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Editor's Note: This Article Review was written while JoAnne M. Foody, MD, FACC was employed at Brigham and Women's Hospital. Her disclosures were updated at the time of submission.
Commentary based on Krakoff LR, Gillespie RL, Ferdinand KC, et al. 2014 hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations. J Am Coll Cardiol 2014;64:394-402.

Background and Objective

A report from panel members appointed to the Eight Joint National Committee (JNC 8) recommended a major paradigm shift in blood pressure (BP) control targets, with goals of systolic BP (SBP) ≤150 mm Hg for adults over 60 years of age. These guidelines may disproportionately impact the black population and women. This report, therefore, sought to provide expert opinion from two writing groups outlining criticisms to the guidelines.

Methods

The state-of-the art manuscript is divided into three sections – an introduction and historical perspective on hypertension guideline reports, a report from the Association of Black Cardiologists (ABC) and clinical specialists in the treatment of hypertension in black patients, and a report from the Working Group on Women's Cardiovascular Health.

Results

The first section of the paper discusses the evidence that the JNC 8 used to make its recommendations and describes ongoing trials in patients over 60 years of age without diabetes or chronic kidney disease (CKD). In the second section of the paper, the ABC outlines the criticisms of the JNC 8, citing that evidence used in formulating the recommendations are flawed by the inclusion of highly selected clinical trials, which are not representative of broader populations and may in fact lead to under-treatment of hypertension in certain populations. Similarly, the Working Group on Women's Cardiovascular Health highlight that since women with hypertension are disproportionately represented in the ≥60 years of age group, the JNC 8 recommendations have the potential to worsen disparities, particularly among older African American women who are the highest risk for heart failure, atrial fibrillation, stroke, and CKD.

Conclusion

The authors conclude by strongly disagreeing with the JNC 8 2014 recommendations to raise the threshold to initiate pharmacologic BP treatment at SBP ≤150 mm Hg for older adults without CKD or diabetes.

Commentary/Perspective

The JNC 8 hypertension guidelines have stirred significant controversy about what constitutes ideal BP targets.¹ As outlined in this state-of-the-art paper, numerous concerns have been raised about the implications of raising the threshold for initiation of pharmacological therapies for hypertension, which may have the unintended consequence of widening health disparities by sex and race/ethnicity.²

The JNC 8 meticulously selected clinical trial evidence to formulate recommendations on hypertension treatment goals and found that there is insufficient data for stringent BP control for adults over 60 years of age without CKD or diabetes.³ Interestingly, the JNC 8 used CARDIOvascloari del Controllo della perssione Arteriosa SIStolica (Cardio-Sis), one of the large randomized control trials that included older adults, to formulate the new guidelines; this trial showed benefit for "tight" hypertension control with reductions in incidence of left ventricular hypertrophy, atrial fibrillation, and need for coronary revascularization, but was criticized for its open label design.²

With the rapidly aging U.S. population, adults over 60 years of age will comprise most of the patients we see in clinical practice and relaxing BP targets may lead to an increased incidence of heart failure, atrial fibrillation, stroke, and CKD. Most cardiovascular events occur in older adults who are at the highest risk of events, even if they don't suffer from CKD or diabetes. This would shift primary prevention strategies toward secondary prevention, essentially reversing large public health gains made in recent decades. Importantly, hypertension and its sequelae disproportionately affect members of racial and ethnic minority groups and women. For example, rates of hypertension-related end-stage renal disease (ESRD) are approximately 4.2 times higher among African Americans.⁴

Instead, the authors of this Expert Analysis article recommend a personalized approach to hypertension management. For most adults over 60 years of age without concerns for frailty or polypharmacy, we recommend continued lifestyle and pharmacological BP control strategies for a goal SBP <140 mm Hg as highlighted by the recommendations from other leading major guidelines and reports.^5,6 There is certainly no evidence to de-escalate existing treatment for patients who are stable on current therapies based on JNC 8 guidelines, as there is no definitive clinical trial data to suggest that the benefits of lenient BP control outweigh the risks.

Finally, because women, minorities, and the elderly have been largely underrepresented in clinical trials,^7,8 it is problematic to extrapolate data from existing trials for all patient groups. Ongoing clinical trials investigating optimal BP targets for older adults without CKD or diabetes should make special efforts to recruit diverse populations of women and minorities.

Risk factor control remains the cornerstone of cardiovascular disease (CVD) prevention and lessening hypertension control, a major modifiable risk factor, may reverse declining trends in CVD morbidity and mortality.

References

1. Wright Jr JT, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med 2014;160:499-503.
2. Krakoff LR, Gillespie RL, Ferdinand KC, et al. 2014 hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations. J Am Coll Cardiol 2014;64:394-402.
3. James PA, Oparil S, Carter BL, 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). JAMA 2014;311:507-20.
4. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics--2014 update: a report from the american heart association. Circulation 2014;129:399-410.
5. Go AS, Bauman M, Coleman King SM, et al. An effective approach to high blood pressure control A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol 2014;63:1230-8.
6. Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension 2010;56:780-800.
7. Peterson ED, Lytle BL, Biswas MS, Coombs L. Willingness to participate in cardiac trials. Am J Geriatr Cardiol 2004;13:11-5.
8. The Society for Women's Health Research, United States Food and Drug Administration Office of Women's Health. Dialogues on Diversifying Clinical Trials: Successful Strategies for Engaging Women and Minorities in Clinical Trials (FDA website). 2011. Available at: http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/WomensHealthResearch/UCM334959.pdf. Accessed 1/5/15.

Keywords: African Americans, Aged, Blood Pressure, Diabetes Mellitus, Disease Management, Expert Testimony, Hypertension, Incidence, Kidney Failure, Chronic, Life Style, Minority Groups, Polypharmacy, Primary Prevention, Public Health, Renal Insufficiency, Chronic, Secondary Prevention, Aneurysm

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