[ Diabetes Type 1 ]

The JNC 8 Hypertension Guidelines: An In-Depth Guide

Hypertension is widely accepted as a risk factor for coronary artery disease, heart failure, stroke, or chronic kidney disease. In type 2 diabetes, hypertension is often present as part of the metabolic syndrome of insulin resistance also including central obesity and dyslipidemia. Thus, appropriate blood pressure and glucose control are of utmost importance. “This is, in my view, the most important blood pressure study of the last 40 years,” Dr. Maybe yes, but quite possibly no. Since many diabetic individuals develop CV events at blood pressure (BP) and cholesterol levels that meet recommended treatment goals, lower goals might improve CV risk reduction. In an accompanying editorial[2], Drs Vlado Perkovic and Anthony Rodgers (University of Sydney, Australia) note that trials aren’t usually all good or all bad and that the serious adverse-event rates here “appear unlikely” to outweigh the overall benefits.

Of those randomized, approximately 25% had microalbuminuria; 3.6% had macroalbuminuria; and 10% had an estimated glomerular filtration rate < 60 mL/min. High blood pressure is also called hypertension. The JAMA writing group recommended that: Healthy adults under the age of 60 should strive for a blood pressure below 140/90. Before receiving alpha-blockers, beta-blockers, or any of several miscellaneous agents, under the JNC 8 guidelines, patients would receive a dosage adjustment and combinations of the 4 first-line therapies. Triple therapy with an ACEI/ARB, CCB, and thiazide-type diuretic would precede use of alpha-blockers, beta-blockers, or any of several other agents. And they all had at least one additional heart risk factor, like a history of heart disease. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials.

However, lowering it to 120 did reduce the risk of stroke. The study, which began in fall 2009, included more than 9,300 participants age 50 and older, recruited from about 100 medical centers and clinical practices throughout the United States and Puerto Rico. Despite the subgroup analysis of ALLHAT, results of the African American Study of Kidney Disease and Hypertension (AASK) support use of first-line or add-on ACEIs to improve kidney-related outcomes in patients of African descent with hypertension, chronic kidney disease, and proteinuria. Researchers randomly assigned 4,733 participants with elevated blood pressure to a target systolic blood pressure of either less than 120 mmHg (the intensive group) or to less than 140 mmHg (the standard group). One exception to the use of ACEIs or ARBs in protection of kidney function applies to patients over the age of 75. The panel cited the potential for ACEIs and ARBs to increase serum creatinine and produce hyperkalemia. Diuretics are often required for ‘resistant’ hypertension.

In addition, the panel expressly prohibits simultaneous use of an ACEI and an ARB in the same patient. This combination has not been shown to improve outcomes. Despite the fact that the 2 medications work at different points in the renin-angiotensin-aldosterone system, other combinations of medications are better options, and the simultaneous use of ACEIs and ARBs is not supported by evidence. Lifestyle Changes As in JNC 7, the JNC 8 guidelines also recommend lifestyle changes as an important component of therapy. There were significantly more complications in hypertensive than in normotensive patients with type 2 diabetes. In addition, to delay development of hypertension, improve the blood pressure–lowering effect of existing medication, and decrease cardiovascular risk, alcohol intake should be limited to 2 drinks daily in men and 1 drink daily in women. Note that 1 drink constitutes 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor.

Quitting smoking also reduces cardiovascular risk. Conclusion The JNC 8 guidelines move away from the assumption that lower blood pressure levels will improve outcomes regardless of the type of agent used to achieve the lower level. Instead, the JNC 8 guidelines encourage use of agents with the best evidence of reducing cardiovascular risk. In addition, the guidelines may lead to less use of antihypertensive medications in younger patients, which will produce equivalent outcomes in terms of cardiovascular events with less potential for adverse events that limit adherence.

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