Perspective:

The following are 10 points to remember from a state-of-the-art review on implications of select recommendations from a report from panel members appointed to the Eighth Joint National Committee charged with publishing the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults:

1. The Joint National Committee 8 Panel (JNC-8P) recommended a major change by defining, for those >60 years of age, a systolic blood pressure (SBP) ≥150 mm Hg threshold for initiation of treatment and treatment goal SBP of <150 mm Hg.

2. A minority portion of the panel preferred to retain the older threshold and treatment goal of 140 mm Hg in the general hypertensive population without diabetes or chronic kidney disease (CKD), except for those >80 years of age who are frail.

3. There is paucity of large randomized, controlled trial data of higher and lower BP goals in those >60 years of age without diabetes or CKD.

4. Clinical judgment needs to be incorporated into the interpretation of the guidelines, which should not be followed as rules necessarily. Perhaps it is more reasonable to consider an optimal range for SBP (rather than a single threshold for treatment), as the authors suggest.

5. Although the past decade saw improvement in coronary heart disease and cardiovascular disease risk for whites, mean predicted risk has increased in African-Americans.

6. Accordingly, the authors of this paper write, ‘We consider it unwise to categorically and somewhat arbitrarily increase goal BP in a population of patients who are already at high risk.’ Pointing to two meta-analyses that support treating BP to a goal of <140 mm Hg, ‘stronger evidence of harm...would be needed to change the goal from this proven beneficial level.’

7. The authors write, ‘These 2014 recommendations [from JNC-8P] offer no recognition that the hypertensive population is primarily female, that older women generally have poorly controlled BP, and that approximately 40% of those with poor BP control are African-American women.’

8. There may be paucity of data from randomized controlled trials to establish optimal SBP thresholds in older people in general, and in women specifically.

9. The authors ‘strongly disagree’ with the new 2014 recommendations to raise the threshold for initiation of drug treatment and SBP goal for older persons.

10. The authors caution that JNC-8P may place high-risk older women, especially African-American women, at ‘unnecessary excess risk.’