Perspective:

The authors of this commentary comprise the minority of panel members of the Eighth Joint National Committee (JNC 8) who disagreed with the recommendation to increase the target systolic blood pressure (SBP) from 140 to 150 mm Hg in persons ages ≥60 years without diabetes mellitus or chronic kidney disease. In their commentary, the authors summarize the evidence and rationale for the minority opinion to maintain the SBP target of ≤140 mm Hg. Challenging the assertion that there is no qualifying evidence comparing an SBP <140 mm Hg to any other SBP goal for persons ages <60 years, the authors highlight the results of the SHEP (Systolic Hypertension in the Elderly Program) and HYVET (Hypertension in the Very Elderly) trials. These trials demonstrated that reducing SBP to approximately 140 mm Hg in older persons is associated with significant benefit without major harm. The authors also caution that reducing the intensity of antihypertensive treatment in older patients, who are perhaps at highest risk for cardiovascular disease, threatens to undermine the decline in cardiovascular disease over recent decades. The commentary is a useful articulation of the minority opinion of JNC 8 and in line with the Institute of Medicine recommendations on guideline development, which encourage ‘a description and explanation of any differences of opinions regarding the recommendation.’ On balance, the JNC 8 are evidence-based recommendations that should not supplant clinical judgment; in select older patients, a SBP target of ≤140 mm Hg may very well be more appropriate than higher-intensity antihypertensive treatment.