By Paul Goldfinger, MD, FACC
You should understand that these JNC 8 (Joint National Commission) guidelines were first published in 1972, and “since then the incidence of strokes has fallen by 70%, and heart failure rates have fallen more than 50%” (Source: NY Times, Gina Kolata 12/18/13)
Most doctors will follow these recommendations, but the JNC stresses the importance of making individualized decisions when treating patients. Such flexibility is essential for excellent quality care.
There are two central issues at play in the field of hypertension. The first is, “What is the definition of hypertension?” The second is, “What is the correct way to treat hypertension?”
There has been no fundamental change in the definition of hypertension in 30 years including the current guidelines. Anyone who has a persistent BP reading of over 140/90 is diagnosed as being hypertensive. Sometimes a patient may only have high systolic (the top number) readings or just high diastolic (bottom number) readings, but in such instances, those patients are also considered to have hypertension.
The diagnosis of hypertension should not be made from just a few BP measurements. Especially unreliable are isolated readings in a doctor’s office. In my practice, I would insist on multiple home readings taken at various times of the day, in various circumstances, and with written documentation. A very good test for diagnosis is a 24-hour ambulatory BP monitor, but insurance companies often will not reimburse for that expense. (about $225.00 ) Sometimes it’s good to get a test anyhow and pay for it yourself.
The JNC 8 report represents the first change in ten years regarding guidelines for physicians as to when and how to treat high blood pressure. This group has its origins at the National Institutes of Health, and it uses evidence derived from RCT’s (randomized clinical trials.) This commission, comprised of experts, took five years of study before coming up with this result.
The actual document is quite complicated. But the most important point is that treatment should be started for anyone over age 60 who has a blood pressure exceeding 150/90. The cutoff used to be 140/90, but the commission decided to be less strict on the systolic number based on the studies.
For those under age 60, 140/90 is still the cutoff number, although the evidence regarding how to treat young hypertensives is less compelling. Unlike the prior recommendations, lower goals for diabetics and with chronic kidney diseases are no longer recommended.
Some of you may have heard from your doctors that your BP should be 120/80 in order to maximize risk reduction, but that concept has been rejected by JNC 8 because it is unproven.
Your doctor may choose to treat your hypertension with non-pharmacologic “life style treatments” that include diet (including salt restriction*,) weight control and exercise. Those treatments should be adopted by anyone with high blood pressure, but there is no strong evidence that they alone can reduce the risk of complications. In addition, life style approaches can be tried without drugs, but only in the mildest cases. If someone has moderate or high readings, there should be no delay in initiating drugs.
The guidelines are very specific regarding which drugs are used, and it is common for patients to require multiple medications in order to keep doses and side effects down.
In our part IV installment, I will share some of the insights and ideas that I have followed after 30 years in practice and which pretty much fall in to the realm of “the art of medicine.” Patients need to know that many decisions which doctors face must be made using sound judgment, experience, collaboration with colleagues, and clinical studies which do not rise to the lofty category of RCT’s.
* Blogfinger article earlier this year about saving lives with salt restriction: