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Guidelines: Hypertension Prevention and Management -- JNC 7

JNC 7 simplifies classification of blood-pressure levels to encourage guideline implementation.

Sponsoring Organization: National High Blood Pressure Education Program Coordinating Committee of the National Heart, Lung, and Blood Institute

Purpose: Since JNC 6 (1997), important new evidence has emerged from observational and clinical trials of hypertension management. The vision of JNC 7 is not only to synthesize this evidence, but also specifically to simplify classification of blood-pressure levels to maximize guideline implementation.

Key Points:

1. For patients 50 and older, elevated systolic BP is a better indicator of cardiovascular risk than elevated diastolic BP.

2. Normal BP is defined as SBP <120 mm Hg and DBP <80 mm Hg.

3. Within the BP range of 115/75 to 185/115 mm Hg, each increment of 20/10 mm Hg doubles cardiovascular risk.

4. SBP of 120-139 mm Hg or DBP of 80-89 mm Hg is defined as prehypertension. The authors recommend lifestyle modification for all patients with prehypertension and drug therapy only for prehypertensive patients with "compelling indications" (heart failure, prior MI, high CHD risk, diabetes, chronic kidney disease, prevention of recurrent stroke).

5. For patients with hypertension, the BP-control target is <140/<90 mm Hg, except in patients with diabetes or renal disease, whose target is <130/<80 mm Hg.

6. Hypertension prevention and treatment should begin with multiple lifestyle modifications, including use of a DASH-type diet.

7. The authors take the position that thiazide-type diuretics -- either alone or in combination with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, or calcium-channel blockers -- should be initial drug therapy for most patients with uncomplicated hypertension (an independent, accompanying meta-analysis of first-line antihypertensive drugs supports this position). The guideline authors recommend that hypertensive patients with compelling indications (listed in Key Point 4) start with another drug class, specific to the compelling condition.

8. Most hypertensive patients will require at least 2 BP-lowering medications to achieve BP goals. If a patient is more than 20/10 mm Hg above goal, the authors recommend that clinicians consider initiating therapy with 2 drugs.

9. Because adherence to antihypertensive treatment is generally poor, a clearly articulated, patient-centered BP-control approach with diligent monitoring is important.

Comment: These guidelines broaden the target population for hypertension control by emphasizing that even slightly elevated BP increases cardiovascular risk. Notably, the low-end threshold for "prehypertension" (120/80 mm Hg) is lower than for the previous designation of high-normal BP. However, bringing already hypertensive patients below 140/90 mm Hg is still a worthy and formidable goal. The guideline authors recommend diuretics as first-line therapy for most patients with uncomplicated hypertension. For most patients cared for by cardiologists, however, the additional cardiovascular benefits of ACE inhibitors and beta-blockers continue to make these attractive first-line antihypertensive therapies. Unlike JNC 6, JNC 7 does not advocate global risk assessment to guide therapy, but treatment still should be tailored to an individual's risk profile. As an editorialist notes, despite an extensive history of JNC guidelines, hypertension awareness and control in the U.S. remain poor. There is much yet to accomplish with these new recommendations as a guide.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology June 13, 2003

Citation(s):

Chobanian AV et al. and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003 May 21; 289:2560-72.

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• Medline abstract (Free)

Psaty BM et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: A network meta-analysis. JAMA 2003 May 21; 289:2534-44.

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• Medline abstract (Free)

Kottke TE et al. JNC 7 -- It's more than high blood pressure. JAMA 2003 May 21; 289:2573-5.

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• Medline abstract (Free)