Looking Beyond JNC 7

Q: Is the Seventh Report of the Joint National Committee for Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC 7) still considered current, or are newer guidelines available?

A: JNC 7 was published 5 years ago and has not yet been updated.¹ Hypertension remains a major worldwide health problem. Studies in all major developed countries, including the United States, have consistently shown that most persons with hypertension either are unaware of their condition or do not receive therapy.

Role of global cardiovascular risk. The vast majority of hypertensive patients have other cardiovascular or metabolic factors that play a significant role in their future risk of cardiovascular disease. In recent years, there has been increasing emphasis on—and debate concerning— the quantification of total (or global) cardiovascular risk in the evaluation and treatment of hypertension.

The current JNC 7 guidelines did recognize the important role that other cardiovascular risk factors play in determining both blood pressure values and total cardiovascular risk. However, JNC 7 treatment recommendations were still largely based on threshold blood pressure levels.

Newer recommendations. In 2005, a writing group of the American Society of Hypertension proposed an alternate classification system that took into consideration not only threshold levels of blood pressure, but also quantified total cardiovascular risk.² Depending on the total estimated risk, treatment might be recommended for a patient whose blood pressure currently would not warrant antihypertensive therapy. Because these alternative proposed guidelines suggested that the initiation and aggressiveness of treatment be individualized and guided by global cardiovascular risk rather than by blood pressure thresholds, their publication generated significant discussion within the hypertension community.

Guidelines from the European Society of Hypertension and the European Society of Cardiology in 2007 also embraced the role of global cardiovascular risk in the evaluation of patients with hypertension.³ In these guidelines, patients are classified not only by grades of hypertension, but also on the basis of total cardiovascular risk; the latter is defined as the risk from multiple coexisting risk factors and target organ damage. These guidelines also stress that the threshold for a diagnosis of hypertension and subsequent drug therapy should remain flexible and should be a function of the patient’s total cardiovascular risk.

I would certainly encourage a review of these recommendations^2,3; they can begin to be used in the evaluation of patients with hypertension.

JNC 8. The eighth Joint National Committee Report on Prevention, Detection, Evaluation, and Treatment of Hypertension will probably be published in late 2008 or in 2009. I expect that report to incorporate the concept of global cardiovascular risk—and to emphasize its importance— in the new treatment recommendations.

Regardless of the content of new guidelines, our ability to improve hypertension control rates will reflect our success in educating patients (which will improve long-term adherence) and in motivating one another to treat aggressively—usually with combination therapy— to achieve and maintain recommended blood pressure goals.