HYPERTENSION IS ONE of the most common modifiable medical conditions. If not detected early and appropriately treated, it can lead to stroke, chronic kidney disease (CKD), myocardial infarction, and death.
Multiple clinical trials have demonstrated increased risk for cardiovascular disease (CVD) and overall mortality in people with uncontrolled hypertension.1,2 In 2012, CVD was the leading cause of death in the United States.3
From 2003 to 2010, the CDC estimated the overall prevalence of hypertension in U.S. adults age 18 or older as 66.9 million. Less than half (47%) reported adequately controlled BP, defined as systolic BP (SBP) less than 140 mm Hg, diastolic BP (DBP) less than 90 mm Hg, or currently using BP medication.4 Among those with hypertension, an estimated 35.8 million people had uncontrolled hypertension.3
Besides the cost to health, hypertension increases medical expenses significantly: Estimated healthcare expenditures for hypertension reach approximately $131 billion annually.3
Healthcare professionals who treat patients with hypertension had long anticipated the promulgation of updated Eighth Joint National Committee (JNC 8) guidelines, previously funded by the National Heart, Lung, and Blood Institute (NHLBI). In June 2013, the NHLBI director announced that the NHLBI would adopt a different approach and would work collaboratively with partner organizations; however, the NHLBI wouldn't be involved in directly publishing guidelines.
The JNC 8 panel members worked independently and didn't partner with other organizations, such as the American College of Cardiology (ACC) or American Heart Association (AHA).5 Unfortunately, this fragmented approach resulted in three documents published by different organizations. In December 2013, two guidelines with key differences were released: the JNC 8 guidelines for management of high BP in adults, and practice guidelines issued by the American Society of Hypertension and the International Society of Hypertension (ASH/ISH).6,7 In addition, in November 2013, the AHA, ACC, and CDC published a science advisory that incorporates principles for the development of treatment algorithms for hypertension management.8
To many clinicians, making sense of these three documents is a daunting task. This article sorts out the similarities and differences among these documents and discusses treatment implications for patients with hypertension.
Reviewing the JNC 8 guidelines
Compared with the previous (JNC 7) guidelines, the JNC 8 guidelines have a narrower focus and are mainly based on evidence obtained from randomized controlled trials. Instead of addressing the entire range of what's known about diagnosing and treating hypertension, panel members focused on three questions that guided the evidence review:
- “In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
- In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
- In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?”6
These questions form the basis for nine recommendations, which are discussed in detail and assigned a score for the strength of the recommendation and the supporting evidence.
- Grade A: a strong recommendation with a high certainty of evidence
- Grade B: implies a moderate recommendation
- Grade C: a weak recommendation
- Grade D: no benefit or the risks outweigh the benefits
- Grade E: expert opinion where the evidence is insufficient or the evidence is unclear or conflicting.6
The panel members gave a Grade A recommendation to initiate pharmacologic treatment in patients in the general population age 60 and older to lower an SBP of 150 mm Hg or higher or a DBP of 90 mm Hg or higher, and to treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. In a corollary recommendation based on expert opinion (Grade E), panel members recommend that if patients age 60 or older are tolerating pharmacologic treatment for high BP with no adverse reactions and SBP is lower (for example, less than 140 mm Hg), no adjustments in medication are necessary to allow the BP to increase. Until more research is available that identifies optimal goals for SBP for hypertensive patients, some experts recommend continuing the JNC 7 SBP goal of lower than 140 mm Hg in patients over age 60.6
The focus is on DBP for those under age 60. For patients in the general population ages 30 to 59, the guideline recommends initiating pharmacologic treatment in those with a DBP of 90 mm Hg or higher to lower DBP to a goal of less than 90 mm Hg (Grade A). Because little evidence supports treating elevated DBP in adults ages 18 to 29, the DBP threshold and goal should be the same as for adults 30 to 59 years of age (Grade E). For inpatients younger than 60, pharmacologic treatment is recommended for SBP of 140 mm Hg or higher with a goal SBP of less than 140 mm Hg (Grade E).
For patients age 18 or older with CKD or diabetes, the recommendation is to initiate pharmacologic treatment to lower SBP of 140 mm Hg or higher or DBP of 90 mm Hg or higher and treat to a goal SBP of less than 140 mm Hg and a goal DBP of less than 90 mm Hg (Grade E).
The initial antihypertensive treatment in non-Black patients, including those with diabetes, should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin II receptor blocker (ARB) (Grade B). In the general Black population, initial antihypertensive therapy should include a thiazide-type diuretic or CCB (Grade B). In the general Black population with diabetes, the recommendation of a thiazide-type diuretic or CCB is Grade C.
In all patients age 18 or older with CKD (regardless of race or diabetes status), initial or add-on therapy should include an ACEI or ARB to improve kidney outcomes (Grade B). Additional medications should be added to achieve the BP goal. Due to possible early decrease in glomerular filtration rate, hypotension, and hyperkalemia, combination therapy with an ACEI and an ARB should be avoided.6,9 Patients who can't achieve BP goals may benefit from a referral to a hypertension specialist.
Lifestyle changes, a healthy diet, weight control, and regular exercise are considered part of hypertension management. These recommendations were discussed in detail in JNC 7, so discussion of these lifestyle changes is limited in the new guidelines. As such, clinicians are referred to previous recommendations by the 2013 Lifestyle Work Group.10 The panel also reminds clinicians that the recommendations are just recommendations and are not a substitute for clinical judgment.
How ASH/ISH guidelines stack up
Compared with JNC 8, the ASH/ISH guidelines are very detailed and designed to “provide a straightforward approach to managing hypertension in the community.”7
These guidelines outline the epidemiology of hypertension and its causes, define and classify hypertension, detail patient evaluation, and discuss pharmacologic and nonpharmacologic treatment issues with special attention to the treatment of Black patients. They also address resistant hypertension, which isn't described in JNC 8, and offer a more detailed discussion of lifestyle interventions.
Under the ASH/ISH guidelines, hypertension is defined as an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher in adults ages 19 to 79. In adults age 80 or older, an SBP greater than 150 mm Hg is considered hypertension.
Patients with SBP between 120 and 139 mm Hg or DBP between 80 and 89 mm Hg can be classified as prehypertensive. These patients should be counseled about lifestyle modifications, not treated with medications. (See Helping patients take charge.)
Additional definitions are given for Stage 1 and Stage 2 hypertension. (See Classification of hypertension under the ASH/ISH guidelines.)
The panel specifies how to diagnose and evaluate patients with hypertension, including the importance of identifying other comorbidities that can influence drug therapy. The authors recommend use of automated electronic BP devices but, due to inaccuracies, don't recommend wrist cuffs and finger devices. Obtaining home BP measurements or using ambulatory BP monitoring, if available, should be considered for patients suspected of having white-coat hypertension. Blood test results that should be evaluated include electrolytes, fasting blood glucose, serum creatinine and blood urea nitrogen, lipids, liver function studies, and hemoglobin/hematocrit; urine specimens should be assessed for albuminuria and red and white blood cells. Electrocardiography is helpful to identify previous myocardial infarction, left atrial and ventricular hypertrophy, and dysrhythmias, which can also influence treatment.
The authors discuss how age, ethnicity/race, comorbidities, availability, affordability, and BP influence the choice of medications. Pharmacologic treatment should be initiated at BP greater than 140/90 mm Hg in patients ages 19 to 79 in whom lifestyle treatments haven't been effective and at BP 150/90 mm Hg or higher in patients age 80 and above. However, patients age 80 and above with diabetes or CKD should be treated if BP is greater than 140/90. An ACEI or ARB is recommended as initial therapy in non-Black patients under age 60; A CCB or thiazide diuretic is recommended for those age 60 and older. A CCB or thiazide diuretic is recommended for Black patients. Combination therapy with a CCB or thiazide diuretic and an ACEI or ARB should be initiated for all patients with BP of 160/100 mm Hg or greater (Stage 2).7
The panel discusses the various classifications of medications, including clinical benefits, monitoring for potential adverse reactions, and helpful hints for beginning these medications. It recommends adding a mineralocorticoid antagonist such as spironolactone, a beta- or alpha-blocker, a centrally acting agent, or a direct vasodilator for patients with resistant hypertension (not controlled on three drugs). If this isn't successful, secondary causes of hypertension, such as obstructive sleep apnea, aldosterone excess, or renal artery stenosis, should be considered.
AHA/ACC/CDC scientific advisory weighs in
Three organizations—the AHA, ACC, and CDC—collaborated to write a scientific advisory on effective approaches to manage hypertension in adults. This advisory is intended to complement and support clinical guidelines and “establish a common platform for the development and implementation of hypertension management algorithms tailored to different practice settings and populations.”8 The advisory serves as a call to action to improve awareness and treatment of hypertension and to increase the number of patients who achieve goals of therapy. Nurses are in an excellent position to facilitate early recognition and management of hypertension in the primary and acute care settings using validated tools, algorithms, strategies, and programs.8
The authors discuss the importance of the development, dissemination, and implementation of evidence-based algorithms. As such, eight principles for creating an effective hypertension management algorithm are recommended. Key principles include the following:
- Base algorithm components and processes on the best available science.
- Keep the format simple so updates can easily be made when better information becomes available.
- Create a feasible and easy implementation strategy.
- Include a patient version at appropriate scientific and language literacy level.
- Consider costs of diagnosis, monitoring, and treatment.
- Develop an algorithm in a format that easily adapts to a team approach to healthcare.
- Develop an algorithm in a format that can be incorporated into electronic health records for use as clinical decision support.
- Include a disclaimer to ensure that the algorithm isn't used to counter the healthcare provider's best clinical judgment.8
These eight principles help to establish a common platform to develop and implement hypertension management strategies. The advisory includes a template that outlines a general approach to develop an effective, evidence-based treatment algorithm and provides an example of such an algorithm for controlling hypertension in adults.
The overriding message is to use evidence-based treatment algorithms to get patients to their BP goals. Algorithms are available at the Million Hearts website at millionhearts.hhs.gov/resources.html.
Although the newest hypertension guidelines have some distinct differences, the main emphasis is on the identification and treatment of this common CVD. Successful hypertension management requires collaboration involving the patient, family, and healthcare team. Comprehensive hypertension management programs that coordinate care through the use of multiple resources have the potential for better overall BP control, reducing mortality and morbidity and improving cardiovascular outcomes.
Promoting health: An ongoing initiative
Healthy People is an initiative promoted by the U.S. government to improve health on a national level. First published in 1990, Healthy People guidelines are released every 10 years with goals of facilitating community collaboration and providing health-focused prevention benchmarks.11 In December 2010, Healthy People 2020 published 26 health indicators organized into 12 topics that offered measurable goals and objectives applicable at local, state, and national levels.11,12
Cardiovascular disease was the leading cause of death in the United States in 2012.3Healthy People 2020 identified heart disease and stroke as among the most pervasive and costly health issues currently affecting Americans.13 The direct and indirect costs of heart disease and stroke were estimated to be $312.6 billion in 2009.14
Healthy People 2020 guidelines identify modifiable risk factors for the prevention of heart disease and stroke, including hypertension, hypercholesterolemia, cigarette smoking, diabetes, poor diet, sedentary lifestyle, and overweight/obesity.3 Through early recognition, prevention and treatment of modifiable risk factors, healthcare providers are in an excellent position to help reduce adverse outcomes of chronic diseases, including hypertension.
Helping patients take charge7
Educate patients about these nonpharmacologic approaches to treating hypertension as recommended in the ASH/ISH guidelines:
- Weight loss. Encourage patients who are overweight or obese to lose weight, which helps to treat hypertension, diabetes, and lipid disorders. Recommend that they substitute fresh fruits and vegetables for more traditional diets and tell them that even modest weight loss is beneficial.
- Salt reduction. Reducing salt intake can reduce BP and decrease the need for medications in patients who are “salt sensitive,” which may be fairly common in Black patients. Inform patients that bread, canned goods, fast foods, pickles, soups, and processed meats may be highly salted. A related problem is that many people eat diets that are low in potassium, so teach them about sources of dietary potassium.
- Exercise. Recommend regular aerobic exercise such as walking, riding bicycles, and climbing stairs. Encourage patients to integrate regular physical activity into their daily routines.
- Alcohol consumption. Up to two drinks a day can help protect against cardiovascular events but discourage heavier consumption, which can raise BP. Women should limit alcohol intake to one drink a day.
- Cigarette smoking. Because smoking is a major cardiovascular risk factor, urge patients who smoke to break the habit.
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13. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Heart Disease and Stroke. http://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke
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