The U.S. National Institutes of Health just published its 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, [Eighth Joint National Committee (JNC 8)]. The new guidelines offer a series of changes from JNC7 which was last issued in 2003.
The big change in the guidelines is its liberalization of the blood pressure goals and the levels at which medications are started for those over 60 years of age in the general population. Previously goals were a systolic blood pressure under 140mmHg. Now, the guidelines recommend starting pharmacological agents at systolic readings equal to or above 150mmHg and or diastolic readings equal to or above 90mmHg.
For those with diabetes who are older than 18 years of age, the JNC8 guidelines are in agreement with those recently issued by the American Diabetes Association. JNC recommends aiming for a goal blood pressure of 140mmHg systolic and 90mmHg diastolic and to use pharmacological agents if the blood pressure equals or exceeds this level.
The JNC8 based its guidelines on evidence from clinical studies showing that more stringent levels of blood pressure in older adults did not provide any clinical benefit and added to the pill burden (both increasing the possibility of drug interactions and the financial load for patients without a good clinical reason).
The report also details the approach health care providers should take to the medication management of hypertension (HTN). Four categories of HTN drugs: thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), and angiotensin receptor blocker (ARB) were determined to be of equal benefit in lowering blood pressure and can be used in any order.
For patients on one agent who are not at goal, an increase in dose or adding a second medication from any one of the four groups is recommend. Additional medications should be added until blood pressure is at goal or a patient is taking three agents and the goal blood pressure still isn’t achieved. Patients requiring more than three medications should be seen by a specialist in blood pressure management.
Not all health care providers or health care organizations are in agreement with the NIH guidelines. The American Heart Association is concerned that liberalizing the goal for those older than 60 could lead to more heart disease as the consequences of high blood pressure develop over years and the studies cited by the JNC8 were not long enough to detect the damage caused by higher blood pressure levels.
Blood pressure measures the force of the blood moving against the walls of the blood vessels. The systolic or upper number is the force of the blood when the heart pumps; the diastolic is a measure of this force when the heart is at rest. The higher the blood pressure the more work the heart has to do to pump the blood around the body. Increasing blood pressure enlarges the heart and weakens it. High blood pressure can also damage the vessels in the kidney, reducing the kidney’s ability to remove excess fluid and bodily wastes.
Preventing complications from diabetes is as easy as A, B, C. That is control your A1C, Blood pressure and Cholesterol. Watching your blood pressure is as important as getting your blood glucose under control because high blood pressure can lead to both heart and kidney disease over time. About one in three adults in the United States have high blood pressure, according to the U.S. National Heart, Lung, and Blood Institute, and two of every three persons with diabetes have hypertension.
In addition to medical management, everyone with high blood pressure should use lifestyle measures to bring their blood pressure to target. This can be done by losing weight, reducing the sodium content of your diet, increasing potassium consumption (unless restricted by your healthcare provider), exercising, moderating alcohol consumption and avoiding smoking.
If you have questions about your blood pressure goals or management, speak with your health care provider.