Review

Hypertension guidelines: Treat patients, not numbers

Wesam Aleyadeh, MD, Erika Hutt-Centeno, MD, Haitham M. Ahmed, MD, MPH and Nishant P. Shah, MD
Cleveland Clinic Journal of Medicine January 2019, 86 (1) 47-56; DOI: https://doi.org/10.3949/ccjm.86a.18027

Article Figures & Data

Tables

  • TABLE 1

    Blood pressure guidelines, 2003–2017

    GuidelinePublishedBlood pressure goals (mm Hg)Notes
    JNC 722003< 140/90 without comorbidity
    < 130/80 with diabetes mellitus or chronic kidney disease    		Introduced the term prehypertension
    Recommended lifestyle modifications
    ACC/AHA/CDC32014< 140/90Recommended polytherapy for stage 2 hypertension
    JNC 842014< 140/90 for < 60 years old
    < 150/90 for ≥ 60 years old    		Addressed intrapopulation variations, race, and comorbidities
    ASH/ISH62014< 140/90 for < 80 years old
    < 150/90 for ≥ 80 years old    		Lacked systematic evidence
    AHA/ACC/ASH72015< 150/90 for > 80 years old
    < 140/90 with coronary artery disease
    < 130/80 with comorbidities
    ADA82017< 140/90 for adults with diabetes mellitus
    < 130/80 for younger adults with diabetes mellitus 120–160/80–105 for pregnant patients with diabetes and preexisting hypertension
    ACP/AAFP92017< 150 systolic for ≥ 60 years old
    < 140 systolic for ≥ 60 years old with transient ischemic attack, stroke, or high cardiovascular risk
    ACC/AHA12017< 130/80 for general population, older patients (≥ 65 years old), and those with comorbiditiesLowered hypertension classification to 130/80 mm Hg

    • AAFP = American Academy of Family Physicians; ACC = American College of Cardiology; ACP = American College of Physicians; ADA = American Diabetes Association; AHA = American Heart Association; ASH = American Society of Hypertension; CDC = Centers for Disease Control and Prevention; ISH = International Society of Hypertension; JNC = Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

  • TABLE 2

    JNC 7 and JNC 8 guidelines compared

    JNC 72JNC 84
    MethodologyNonsystematic literature review by expert committeesSystematic review of randomized controlled trials
    Treatment goal (mm Hg)< 140/90 for most patients
    < 130/80 for patients with diabetes
    < 130/80 for patients with chronic kidney disease    		< 140/90 for < 60 years old
    < 150/90 for ≥ 60 years old
    Drug therapyRecommended use of 5 drug classes; thiazide diuretic for initial treatment in most casesRecommended 4 classes of drugs to be used; thiazide diuretic, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, or calcium channel blocker
    Special recommendationsHeart failure, postmyocardial infarction, high coronary disease risk, diabetes, chronic kidney disease, and recurrent stroke preventionBlack and nonblack patient groups, chronic kidney disease, and diabetes
    Lifestyle recommendationsBased on literature review and expert opinionEndorsed the evidence-based findings of the Lifestyle Work Group

    • JNC = Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

  • TABLE 3

    Important clinical trials that influenced revised blood pressure guidelines

    TrialOutcomesKey conclusions
    Systolic BP goal < 150 mm Hg
    SHEP21 (1991)Cardiovascular events: RR 0.64, 95% CI 0.50–0.82, P = .0003
    Heart failure: RR 0.51, 95% CI 0.37–0.7, P < .001
    Strokes: RR 0.64, 95% CI 0.50–0.82, P = .0003    		Hypertension treatment significantly reduced fatal and nonfatal risk of stroke in patients older than 60 with systolic BP above 160 mm Hg
    HYVET21 (2003)Stroke events: HR 0.47, 95% CI 0.24–0.93
    Stroke mortality: HR 0.57; 95% CI 0.25–1.32
    Cardiovascular mortality: HR 1.13, 95% CI 0.66–1.94
    Total mortality: HR 1.23, 95% CI 0.75–2.01    		Hypertension treatment in patients older than 80 significantly reduced fatal and nonfatal strokes but may increase stroke and cardiovascular mortality
    Systolic BP goal < 140 mm Hg
    FEVER22 (2005)Average systolic blood pressure 4.2 mm Hg lower in treated group than in placebo group
    All cardiovascular events: HR 0.73, P = .0002
    Coronary events: HR 0.68, P = .015
    Heart failure: HR 0.70, P = .26    		Hypertension treatment in Chinese participants age ≥ 50 with baseline SBP of 140–180 mm Hg produced only a modest reduction in SBP but substantially reduced cardiovascular events
    JATOS23 (2008)Standard vs intensive treatment
    SBP > 160 mm Hg SBP: 135.9 vs 145.6 mm Hg (P < .001)
    Primary end points: morbidity (P = .99), mortality (P = .81)    		A 2-year trial of intensive treatment in Japanese participants age 65 and older with hypertension (SPB > 160 mm Hg) found no significant difference between standard- and intensive-treatment groups in primary end points
    VALISH24 (2010)Strict vs moderate BP control (< 140 mm Hg vs between 140 and 150 mm Hg)
    Primary end points: cardiovascular events: HR 0.89, 95% CI 0.60–1.34
    SBP: 136.6 vs 142.0 mm Hg (P < .001)    		A 3-year trial comparing strict vs moderate treatment in reducing cardiovascular mortality and morbidity in elderly patients (ages 70–84) with hypertension (mean SBP = 169.5 mm Hg) found no significant difference between the groups in primary outcome end points

    • BP = blood pressure; CI = 95% confidence interval; FEVER = Felodipine Event Reduction Study; HYVET = Hypertension in the Very Elderly Trial; HR = hazard ratio; JATOS = Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients; RR = relative risk; SBP = systolic blood pressure; SHEP = Systolic Hypertension in the Elderly Program; VALISH = Valsartan in Elderly Isolated Systolic Hypertension study

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