lower BP at SBP
of 140 mm Hg or higher and treat to a goal SBP of
lower than 140 mm Hg.
Expert Opinion – Grade E

• While there is high-quality evidence to support a
specific SBP threshold and goal for persons aged 60
years or older the panel found insufficient evidence
from good- or fair-quality RCTs to support a specific
SBP threshold or goal for persons younger than 60
years.
• In the absence of such evidence, the panel
recommends an SBP treatment threshold of 140
mm Hg or higher and an SBP treatment goal of
lower than 140 mm Hg based on several factors.

• First, in the absence of any RCTs that compared the current SBP standard
of 140 mm Hg with another higher or lower standard in this age group, there
was no compelling reason to change current recommendations.
• Second, in the DBP trials that demonstrated the benefit of treating DBP to
lower than 90 mm Hg, many of the study participants who achieved DBP of
lower than 90 mm Hg were also likely to have achieved SBPs of lower than
140 mm Hg with treatment. It is not possible to determine whether the
outcome benefits in these trials were due to lowering DBP, SBP, or both.
• Third, given the recommended SBP goal of lower than 140 mm Hg in adults
with diabetes or CKD (recommendations 4 and 5), a similar SBP goal for the
general population younger than 60 years may facilitate guideline
implementation.

Recommendation 4
• In the population aged 18 years or older with CKD,
initiate pharmacologic treatment to lower BP at SBP
of 140 mm Hg or higher or DBP of 90 mm Hg or
higher and treat to goal SBP of lower than 140 mm
Hg and goal DBP lower than 90 mm Hg.
• Expert Opinion – Grade E

• Recommendation applies to individuals younger than 70
years with an estimated GFR or measured GFR less than
60 mL/min/1.73 m2 and in people of any age with
albuminuria defined as greater than 30 mg of albumin/g of
creatinine at any level of GFR.
• No benefit in mortality, or cardiovascular or
cerebrovascular health outcomes with antihypertensive
drug therapy to a lower BP goal
• Evidence of moderate quality demonstrating no benefit in
delaying renal progression by further lowering BP.

• The panel cannot make a recommendation for a BP
goal for people aged 70 years or older with GFR
less than 60 mL/min/1.73m2
• No outcome trials reviewed by the panel included
large numbers of adults older than 70 years with
CKD.
• Antihypertensive treatment should be individualized,
taking into consideration factors such as frailty,
comorbidities, and albuminuria.

Recommendation 5
• In the population aged 18 years or older with
diabetes, initiate pharmacologic treatment to lower
BP at SBP of 140 mm Hg or higher or DBP of 90
mm Hg or higher and treat to a goal SBP of lower
than 140 mm Hg and goal DBP lower than 90 mm
Hg.

• There is moderate-quality evidence from 3 trials (SHEP, Syst-Eur,
and UKPDS) that treatment to an SBP goal of lower than 150 mm
Hg improves cardiovascular and cerebrovascular health outcomes
and lowers mortality in adults with diabetes and hypertension
• The panel also recognizes that an SBP goal of lower than 130 mm
Hg is commonly recommended for adults with diabetes and
hypertension. However, this lower SBP goal is not supported by any
RCT that randomized participants into 2 or more groups in which
treatment was initiated at a lower SBP threshold than 140 mm Hg or
into treatment groups in which the SBP goal was lower than 140
mm Hg and that assessed the effects of a lower SBP threshold or
goal on important health outcomes

Recommendation 6
• In the general nonblack population, including those
with diabetes, initial antihypertensive treatment
should include a thiazide-type diuretic, calcium
channel blocker (CCB), angiotensin-converting
enzyme inhibitor (ACEI), or angiotensin receptor
blocker (ARB). Moderate Recommendation – Grade
B

• Each of the 4 drug classes recommended by the
panel in recommendation 6 yielded comparable
effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes, with one
exception: heart failure.
• Initial treatment with a thiazide-type diuretic was
more effective than a CCB or ACEI and an ACEI
was more effective than a CCB in improving heart
failure outcomes.

• The panel did not recommend β-blockers for the initial
treatment of hypertension because in one study use of β-
blockers resulted in a higher rate of the primary composite
outcome of cardiovascular death, myocardial infarction, or
stroke compared to use of an ARB, a finding that was driven
largely by an increase in stroke. In the other studies that
compared a β-blocker to the 4 recommended drug classes, the
β-blocker performed similarly to the other drugs.
• α-Blockers were not recommended as first-line therapy be-
cause in one study initial treatment with an α-blocker resulted in
worse cerebrovascular, heart failure, and combined
cardiovascular outcomes than initial treatment with a diuretic

• There were no RCTs of good or fair quality
comparing the following drug classes to the 4
recommended classes: dual α1- + β-blocking agents
(eg, carvedilol), vasodilating β-blockers (eg,
nebivolol), central α2-adrenergic agonists (eg,
clonidine), direct vasodilators (eg, hydralazine),
aldosterone receptor antagonists (eg,
spironolactone), peripherally acting adrenergic
antagonists (reserpine), and loop diuretics (eg,
furosemide). Therefore, these drug classes are not
recommended as first-line therapy.

• Recommendation also applies to those with diabetes.
• First, many people will require treatment with more than one antihypertensive drug to
achieve BP control. While this recommendation applies only to the choice of the initial
antihypertensive drug, the panel suggests that any of these 4 classes would be good
choices as add-on agents (recommendation 9).
• Second, this recommendation is specific for thiazide-type diuretics, which include
thiazide diuretics, chlorthalidone, and indapamide; it does not include loop or
potassium-sparing diuretics.
• Third, it is important that medications be dosed adequately to achieve results similar to
those seen in the RCTs (Table 4).
• Fourth, RCTs that were limited to specific nonhypertensive populations, such as those
with coronary artery disease or heart failure, were not reviewed for this
recommendation. Therefore, recommendation 6 should be applied with caution to
these populations.

Recommendation 7
• In the general black population, including those with
diabetes, initial antihypertensive treatment should
include a thiazide-type diuretic or CCB.
For general black population: Moderate
Recommendation – Grade B For black patients with
diabetes: Weak Recommendation – Grade C

Recommendation 8
• In the population aged 18 years or older with CKD
and hypertension, initial (or add-on) antihypertensive
treatment should include an ACEI or ARB to
improve kidney outcomes. This applies to all CKD
patients with hypertension regardless of race or
diabetes status. Moderate Recommendation –
Grade B

• Evidence is moderate that treatment with an ACEI or ARB improves
kidney outcomes for patients with CKD. This recommendation applies to
CKD patients with and without proteinuria, as studies using ACEIs or
ARBs showed evidence of improved kidney outcomes in both groups.
• This recommendation is based primarily on kidney outcomes because
there is less evidence favoring ACEI or ARB for cardiovascular outcomes
in patients with CKD.
• Recommendation 8 applies to adults aged 18 years or older with CKD,
but there is no evidence to support renin-angiotensin system inhibitor
treatment in those older than 75 years. Although treatment with an ACEI
or ARB may be beneficial in those older than 75 years, use of a thiazide-
type diuretic or CCB is also an option for individuals with CKD in this age
group.

Recommendation 9
• The main objective of hypertension treatment is to attain and maintain goal
BP. If goal BP is not reached within a month of treatment, increase the dose
of the initial drug or add a second drug from one of the classes in
recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). 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, add and titrate a third
drug from the list provided. Do not use an ACEI and an ARB together in the
same patient. If goal BP cannot be reached using 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.

• How should clinicians titrate and combine the drugs
recommended in this report? There were no RCTs
and thus the panel relied on expert opinion. Three
strategies (Table 5) have been used in RCTs of high
BP treatment but were not compared with each
other.

• Each strategy is an acceptable pharmacologic
treatment strategy that can be tailored based on
individual circumstances, clinician and patient
preferences, and drug tolerability. With each
strategy, clinicians should regularly assess BP,
encourage evidence-based lifestyle and adherence
interventions, and adjust treatment until goal BP is
attained and maintained.

Limitations
• This evidence-based guideline for the management of
high BP in adults is not a comprehensive guideline and
is limited in scope because of the focused evidence
review to address the 3 specific questions
• Treatment adherence and medication costs were
thought to be beyond the scope of this review, but the
panel acknowledges the importance of both issues.
• Panel relied upon RCTs alone

• Many of the reviewed studies were conducted when the
overall risk of cardiovascular morbidity and mortality was
substantially higher than it is today; therefore, effect sizes
may have been overestimated.
• In many studies focused on DBP, participants also had
elevated SBP so it was not possible to determine whether the
benefit observed in those trials arose from lowering DBP,
SBP, or both.
• The review was not designed to determine whether therapy-
associated adverse effects and harms resulted in significant
changes in important health outcomes.

• Important to note that this evidence-based guideline has not
redefined high BP, and the panel believes that the 140/90
mm Hg definition from JNC 7 remains reasonable.
• For all persons with hypertension, the potential benefits of a
healthy diet, weight control, and regular exercise cannot be
overemphasized. These lifestyle treatments have the
potential to improve BP control and even reduce medication
needs. Although the authors of this hypertension guideline
did not conduct an evidence review of lifestyle treatments in
patients taking and not taking antihypertensive medication,
they support the recommendations of the 2013 Lifestyle
Work Group.

• The recommendations from this evidence-based guideline
from panel members appointed to the Eighth Joint National
Committee (JNC 8) offer clinicians an analysis of what is
known and not known about BP treatment thresholds,
goals, and drug treatment strategies to achieve those goals
based on evidence from RCTs.
• 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.

Lifestyle Workgroup
Recommendations
• Advise adults who may benefit from blood pressure lowering to:
• 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low‐fat
dairy products, poultry, fish, legumes, non‐tropical vegetable oils and nuts; and limits intake of sweets, sugar‐
sweetened beverages and red meats.
• Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and
nutrition therapy for other medical conditions (including diabetes).
• Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the
American Heart Association Diet.
Strength: A (strong)
• 2. Lower sodium intake.
(Strong Recommendation – Grade A)
• 3. Consume no more than 2,400 mg of sodium per day and that a further reduction of sodium intake to 1,500 mg
can result in even greater reduction in blood pressure. Even without achieving these goals, reducing sodium
intake by at least 1,000 mg per day lowers blood pressure. (Moderate Recommendation – Grade B)
• 4. Combine the DASH dietary pattern with lower sodium intake. (Strong Recommendation – Grade A)

• Lifestyle Physical Activity Recommendation
1. In general, advise adults to engage in aerobic
physical activity to lower blood pressure: 3 to 4
sessions a week, lasting on average 40 minutes per
session involving moderate‐to‐vigorous intensity
physical activity.
(Moderate Recommendation – Grade B)

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