New Guidelines for the Use of Blood Pressure Medication

An expert panel formed by the National Heart, Lung, and Blood Institute published the Eighth Joint National Committee (JNC-8) in the Journal of the American Medical Association. These latest recommendations focused mainly on the pharmaceutical treatment of hypertension (HTN). Two key recommendations that differ from the prior 2003 JCP-7 guidelines are:

• Americans aged 60 or older should only take HTN medication (meds) if their blood pressure (BP) exceeds 150/90. JNC-7 had recommended them whenever BP was higher than 140/90.
• Diabetics and kidney patients younger than age 60 should be prescribed drugs at the same BP levels as everyone else, which is when their BP is above 140/90. JNC-7 had recommended BP meds for these patients when BP was above 130/80.

The scientific basis for these changes was pretty simple. Clinical trials have failed to show any convincing evidence that the prior treatment goals achieved with BP meds produced more benefits than risks. Driving BP lower than 150/90 in people over 60 -- and down to 130/80 or less in younger people with diabetes and kidney problems -- has simply not been proven to provide better health outcomes in controlled clinical trials.Up until JNC-8, the previous guidelines had been pushing the BP targets for initiating the use of BP meds lower based on the unproven assumption that achieving a lower BP with drugs would reduce cardiovascular disease (CVD) and total mortality to the same extent as having a lower BP without the use of BP meds. Sadly, research has increasingly proven this assumption is incorrect. The truth is people with pre-HTN and even many with what is stage 1 HTN have to live with a 2-4-fold increase in risk of suffering a stroke or heart attack or having their kidneys or hearts fail because the new guidelines say the only way to reduce that much higher risk of CVD is with diet and lifestyle changes, because there is no convincing evidence that doing so with BP meds makes much difference. The JNC-8 guidelines are bad for the pharmaceutical industry and MDs but potentially good for RDNs. Why only potentially? Because the American Medical Association's (AMA) Relative Value Committee (RVC) has Medicare, Medicaid, and most private insurers will not pay for RDNs to provide expert dietary counseling to help lower elevated BP. So even though a DASH-style diet and weight loss combined with other lifestyle changes often work better than drugs for lowering BP, the AMA (via its RVC) still opposes 3rd party payment from health insurers for expert dietary counseling. This despite the fact that diet and lifestyle changes do not have the adverse side effects exhibited by BP meds and so can be used to treat people whose BP puts them at much higher risk for CVD.While the new JNC-8 guidelines roll back the use of BP meds, they certainly do not imply that a BP of say 145/87 in a 62-year-old is without risk. Indeed, the value of diet and lifestyle changes, to reduce even modestly elevated BP, was affirmed by the expert panel. The panel stressed the need to implement healthy lifestyle interventions as a first line of treatment. Suzanne Oparil, MD, stated: "For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized." The report continues, "These lifestyle treatments have the potential to improve blood pressure control and even reduce medication needs."So JNC-8 appears to be a bit of a catch-22 for the current MD-centric treatment of elevated BP. The risk of death from CVD events has been shown to rise exponentially as BP increases above the 110-115/70-75 optimal, lowest-risk range. So while the AMA's RVC opposes payment to non-MDs for diet and lifestyle changes, the data from clinical trials and the JNC-8 are putting more emphasis on treating elevated BP with diet and lifestyle rather than BP meds.Bottom Line: JNC-8's new recommendations do recognize that the increasingly aggressive use of BP drugs to push BP closer to physiologically normal levels often prompt more harm than benefits. As a result, JNC-8 raises the bar for when it is appropriate to prescribe BP drugs. The new guidelines make it even clearer that diet and lifestyle changes should be the top priority for everyone with above normal BP. Use of BP meds is neither as safe nor potentially as effective as a low-sodium DASH diet coupled with increased activity and weight loss. BP meds can also sometimes worsen other metabolic abnormalities frequently associated with HTN, whereas diet and exercise programs can frequently improve other risk factors. The real solution to diet and inactivity promoted ills is not more aggressive use of drugs and surgery but more emphasis on a healthier diet and exercise program that prevents these problems. Plus, these are often safer and more effective treatments than prescription pills.By James J. Kenney, PhD, FACN