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What Are the Thresholds for Initiating Treatment for High Blood Pressure as Listed in the Current JNC8 Guidelines?

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A key difference among the guideline statements is in their target audiences. The primary intention of JNC 8 was to put forward strict evidence-based recommendations focusing on thresholds for defining and treating hypertension and the selection of antihypertensive drug classes. Likewise, the recent guidelines of the European Society of Hypertension and the European Society of Cardiology, although broader in scope, provided recommendations that were based on available evidence

The recent joint guidelines of ASH/ISH, although utilizing the same major sources of evidence as the JNC 8 and European publications, also considered a wider range of research articles that could support a more complete and practical guidance for practitioners in the community.

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Despite the availability of effective pharmacological treatments to aid the control of blood pressure, the global rate of uncontrolled blood pressure remains high. As such, further measures are required to improve blood pressure control. Recently, several national and international guidelines for the management of hypertension have been published. These aim to provide easily accessible information for healthcare professionals and patients to aid the diagnosis and treatment of hypertension. In this review, we have compared new and current guidelines from the American and International Societies of Hypertension; the American Heart Association, American College of Cardiology and the US Center for Disease Control and Prevention; the panel appointed to the Eighth Joint National Committee; the European Societies of Hypertension and Cardiology; the French Society of Hypertension; the Canadian Hypertension Education Program; the National Institute for Health and Clinical Excellence (UK); the Taiwan Society of Cardiology and the Chinese Hypertension League. We have identified consensus opinion regarding best practises for the management of hypertension and have highlighted any discrepancies between the recommendations. In general there is good agreement between the guidelines, however, in some areas, such as target blood pressure ranges for the elderly, further trials are required to provide sufficient high-quality evidence to form the basis of recommendations. Effective treatments to control blood pressure (BP) are available but measures need to be taken to ensure their use is maximised in the required patient groups. To achieve this, effective multifactorial programmes with strategies to manage blood pressure are being sought. As part of this programme, clear evidence-based guidelines that can be readily implemented across diverse populations are required. Indeed, clinical guidelines are considered the intersection between evidence and clinical practice to improve patients’ CV outcomes

Guidelines are required to be evidence based and identify best practises through impartial evaluation of the available data. The resulting guidelines should be simple to follow and straightforward to implement. They must provide flexible recommendations, which consider the country’s unique healthcare system, to both enable their implementation across a wide range of clinical practices and to facilitate patient specific personalisation of treatment.

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More than 2 decades have passed since the publication of the JNC 7 guidelines. In 2013, the National Heart, Lung, and Blood Institute announced that after JNC 8, it would no longer develop guidelines and would instead support the medical societies in the development of their own guidelines (Ezzati M., Vander Hoorn S., 2006). The Institute of Medicine's report “Clinical Practice Guidelines We Can Trust” outlined a pathway to guideline development that placed strong emphasis on the use of randomized clinical trials, which was the approach that this panel followed in the creation of this 2013 report. Controversy arose, especially in regard to the first recommendation in the guideline. An increase in the systolic threshold for treatment of patients older than 60 years was thought by some of the members of the committee to lack support by the available data and to result, possibly, in suboptimal treatment of patients at increased risk of cardiovascular events. The decision to increase the BP threshold arose, in part, in response to data from the VALISH and JATOS trials, 2 Japanese studies that did not show benefit when an ambitious target (BP goal of <140/90 mmHg) was compared with a milder one (BP goal of ≤150/90 mmHg). However, these studies were remarkable for low event rates, which rendered them underpowered to detect a significant difference in major endpoints. Other guidelines, such as those of the European Society of Cardiology, recommended a higher threshold for treatment (SBP ≥150/90 mmHg) of patients older than 80 years. In response to JNC 8, the American Heart Association and the American College of Cardiology, in association with the American Society of Hypertension, are in the process of producing an HTN guideline this year that will provide clinicians with another layer of information, to assist in determining optimal treatment thresholds for their patients. In tailoring medical therapy for HTN, clinicians should use their best judgment with the available evidence in determining reasonable BP goals (James P

A., Oparil S., Carter B. L., 2014). This is particularly true in the elderly (age, >60 yr), in whom issues such as cardiovascular risk, frailty, side effects, cost, and patient preference affect therapy more acutely.

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Summing up, a third drug should be added if necessary; however, if the target blood pressure cannot be achieved using only the drug classes listed above, antihypertensive drugs from other classes can be used (e.g., beta blockers, aldosterone antagonists)

Referral to a physician with expertise in treating hypertension may be necessary for patients who do not reach the target blood pressure using these strategies. Adults with CKD and hypertension should receive an ACE inhibitor or ARB as initial or add-on therapy, based on moderate evidence that these medications improve kidney-related outcomes in these patients.

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Hasan R. S., Beiser A., Seshadri S., Larson M. G., Kannel W. B., D'Agostino R. B., Levy D. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA. 2002;287(8):1003–10.

Ezzati M., Vander Hoorn S., Lopez A. D., Danaei G., Rodgers A., Mathers C. D., Murray C. J. L. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In: Lopez A. D., Mathers C. D., Ezzati M., Jamison D. T., Murray C. J. L., editors. Global burden of disease and risk factors. New York: Oxford University Press; 2006. pp. 241–396. p.

Heidenreich P. A., Trogdon J. G., Khavjou O. A., Butler J., Dracup K., Ezekowitz M. D. et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933–44.

James P. A., Oparil S., Carter B. L., Cushman W. C., Dennison-Himmelfarb C., Handler J. et al. 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)

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