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Special Communication | February 5, 2014

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)
FREE

Paul A. James, MD1; Suzanne Oparil, MD2; Barry L. Carter, PharmD1; William
C. Cushman, MD3; Cheryl Dennison-Himmelfarb, RN, ANP, PhD4;
Joel Handler, MD5; Daniel T. Lackland, DrPH6; Michael L. LeFevre, MD, MSPH7;
Thomas D. MacKenzie, MD, MSPH8; Olugbenga Ogedegbe, MD, MPH, MS9; Sidney
C. Smith Jr, MD10; Laura P. Svetkey, MD, MHS11; Sandra J. Taler, MD12; Raymond
R. Townsend, MD13; Jackson T. Wright Jr, MD, PhD14; Andrew S. Narva, MD15;
Eduardo Ortiz, MD, MPH16,17
1University of Iowa, Iowa City
2University of Alabama at Birmingham School of Medicine
3Memphis Veterans Affairs Medical Center and the University
of Tennessee,
Memphis
4Johns Hopkins University School of Nursing, Baltimore, Maryland
5Kaiser Permanente, Anaheim, California
6Medical University of South Carolina, Charleston
7University of Missouri, Columbia
8Denver Health and Hospital Authority and the University of Colorado

School of Medicine, Denver

9New York University School of Medicine, New York, New York
10University of North Carolina at Chapel Hill
11Duke University, Durham, North Carolina
12Mayo Clinic College of Medicine, Rochester, Minnesota
13University of Pennsylvania, Philadelphia
14Case Western Reserve University, Cleveland, Ohio

15
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15National
Institute of Diabetes and Digestive and Kidney Diseases,
Bethesda, Maryland
16at the time of the project,National Heart, Lung, and Blood Institute,
Bethesda, Maryland
17currently with ProVation Medical, Wolters Kluwer Health, Minneapolis,
Minnesota

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

ABSTRACT
Hypertension is the most common condition seen in primary care and leads
to myocardial infarction, stroke, renal failure, and death if not detected early
and treated appropriately. Patients want to be assured that blood pressure
(BP) treatment will reduce their disease burden, while clinicians want
guidance on hypertension management using the best scientific evidence.
This report takes a rigorous, evidence-based approach to recommend
treatment thresholds, goals, and medications in the management of
hypertension in adults. Evidence was drawn from randomized controlled
trials, which represent the gold standard for determining efficacy and
effectiveness. Evidence quality and recommendations were graded based
on their effect on important outcomes.

There is strong evidence to support treating hypertensive persons aged 60

years or older to a BP goal of less than 150/90 mm Hg and hypertensive
persons 30 through 59 years of age to a diastolic goal of less than 90 mm
Hg; however, there is insufficient evidence in hypertensive persons younger
than 60 years for a systolic goal, or in those younger than 30 years for a
diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg
for those groups based on expert opinion. The same thresholds and goals
are recommended for hypertensive adults with diabetes or nondiabetic
chronic kidney disease (CKD) as for the general hypertensive population

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younger than 60 years. There is moderate evidence to support initiating drug

treatment with an angiotensin-converting enzyme inhibitor, angiotensin
receptor blocker, calcium channel blocker, or thiazide-type diuretic in the
nonblack hypertensive population, including those with diabetes. In the black
hypertensive population, including those with diabetes, a calcium channel
blocker or thiazide-type diuretic is recommended as initial therapy. There is
moderate evidence to support initial or add-on antihypertensive therapy with
an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker
in persons with CKD to improve kidney outcomes.

Although this guideline provides evidence-based recommendations for the

management of high BP and should meet the clinical needs of most
patients, these recommendations are not a substitute for clinical judgment,
and decisions about care must carefully consider and incorporate the clinical
characteristics and circumstances of each individual patient.

Hypertension remains one of the most important preventable contributors to

disease and death. Abundant evidence from randomized controlled trials
(RCTs) has shown benefit of antihypertensive drug treatment in reducing
important health outcomes in persons with hypertension.1- 3 Clinical
guidelines are at the intersection between research evidence and clinical
actions that can improve patient outcomes. The Institute of Medicine Report
Clinical Practice Guidelines We Can Trust outlined a pathway to guideline
development and is the approach that this panel aspired to in the creation of
this report.4

The panel members appointed to the Eighth Joint National Committee (JNC
8) used rigorous evidence-based methods, developing Evidence Statements
and recommendations for blood pressure (BP) treatment based on a
systematic review of the literature to meet user needs, especially the needs
of the primary care clinician. This report is an executive summary of the

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evidence and is designed to provide clear recommendations for all

clinicians. Major differences from the previous JNC report are summarized in
Table 1. The complete evidence summary and detailed description of the
evidence review and methods are provided online (see Supplement).

Table 1. Comparison of Current Recommendations With JNC 7 Guidelines

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THE PROCESS
The panel members appointed to JNC 8 were selected from more than 400
nominees based on expertise in hypertension (n = 14), primary care (n = 6),
including geriatrics (n = 2), cardiology (n = 2), nephrology (n = 3), nursing (n = 
1), pharmacology (n = 2), clinical trials (n = 6), evidence-based medicine (n = 
3), epidemiology (n = 1), informatics (n = 4), and the development and
implementation of clinical guidelines in systems of care (n = 4).

The panel also included a senior scientist from the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK), a senior medical
officer from the National Heart, Lung, and Blood Institute (NHLBI), and a
senior scientist from NHLBI who withdrew from authorship prior to
publication. Two members left the panel early in the process before the
evidence review because of new job commitments that prevented them from
continuing to serve. Panel members disclosed any potential conflicts of
interest including studies evaluated in this report and relationships with
industry. Those with conflicts were allowed to participate in discussions as
long as they declared their relationships, but they recused themselves from
voting on evidence statements and recommendations relevant to their

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relationships or conflicts. Four panel members (24%) had relationships with

industry or potential conflicts to disclose at the outset of the process.

In January 2013, the guideline was submitted for external peer review by
NHLBI to 20 reviewers, all of whom had expertise in hypertension, and to 16
federal agencies. Reviewers also had expertise in cardiology, nephrology,
primary care, pharmacology, research (including clinical trials), biostatistics,
and other important related fields. Sixteen individual reviewers and 5 federal
agencies responded. Reviewers’ comments were collected, collated, and
anonymized. Comments were reviewed and discussed by the panel from
March through June 2013 and incorporated into a revised document.
(Reviewers’ comments and suggestions, and responses and disposition by
the panel are available on request from the authors.)

QUESTIONS GUIDING THE EVIDENCE

REVIEW
This evidence-based hypertension guideline focuses on the panel’s 3
highest-ranked questions related to high BP management identified through
a modified Delphi technique.5 Nine recommendations are made reflecting
these questions. These questions address thresholds and goals for
pharmacologic treatment of hypertension and whether particular
antihypertensive drugs or drug classes improve important health outcomes
compared with other drug classes.

1. In adults with hypertension, does initiating antihypertensive

pharmacologic therapy at specific BP thresholds improve health
outcomes?

2. In adults with hypertension, does treatment with antihypertensive

pharmacologic therapy to a specified BP goal lead to improvements in

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health outcomes?

3. In adults with hypertension, do various antihypertensive drugs or drug

classes differ in comparative benefits and harms on specific health
outcomes?

THE EVIDENCE REVIEW

The evidence review focused on adults aged 18 years or older with
hypertension and included studies with the following prespecified
subgroups: diabetes, coronary artery disease, peripheral artery disease,
heart failure, previous stroke, chronic kidney disease (CKD), proteinuria,
older adults, men and women, racial and ethnic groups, and smokers.
Studies with sample sizes smaller than 100 were excluded, as were studies
with a follow-up period of less than 1 year, because small studies of brief
duration are unlikely to yield enough health-related outcome information to
permit interpretation of treatment effects. Studies were included in the
evidence review only if they reported the effects of the studied interventions
on any of these important health outcomes:

Overall mortality, cardiovascular disease (CVD)–related mortality, CKD-

related mortality

Myocardial infarction, heart failure, hospitalization for heart failure,

stroke

Coronary revascularization (includes coronary artery bypass surgery,

coronary angioplasty and coronary stent placement), other
revascularization (includes carotid, renal, and lower extremity
revascularization)

End-stage renal disease (ESRD) (ie, kidney failure resulting in dialysis

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or transplantation), doubling of creatinine level, halving of glomerular

filtration rate (GFR).

The panel limited its evidence review to RCTs because they are less subject
to bias than other study designs and represent the gold standard for
determining efficacy and effectiveness.6 The studies in the evidence review
were from original publications of eligible RCTs. These studies were used to
create evidence tables and summary tables that were used by the panel for
their deliberations (see Supplement). Because the panel conducted its own
systematic review using original studies, systematic reviews and meta-
analyses of RCTs conducted and published by other groups were not
included in the formal evidence review.

Initial search dates for the literature review were January 1, 1966, through
December 31, 2009. The search strategy and PRISMA diagram for each
question is in the online Supplement. To ensure that no major relevant
studies published after December 31, 2009, were excluded from
consideration, 2 independent searches of PubMed and CINAHL between
December 2009 and August 2013 were conducted with the same MeSH
terms as the original search. Three panel members reviewed the results.
The panel limited the inclusion criteria of this second search to the following.
(1) The study was a major study in hypertension (eg, ACCORD-BP, SPS3;
however, SPS3 did not meet strict inclusion criteria because it included
nonhypertensive participants. SPS3 would not have changed our
conclusions/recommendations because the only significant finding
supporting a lower goal for BP occurred in an infrequent secondary
outcome).7,8 (2) The study had at least 2000 participants. (3) The study was
multicentered. (4) The study met all the other inclusion/exclusion criteria.
The relatively high threshold of 2000 participants was used because of the
markedly lower event rates observed in recent RCTs such as ACCORD,
suggesting that larger study populations are needed to obtain interpretable

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results. Additionally, all panel members were asked to identify newly

published studies for consideration if they met the above criteria. No
additional clinical trials met the previously described inclusion criteria.
Studies selected were rated for quality using NHLBI’s standardized quality
rating tool (see Supplement) and were only included if rated as good or fair.

An external methodology team performed the literature review, summarized

data from selected papers into evidence tables, and provided a summary of
the evidence. From this evidence review, the panel crafted evidence
statements and voted on agreement or disagreement with each statement.
For approved evidence statements, the panel then voted on the quality of
the evidence (Table 2). Once all evidence statements for each critical
question were identified, the panel reviewed the evidence statements to
craft the clinical recommendations, voting on each recommendation and on
the strength of the recommendation (Table 3). For both evidence statements
and recommendations, a record of the vote count (for, against, or recusal)
was made without attribution. The panel attempted to achieve 100%
consensus whenever possible, but a two-thirds majority was considered
acceptable, with the exception of recommendations based on expert
opinion, which required a 75% majority agreement to approve.

Table 2. Evidence Quality Rating

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Table 3. Strength of Recommendation

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RESULTS (RECOMMENDATIONS)
The following recommendations are based on the systematic evidence
review described above (Box). Recommendations 1 through 5 address
questions 1 and 2 concerning thresholds and goals for BP treatment.
Recommendations 6, 7, and 8 address question 3 concerning selection of
antihypertensive drugs. Recommendation 9 is a summary of strategies
based on expert opinion for starting and adding antihypertensive drugs. The
evidence statements supporting the recommendations are in the online
Supplement.

Box. Recommendations for Management of Hypertension

Recommendation 1
In the general population aged ≥60 years, initiate pharmacologic
treatment to lower blood pressure (BP) at systolic blood pressure (SBP)
≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a
goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong
Recommendation – Grade A)
Corollary Recommendation
In the general population aged ≥60 years, if pharmacologic treatment for
high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is
well tolerated and without adverse effects on health or quality of life,
treatment does not need to be adjusted. (Expert Opinion – Grade E)
Recommendation 2
In the general population <60 years, initiate pharmacologic treatment to
lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For
ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29
years, Expert Opinion – Grade E)

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Recommendation 3
In the general population <60 years, initiate pharmacologic treatment to
lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg.
(Expert Opinion – Grade E)
Recommendation 4
In the population aged ≥18 years with chronic kidney disease (CKD),
initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP
≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm
Hg. (Expert Opinion – Grade E)
Recommendation 5
In the population aged ≥18 years with diabetes, initiate pharmacologic
treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat
to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion –
Grade E)
Recommendation 6
In the general nonblack population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic, calcium
channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI),
or angiotensin receptor blocker (ARB). (Moderate Recommendation –
Grade B)
Recommendation 7
In the general black population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic or CCB.
(For general black population: Moderate Recommendation – Grade B; for
black patients with diabetes: Weak Recommendation – Grade C)
Recommendation 8
In the population aged ≥18 years with CKD, initial (or add-on)
antihypertensive treatment should include an ACEI or ARB to improve
kidney outcomes. This applies to all CKD patients with hypertension

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regardless of race or diabetes status. (Moderate Recommendation –

Grade B)
Recommendation 9
The main objective of hypertension treatment is to attain and maintain
goal BP. If goal BP is not reached within a month of treatment, increase
the dose of the initial drug or add a second drug from one of the classes in
recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The
clinician should continue to assess BP and adjust the treatment regimen
until goal BP is reached. If goal BP cannot be reached with 2 drugs, add
and titrate a third drug from the list provided. Do not use an ACEI and an
ARB together in the same patient. If goal BP cannot be reached using
only the drugs in recommendation 6 because of a contraindication or the
need to use more than 3 drugs to reach goal BP, antihypertensive drugs
from other classes can be used. Referral to a hypertension specialist may
be indicated for patients in whom goal BP cannot be attained using the
above strategy or for the management of complicated patients for whom
additional clinical consultation is needed. (Expert Opinion – Grade E)

In the general population aged 60 years or older, initiate pharmacologic

treatment to lower BP at systolic blood pressure (SBP) of 150 mm Hg or
higher or diastolic blood pressure (DBP) of 90 mm Hg or higher and treat to
a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg.

Strong Recommendation – Grade A

In the general population aged 60 years or older, if pharmacologic treatment

for high BP results in lower achieved SBP (for example, <140 mm Hg) and
treatment is not associated with adverse effects on health or quality of life,
treatment does not need to be adjusted.

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Expert Opinion – Grade E

Recommendation 1 is based on evidence statements 1 through 3 from

question 2 in which there is moderate- to high-quality evidence from RCTs
that in the general population aged 60 years or older, treating high BP to a
goal of lower than 150/90 mm Hg reduces stroke, heart failure, and coronary
heart disease (CHD). There is also evidence (albeit low quality) from
evidence statement 6, question 2 that setting a goal SBP of lower than 140
mm Hg in this age group provides no additional benefit compared with a
higher goal SBP of 140 to 160 mm Hg or 140 to 149 mm Hg.9,10

To answer question 2 about goal BP, the panel reviewed all RCTs that met
the eligibility criteria and that either compared treatment with a particular
goal vs no treatment or placebo or compared treatment with one BP goal
with treatment to another BP goal. The trials on which these evidence
statements and this recommendation are based include HYVET, Syst-Eur,
SHEP, JATOS, VALISH, and CARDIO-SIS.1- 3,9- 11 Strengths, limitations,
and other considerations related to this evidence review are presented in the
evidence statement narratives and clearly support the benefit of treating to a
BP lower than 150 mm Hg.

The corollary to recommendation 1 reflects that there are many treated

hypertensive patients aged 60 years or older in whom SBP is currently lower
than 140 mm Hg, based on implementation of previous guideline
recommendations.12 The panel’s opinion is that in these patients, it is not
necessary to adjust medication to allow BP to increase. In 2 of the trials that
provide evidence supporting an SBP goal lower than 150 mm Hg, the
average treated SBP was 143 to 144 mm Hg.2,3 Many participants in those
studies achieved an SBP lower than 140 mm Hg with treatment that was
generally well tolerated. Two other trials9,10 suggest there was no benefit for
an SBP goal lower than 140 mm Hg, but the confidence intervals around the

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effect sizes were wide and did not exclude the possibility of a clinically
important benefit. Therefore, the panel included a corollary recommendation
based on expert opinion that treatment for hypertension does not need to be
adjusted if treatment results in SBP lower than 140 mm Hg and is not
associated with adverse effects on health or quality of life.

While all panel members agreed that the evidence supporting

recommendation 1 is very strong, the panel was unable to reach unanimity
on the recommendation of a goal SBP of lower than 150 mm Hg. Some
members recommended continuing the JNC 7 SBP goal of lower than 140
mm Hg for individuals older than 60 years based on expert opinion.12 These
members concluded that the evidence was insufficient to raise the SBP
target from lower than 140 to lower than 150 mm Hg in high-risk groups,
such as black persons, those with CVD including stroke, and those with
multiple risk factors. The panel agreed that more research is needed to
identify optimal goals of SBP for patients with high BP.

In the general population younger than 60 years, initiate pharmacologic

treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal
DBP of lower than 90 mm Hg.

For ages 30 through 59 years, Strong Recommendation – Grade A

For ages 18 through 29 years, Expert Opinion – Grade E

Recommendation 2 is based on high-quality evidence from 5 DBP trials

(HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA
Cooperative) that demonstrate improvements in health outcomes among
adults aged 30 through 69 years with elevated BP.13- 18 Initiation of
antihypertensive treatment at a DBP threshold of 90 mm Hg or higher and
treatment to a DBP goal of lower than 90 mm Hg reduces cerebrovascular
events, heart failure, and overall mortality (question 1, evidence statements

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10, 11, 13; question 2, evidence statement 10). In further support for a DBP
goal of lower than 90 mm Hg, the panel found evidence that there is no
benefit in treating patients to a goal of either 80 mm Hg or lower or 85 mm
Hg or lower compared with 90 mm Hg or lower based on the HOT trial, in
which patients were randomized to these 3 goals without statistically
significant differences between treatment groups in the primary or secondary
outcomes (question 2, evidence statement 14).19

In adults younger than 30 years, there are no good- or fair-quality RCTs that
assessed the benefits of treating elevated DBP on health outcomes
(question 1, evidence statement 14). In the absence of such evidence, it is
the panel’s opinion that in adults younger than 30 years, the DBP threshold
and goal should be the same as in adults 30 through 59 years of age.

In the general population younger than 60 years, initiate pharmacologic

treatment to lower BP at SBP of 140 mm Hg or higher and treat to a goal
SBP of lower than 140 mm Hg.

Expert Opinion – Grade E

Recommendation 3 is based on expert opinion. While there is high-quality

evidence to support a specific SBP threshold and goal for persons aged 60
years or older (See recommendation 1), the panel found insufficient
evidence from good- or fair-quality RCTs to support a specific SBP threshold
or goal for persons younger than 60 years. In the absence of such evidence,
the panel recommends an SBP treatment threshold of 140 mm Hg or higher
and an SBP treatment goal of lower than 140 mm Hg based on several
factors.

First, in the absence of any RCTs that compared the current SBP standard
of 140 mm Hg with another higher or lower standard in this age group, there
was no compelling reason to change current recommendations. Second, in

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the DBP trials that demonstrated the benefit of treating DBP to lower than 90
mm Hg, many of the study participants who achieved DBP of lower than 90
mm Hg were also likely to have achieved SBPs of lower than 140 mm Hg
with treatment. It is not possible to determine whether the outcome benefits
in these trials were due to lowering DBP, SBP, or both. Third, given the
recommended SBP goal of lower than 140 mm Hg in adults with diabetes or
CKD (recommendations 4 and 5), a similar SBP goal for the general
population younger than 60 years may facilitate guideline implementation.

In the population aged 18 years or older with CKD, initiate pharmacologic

treatment to lower BP at SBP of 140 mm Hg or higher or DBP of 90 mm Hg
or higher and treat to goal SBP of lower than 140 mm Hg and goal DBP
lower than 90 mm Hg.

Expert Opinion – Grade E

Based on the inclusion criteria used in the RCTs reviewed by the panel, this
recommendation applies to individuals younger than 70 years with an
estimated GFR or measured GFR less than 60 mL/min/1.73 m2 and in
people of any age with albuminuria defined as greater than 30 mg of
albumin/g of creatinine at any level of GFR.

Recommendation 4 is based on evidence statements 15-17 from question 2.

In adults younger than 70 years with CKD, the evidence is insufficient to
determine if there is a benefit in mortality, or cardiovascular or
cerebrovascular health outcomes with antihypertensive drug therapy to a
lower BP goal (for example, <130/80 mm Hg) compared with a goal of lower
than 140/90 mm Hg (question 2, evidence statement 15). There is evidence
of moderate quality demonstrating no benefit in slowing the progression of
kidney disease from treatment with antihypertensive drug therapy to a lower
BP goal (for example, <130/80 mm Hg) compared with a goal of lower than
140/90 mm Hg (question 2, evidence statement 16).
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Three trials that met our criteria for review addressed the effect of
antihypertensive drug therapy on change in GFR or time to development of
ESRD, but only one trial addressed cardiovascular disease end points.
Blood pressure goals differed across the trials, with 2 trials (AASK and
MDRD) using mean arterial pressure and different targets by age, and 1 trial
(REIN-2) using only DBP goals.20- 22 None of the trials showed that
treatment to a lower BP goal (for example, <130/80 mm Hg) significantly
lowered kidney or cardiovascular disease end points compared with a goal
of lower than 140/90 mm Hg.

For patients with proteinuria (>3 g/24 hours), post hoc analysis from only 1
study (MDRD) indicated benefit from treatment to a lower BP goal (<130/80
mm Hg), and this related to kidney outcomes only.22 Although post hoc
observational analyses of data from this trial and others suggested benefit
from the lower goal at lower levels of proteinuria, this result was not seen in
the primary analyses or in AASK or REIN-2 (question 2, evidence statement
17).20,21

Based on available evidence the panel cannot make a recommendation for

a BP goal for people aged 70 years or older with GFR less than 60
mL/min/1.73m2. The commonly used estimating equations for GFR were not
developed in populations with significant numbers of people older than 70
years and have not been validated in older adults. No outcome trials
reviewed by the panel included large numbers of adults older than 70 years
with CKD. Further, the diagnostic criteria for CKD do not consider age-
related decline in kidney function as reflected in estimated GFR. Thus, when
weighing the risks and benefits of a lower BP goal for people aged 70 years
or older with estimated GFR less than 60 mL/min/1.73m2, antihypertensive
treatment should be individualized, taking into consideration factors such as
frailty, comorbidities, and albuminuria.

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In the population aged 18 years or older with diabetes, initiate

pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher or
DBP of 90 mm Hg or higher and treat to a goal SBP of lower than 140 mm
Hg and goal DBP lower than 90 mm Hg.

Expert Opinion – Grade E

Recommendation 5 is based on evidence statements 18-21 from question 2,

which address BP goals in adults with both diabetes and hypertension.
There is moderate-quality evidence from 3 trials (SHEP, Syst-Eur, and
UKPDS) that treatment to an SBP goal of lower than 150 mm Hg improves
cardiovascular and cerebrovascular health outcomes and lowers mortality
(see question 2, evidence statement 18) in adults with diabetes and
hypertension.23- 25 No RCTs addressed whether treatment to an SBP goal
of lower than 140 mm Hg compared with a higher goal (for example, <150
mm Hg) improves health outcomes in adults with diabetes and hypertension.
In the absence of such evidence, the panel recommends an SBP goal of
lower than 140 mm Hg and a DBP goal lower than 90 mm Hg in this
population based on expert opinion, consistent with the BP goals in
recommendation 3 for the general population younger than 60 years with
hypertension. Use of a consistent BP goal in the general population younger
than 60 years and in adults with diabetes of any age may facilitate guideline
implementation. This recommendation for an SBP goal of lower than 140
mm Hg in patients with diabetes is also supported by the ACCORD-BP trial,
in which the control group used this goal and had similar outcomes
compared with a lower goal.7

The panel recognizes that the ADVANCE trial tested the effects of treatment
to lower BP on major macrovascular and microvascular events in adults with
diabetes who were at increased risk of CVD, but the study did not meet the
panel’s inclusion criteria because participants were eligible irrespective of

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baseline BP, and there were no randomized BP treatment thresholds or

goals.26

The panel also recognizes that an SBP goal of lower than 130 mm Hg is
commonly recommended for adults with diabetes and hypertension.
However, this lower SBP goal is not supported by any RCT that randomized
participants into 2 or more groups in which treatment was initiated at a lower
SBP threshold than 140 mm Hg or into treatment groups in which the SBP
goal was lower than 140 mm Hg and that assessed the effects of a lower
SBP threshold or goal on important health outcomes. The only RCT that
compared an SBP treatment goal of lower than 140 mm Hg with a lower
SBP goal and assessed the effects on important health outcomes is
ACCORD-BP, which compared an SBP treatment goal of lower than 120
mm Hg with a goal lower than 140 mm Hg.7 There was no difference in the
primary outcome, a composite of cardiovascular death, nonfatal myocardial
infarction, and nonfatal stroke. There were also no differences in any of the
secondary outcomes except for a reduction in stroke. However, the
incidence of stroke in the group treated to lower than 140 mm Hg was much
lower than expected, so the absolute difference in fatal and nonfatal stroke
between the 2 groups was only 0.21% per year. The panel concluded that
the results from ACCORD-BP did not provide sufficient evidence to
recommend an SBP goal of lower than 120 mm Hg in adults with diabetes
and hypertension.

The panel similarly recommends the same goal DBP in adults with diabetes
and hypertension as in the general population (<90 mm Hg). Despite some
existing recommendations that adults with diabetes and hypertension should
be treated to a DBP goal of lower than 80 mm Hg, the panel did not find
sufficient evidence to support such a recommendation. For example, there
are no good- or fair-quality RCTs with mortality as a primary or secondary
prespecified outcome that compared a DBP goal of lower than 90 mm Hg

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with a lower goal (evidence statement 21).

In the HOT trial, which is frequently cited to support a lower DBP goal,
investigators compared a DBP goal of 90 mm Hg or lower vs a goal of 80
mm Hg or lower.19 The lower goal was associated with a reduction in a
composite CVD outcome (question 2, evidence statement 20), but this was
a post hoc analysis of a small subgroup (8%) of the study population that
was not prespecified. As a result, the evidence was graded as low quality.

Another commonly cited study to support a lower DBP goal is UKPDS,25

which had a BP goal of lower than 150/85 mm Hg in the more-intensively
treated group compared with a goal of lower than 180/105 mm Hg in the
less-intensively treated group. UKPDS did show that treatment in the lower
goal BP group was associated with a significantly lower rate of stroke, heart
failure, diabetes-related end points, and deaths related to diabetes.
However, the comparison in UKPDS was a DBP goal of lower than 85 mm
Hg vs lower than105 mm Hg; therefore, it is not possible to determine
whether treatment to a DBP goal of lower than 85 mm Hg improves
outcomes compared with treatment to a DBP goal of lower than 90 mm Hg.
In addition, UKPDS was a mixed systolic and diastolic BP goal study
(combined SBP and DBP goals), so it cannot be determined if the benefits
were due to lowering SBP, DBP, or both.

In the general nonblack population, including those with diabetes, initial

antihypertensive treatment should include a thiazide-type diuretic, calcium
channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or
angiotensin receptor blocker (ARB).

Moderate Recommendation – Grade B

For this recommendation, only RCTs that compared one class of

antihypertensive medication to another and assessed the effects on health

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outcomes were reviewed; placebo-controlled RCTs were not included.

However, the evidence review was informed by major placebo-controlled
hypertension trials, including 3 federally funded trials (VA Cooperative Trial,
HDFP, and SHEP), that were pivotal in demonstrating that treatment of
hypertension with antihypertensive medications reduces cardiovascular or
cerebrovascular events and/or mortality.3,13,18 These trials all used thiazide-
type diuretics compared with placebo or usual care as the basis of therapy.
Additional evidence that BP lowering reduces risk comes from trials of β-
blocker vs placebo16,27 and CCB vs placebo.1

Each of the 4 drug classes recommended by the panel in recommendation 6

yielded comparable effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes, with one exception: heart failure.
Initial treatment with a thiazide-type diuretic was more effective than a CCB
or ACEI (question 3, evidence statements 14 and 15), and an ACEI was
more effective than a CCB (question 3, evidence statement 1) in improving
heart failure outcomes. While the panel recognized that improved heart
failure outcomes was an important finding that should be considered when
selecting a drug for initial therapy for hypertension, the panel did not
conclude that it was compelling enough within the context of the overall
body of evidence to preclude the use of the other drug classes for initial
therapy. The panel also acknowledged that the evidence supported BP
control, rather than a specific agent used to achieve that control, as the most
relevant consideration for this recommendation.

The panel did not recommend β-blockers for the initial treatment of
hypertension because in one study use of β-blockers resulted in a higher
rate of the primary composite outcome of cardiovascular death, myocardial
infarction, or stroke compared to use of an ARB, a finding that was driven
largely by an increase in stroke (question 3, evidence statement 22).28 In
the other studies that compared a β-blocker to the 4 recommended drug

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classes, the β-blocker performed similarly to the other drugs (question 3,

evidence statement 8) or the evidence was insufficient to make a
determination (question 3, evidence statements 7, 12, 21, 23, and 24).

α-Blockers were not recommended as first-line therapy because in one

study initial treatment with an α-blocker resulted in worse cerebrovascular,
heart failure, and combined cardiovascular outcomes than initial treatment
with a diuretic (question 3, evidence statement 13).29 There were no RCTs
of good or fair quality comparing the following drug classes to the 4
recommended classes: dual α1- + β-blocking agents (eg, carvedilol),
vasodilating β-blockers (eg, nebivolol), central α2-adrenergic agonists (eg,
clonidine), direct vasodilators (eg, hydralazine), aldosterone receptor
antagonists (eg, spironolactone), adrenergic neuronal depleting agents
(reserpine), and loop diuretics (eg, furosemide) (question 3, evidence
statement 30). Therefore, these drug classes are not recommended as first-
line therapy. In addition, no eligible RCTs were identified that compared a
diuretic vs an ARB, or an ACEI vs an ARB. ONTARGET was not eligible
because hypertension was not required for inclusion in the study.30

Similar to those for the general population, this recommendation applies to

those with diabetes because trials including participants with diabetes
showed no differences in major cardiovascular or cerebrovascular outcomes
from those in the general population (question 3, evidence statements 36-
48).

The following important points should be noted. First, many people will
require treatment with more than one antihypertensive drug to achieve BP
control. While this recommendation applies only to the choice of the initial
antihypertensive drug, the panel suggests that any of these 4 classes would
be good choices as add-on agents (recommendation 9). Second, this
recommendation is specific for thiazide-type diuretics, which include thiazide

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diuretics, chlorthalidone, and indapamide; it does not include loop or

potassium-sparing diuretics. Third, it is important that medications be dosed
adequately to achieve results similar to those seen in the RCTs (Table 4).
Fourth, RCTs that were limited to specific nonhypertensive populations, such
as those with coronary artery disease or heart failure, were not reviewed for
this recommendation. Therefore, recommendation 6 should be applied with
caution to these populations. Recommendations for those with CKD are
addressed in recommendation 8.

Table 4. Evidence-Based Dosing for Antihypertensive Drugs

View Large | Save Table | Download Slide (.ppt) | View in Article Context

In the general black population, including those with diabetes, initial

antihypertensive treatment should include a thiazide-type diuretic or CCB.

For general black population: Moderate Recommendation – Grade B

For black patients with diabetes: Weak Recommendation – Grade C

Recommendation 7 is based on evidence statements from question 3. In

cases for which evidence for the black population was the same as for the
general population, the evidence statements for the general population
apply to the black population. However, there are some cases for which the
results for black persons were different from the results for the general
population (question 3, evidence statements 2, 10, and 17). In those cases,
separate evidence statements were developed.

This recommendation stems from a prespecified subgroup analysis of data

from a single large trial (ALLHAT) that was rated good.31 In that study, a
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thiazide-type diuretic was shown to be more effective in improving

cerebrovascular, heart failure, and combined cardiovascular outcomes
compared to an ACEI in the black patient subgroup, which included large
numbers of diabetic and nondiabetic participants (question 3, evidence
statements 10, 15 and 17). Therefore, the recommendation is to choose
thiazide-type diuretics over ACEI for black patients. Although a CCB was
less effective than a diuretic in preventing heart failure in the black subgroup
of this trial (question 3, evidence statement 14), there were no differences in
other outcomes (cerebrovascular, CHD, combined cardiovascular, and
kidney outcomes, or overall mortality) between a CCB and a diuretic
(question 3, evidence statements 6, 8, 11, 18, and 19). Therefore, both
thiazide-type diuretics and CCBs are recommended as first-line therapy for
hypertension in black patients.

The panel recommended a CCB over an ACEI as first-line therapy in black

patients because there was a 51% higher rate (relative risk, 1.51; 95% CI,
1.22-1.86) of stroke in black persons in ALLHAT with the use of an ACEI as
initial therapy compared with use of a CCB (question 3, evidence statement
2).32 The ACEI was also less effective in reducing BP in black individuals
compared with the CCB (question 3, evidence statement 2).32 There were
no outcome studies meeting our eligibility criteria that compared diuretics or
CCBs vs β-blockers, ARBs, or other renin-angiotensin system inhibitors in
black patients.

The recommendation for black patients with diabetes is weaker than the
recommendation for the general black population because outcomes for the
comparison between initial use of a CCB compared to initial use of an ACEI
in black persons with diabetes were not reported in any of the studies
eligible for our evidence review. Therefore, this evidence was extrapolated
from findings in the black participants in ALLHAT, 46% of whom had
diabetes. Additional support comes from a post hoc analysis of black

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participants in ALLHAT that met the criteria for the metabolic syndrome, 68%
of whom had diabetes.33 However, this study did not meet the criteria for our
review because it was a post hoc analysis. This recommendation also does
not address black persons with CKD, who are addressed in
recommendation 8.

In the population aged 18 years or older with CKD and hypertension, initial
(or add-on) antihypertensive treatment should include an ACEI or ARB to
improve kidney outcomes. This applies to all CKD patients with hypertension
regardless of race or diabetes status.

Moderate Recommendation – Grade B

The evidence is moderate (question 3, evidence statements 31-32) that

treatment with an ACEI or ARB improves kidney outcomes for patients with
CKD. This recommendation applies to CKD patients with and without
proteinuria, as studies using ACEIs or ARBs showed evidence of improved
kidney outcomes in both groups.

This recommendation is based primarily on kidney outcomes because there

is less evidence favoring ACEI or ARB for cardiovascular outcomes in
patients with CKD. Neither ACEIs nor ARBs improved cardiovascular
outcomes for CKD patients compared with a β-blocker or CCB (question 3,
evidence statements 33-34). One trial (IDNT) did show improvement in heart
failure outcomes with an ARB compared with a CCB, but this trial was
restricted to a population with diabetic nephropathy and proteinuria
(question 3, evidence statement 5).34 There are no RCTs in the evidence
review that directly compared ACEI to ARB for any cardiovascular outcome.
However, both are renin-angiotensin system inhibitors and have been shown
to have similar effects on kidney outcomes (question 3, evidence statements
31-32).

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Recommendation 8 is specifically directed at those with CKD and

hypertension and addresses the potential benefit of specific drugs on kidney
outcomes. The AASK study showed the benefit of an ACEI on kidney
outcomes in black patients with CKD and provides additional evidence that
supports ACEI use in that population.21 Additional trials that support the
benefits of ACEI or ARB therapy did not meet our inclusion criteria because
they were not restricted to patients with hypertension.35,36 Direct renin
inhibitors are not included in this recommendation because there were no
studies demonstrating their benefits on kidney or cardiovascular outcomes.

The panel noted the potential conflict between this recommendation to use
an ACEI or ARB in those with CKD and hypertension and the
recommendation to use a diuretic or CCB (recommendation 7) in black
persons: what if the person is black and has CKD? To answer this, the panel
relied on expert opinion. In black patients with CKD and proteinuria, an ACEI
or ARB is recommended as initial therapy because of the higher likelihood of
progression to ESRD.21 In black patients with CKD but without proteinuria,
the choice for initial therapy is less clear and includes a thiazide-type
diuretic, CCB, ACEI, or ARB. If an ACEI or ARB is not used as the initial
drug, then an ACEI or ARB can be added as a second-line drug if necessary
to achieve goal BP. Because the majority of patients with CKD and
hypertension will require more than 1 drug to achieve goal BP, it is
anticipated that an ACEI or ARB will be used either as initial therapy or as
second-line therapy in addition to a diuretic or CCB in black patients with
CKD.

Recommendation 8 applies to adults aged 18 years or older with CKD, but

there is no evidence to support renin-angiotensin system inhibitor treatment
in those older than 75 years. Although treatment with an ACEI or ARB may
be beneficial in those older than 75 years, use of a thiazide-type diuretic or
CCB is also an option for individuals with CKD in this age group.

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Use of an ACEI or an ARB will commonly increase serum creatinine and

may produce other metabolic effects such as hyperkalemia, particularly in
patients with decreased kidney function. Although an increase in creatinine
or potassium level does not always require adjusting medication, use of
renin-angiotensin system inhibitors in the CKD population requires
monitoring of electrolyte and serum creatinine levels, and in some cases,
may require reduction in dose or discontinuation for safety reasons.

The main objective of hypertension treatment is to attain and maintain goal

BP. If goal BP is not reached within a month of treatment, increase the dose
of the initial drug or add a second drug from one of the classes in
recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician
should continue to assess BP and adjust the treatment regimen until goal
BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a
third drug from the list provided. Do not use an ACEI and an ARB together in
the same patient. If goal BP cannot be reached using the drugs in
recommendation 6 because of a contraindication or the need to use more
than 3 drugs to reach goal BP, antihypertensive drugs from other classes
can be used. Referral to a hypertension specialist may be indicated for
patients in whom goal BP cannot be attained using the above strategy or for
the management of complicated patients for whom additional clinical
consultation is needed.

Expert Opinion – Grade E

Recommendation 9 was developed by the panel in response to a perceived

need for further guidance to assist in implementation of recommendations 1
through 8. Recommendation 9 is based on strategies used in RCTs that
demonstrated improved patient outcomes and the expertise and clinical
experience of panel members. This recommendation differs from the other
recommendations because it was not developed in response to the 3 critical

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questions using a systematic review of the literature. The Figure is an

algorithm summarizing the recommendations. However, this algorithm has
not been validated with respect to achieving improved patient outcomes.

Figure.

2014 Hypertension Guideline Management Algorithm

SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting
enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs
should not be used in combination.bIf blood pressure fails to be maintained at goal, reenter the
algorithm where appropriate based on the current individual therapeutic plan.

View Large | Save Figure | Download Slide (.ppt) | View in Article Context

How should clinicians titrate and combine the drugs recommended in this
report? There were no RCTs and thus the panel relied on expert opinion.
Three strategies (Table 5) have been used in RCTs of high BP treatment but
were not compared with each other. Based on the evidence reviewed for
questions 1 through 3 and on the expert opinion of the panel members, it is
not known if one of the strategies results in improved cardiovascular
outcomes, cerebrovascular outcomes, kidney outcomes, or mortality
compared with an alternative strategy. There is not likely to be evidence
from well-designed RCTs that compare these strategies and assess their

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effects on important health outcomes. There may be evidence that different

strategies result in more rapid attainment of BP goal or in improved
adherence, but those are intermediate outcomes that were not included in
the evidence review. Therefore, each strategy is an acceptable
pharmacologic treatment strategy that can be tailored based on individual
circumstances, clinician and patient preferences, and drug tolerability. With
each strategy, clinicians should regularly assess BP, encourage evidence-
based lifestyle and adherence interventions, and adjust treatment until goal
BP is attained and maintained. In most cases, adjusting treatment means
intensifying therapy by increasing the drug dose or by adding additional
drugs to the regimen. To avoid unnecessary complexity in this report, the
hypertension management algorithm (Figure) does not explicitly define all
potential drug treatment strategies.

Table 5. Strategies to Dose Antihypertensive Drugsa

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Finally, panel members point out that in specific situations, one

antihypertensive drug may be replaced with another if it is perceived not to
be effective or if there are adverse effects.

LIMITATIONS
This evidence-based guideline for the management of high BP in adults is
not a comprehensive guideline and is limited in scope because of the
focused evidence review to address the 3 specific questions (Table 1).
Clinicians often provide care for patients with numerous comorbidities or
other important issues related to hypertension, but the decision was made to

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focus on 3 questions considered to be relevant to most physicians and

patients. Treatment adherence and medication costs were thought to be
beyond the scope of this review, but the panel acknowledges the importance
of both issues.

The evidence review did not include observational studies, systematic

reviews, or meta-analyses, and the panel did not conduct its own meta-
analysis based on prespecified inclusion criteria. Thus, information from
these types of studies was not incorporated into the evidence statements or
recommendations. Although this may be considered a limitation, the panel
decided to focus only on RCTs because they represent the best scientific
evidence and because there were a substantial number of studies that
included large numbers of patients and met our inclusion criteria.
Randomized controlled trials that included participants with normal BP were
excluded from our formal analysis. In cases in which high-quality evidence
was not available or the evidence was weak or absent, the panel relied on
fair-quality evidence, panel members’ knowledge of the published literature
beyond the RCTs reviewed, and personal experience to make
recommendations. The duration of the guideline development process
following completion of the systematic search may have caused the panel to
miss studies published after our literature review. However, a bridge search
was performed through August 2013, and the panel found no additional
studies that would have changed the recommendations.

Many of the reviewed studies were conducted when the overall risk of
cardiovascular morbidity and mortality was substantially higher than it is
today; therefore, effect sizes may have been overestimated. Further, RCTs
that enrolled prehypertensive or nonhypertensive individuals were excluded.
Thus, our recommendations do not apply to those without hypertension. In
many studies focused on DBP, participants also had elevated SBP so it was
not possible to determine whether the benefit observed in those trials arose

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from lowering DBP, SBP, or both. In addition, the ability to compare studies
from different time periods was limited by differences in clinical trial design
and analytic techniques.

While physicians use cost, adherence, and often observational data to make
treatment decisions, medical interventions should whenever possible be
based first and foremost on good science demonstrating benefits to patients.
Randomized controlled trials are the gold standard for this assessment and
thus were the basis for providing the evidence for our clinical
recommendations. Although adverse effects and harms of antihypertensive
treatment documented in the RCTs were considered when the panel made
its decisions, the review was not designed to determine whether therapy-
associated adverse effects and harms resulted in significant changes in
important health outcomes. In addition, this guideline was not endorsed by
any federal agency or professional society prior to publication and thus is a
departure from previous JNC reports. The panel anticipates that an objective
assessment of this report following publication will allow open dialogue
among endorsing entities and encourage continued attention to rigorous
methods in guideline development, thus raising the standard for future
guidelines.

DISCUSSION
The recommendations based on RCT evidence in this guideline differ from
recommendations in other currently used guidelines supported by expert
consensus (Table 6). For example, JNC 7 and other guidelines
recommended treatment to lower BP goals in patients with diabetes and
CKD based on observational studies.12 Recently, several guideline
documents such as those from the American Diabetes Association have
raised the systolic BP goals to values that are similar to those recommended
in this evidence-based guideline.37- 42 Other guidelines such as those of the

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European Society of Hypertension/European Society of Cardiology also

recommend a systolic BP goal of lower than 150 mm Hg, but it is not clear at
what age cutoff in the general population this goal specifically applies.37
This changing landscape is understandable given the lack of clear RCT
evidence in many clinical situations.

Table 6. Guideline Comparisons of Goal BP and Initial Drug Therapy for

Adults With Hypertension

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The panel was originally constituted as the “Eighth Joint National Committee
on the Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 8).” In March 2008 NHLBI sent letters inviting the co-chairs
and committee members to serve on JNC 8. The charge to the committee
was as follows: “The JNC 8 will review and synthesize the latest available
scientific evidence, update existing clinical recommendations, and provide
guidance to busy primary care clinicians on the best approaches to manage
and control hypertension in order to minimize patients’ risk for
cardiovascular and other complications.” The committee was also asked to
identify and prioritize the most important questions for the evidence review.
In June 2013, NHLBI announced its decision to discontinue developing
clinical guidelines including those in process, instead partnering with
selected organizations that would develop the guidelines.43,44 Importantly,
participation in this process required that these organizations be involved in
producing the final content of the report. The panel elected to pursue
publication independently to bring the recommendations to the public in a
timely manner while maintaining the integrity of the predefined process. This

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report is therefore not an NHLBI sanctioned report and does not reflect the
views of NHLBI.

CONCLUSIONS
It is important to note that this evidence-based guideline has not redefined
high BP, and the panel believes that the 140/90 mm Hg definition from JNC
7 remains reasonable. The relationship between naturally occurring BP and
risk is linear down to very low BP, but the benefit of treating to these lower
levels with antihypertensive drugs is not established. For all persons with
hypertension, the potential benefits of a healthy diet, weight control, and
regular exercise cannot be overemphasized. These lifestyle treatments have
the potential to improve BP control and even reduce medication needs.
Although the authors of this hypertension guideline did not conduct an
evidence review of lifestyle treatments in patients taking and not taking
antihypertensive medication, we support the recommendations of the 2013
Lifestyle Work Group.45

The recommendations from this evidence-based guideline from panel

members appointed to the Eighth Joint National Committee (JNC 8) offer
clinicians an analysis of what is known and not known about BP treatment
thresholds, goals, and drug treatment strategies to achieve those goals
based on evidence from RCTs. However, these recommendations are not a
substitute for clinical judgment, and decisions about care must carefully
consider and incorporate the clinical characteristics and circumstances of
each individual patient. We hope that the algorithm will facilitate
implementation and be useful to busy clinicians. The strong evidence base
of this report should inform quality measures for the treatment of patients
with hypertension.

ARTICLE INFORMATION
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Corresponding Author: Paul A. James, MD, University of Iowa, 200

Hawkins Dr, 01286-D PFP, Iowa City, IA 52242-1097 (paul-
[email protected]).

Published Online: December 18, 2013. doi:10.1001/jama.2013.284427.

Author Contributions: Drs James and Oparil had full access to all of the
data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis.

Study concept and design, acquisition of data, analysis and interpretation of

data, drafting of the manuscript, critical revision of the manuscript for
important intellectual content, administrative, technical, and material
support, and study supervision: All authors.

Conflict of Interest Disclosures: All authors have completed and

submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.
Dr Oparil reports individual and institutional payment related to board
membership from Bayer, Daiichi Sankyo, Novartis, Medtronic, and Takeda;
individual consulting fees from Backbeat, Bayer, Boehringer-Ingelheim,
Bristol Myers-Squibb, Daiichi Sankyo, Eli Lilly, Medtronic, Merck, Pfizer, and
Takeda; receipt of institutional grant funding from AstraZeneca, Daiichi
Sankyo, Eisai Inc, Gilead, Medtronic, Merck, Novartis, Takeda Global
Research and Development Inc; individual payment for lectures from Daiichi
Sankyo, Merck, Novartis, and Pfizer; individual and institutional payment for
development of educational presentations from ASH/AHSR (Daiichi
Sankyo); and individual and institutional payment from Amarin Pharma Inc,
Daiichi Sankyo, and LipoScience Inc for educational grant(s) for the Annual
UAB Vascular Biology & Hypertension Symposium. Dr Cushman reports
receipt of institutional grant support from Merck, Lilly, and Novartis; and
consulting fees from Novartis, Sciele Pharmaceuticals, Takeda, sanofi-

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aventis, Gilead, Calpis, Pharmacopeia, Theravance, Daiichi-Sankyo, Noven,

AstraZeneca Spain, Merck, Omron, and Janssen. Dr Townsend reports
board membership with Medtronic, consultancy for Janssen,
GlaxoSmithKline, and Merck, and royalties/educational-related payments
from Merck, UpToDate, and Medscape. Dr Wright reports receipt of
consulting fees from Medtronic, CVRx, Takeda, Daiichi-Sankyo, Pfizer,
Novartis, and Take Care Health. The other authors report no disclosures.

Funding/Support: The evidence review for this project was funded by the
National Heart, Lung, and Blood Institute (NHLBI).

Role of the Sponsor: The design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review,
and approval of the manuscript; and decision to submit the manuscript for
publication are the responsibilities of the authors alone and independent of
NHLBI.

Disclaimer: The views expressed do not represent those of the NHLBI, the
National Institute of Diabetes and Digestive and Kidney Diseases, the
National Institutes of Health, or the federal government.

Additional Contributions: We thank Cory V. Evans, MPP, who at the time

of the project was a senior research analyst and contract lead for JNC 8 with
Leidos (formerly Science Applications International Corporation) and Linda
J. Lux, MPA, RTI International, for their support. We also thank Lawrence J.
Fine, MD, DrPH, NHLBI, for his work with the panel. Those named here
were compensated in their roles as consultants on the project.

Correction: This article was corrected for the description of reserpine in

Recommendation 6, addition of a footnote to Table 5, and text in the
Discussion on January 21, 2014; this article was corrected for information
under “Initial Drug Treatment Options” in Table 6 and clarification of the

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rationale for Question 2: Evidence Statement 17 in the online supplement on

April 3, 2014.

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