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JNC 8 minority report explains objections to raising systolic BP targets
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Some panel members appointed to the Institute of Medicine’s Eighth Joint National Committee have written a commentary published in Annals of Internal Medicine to explain why they voted against relaxing the recommended systolic BP target to 150 mm Hg for patients aged at least 60 years without diabetes or chronic kidney disease.
The report of the panel appointed to JNC 8, published in JAMA in December, stated that there was insufficient evidence to support continuing to target systolic BP of 140 mm Hg in patients aged at least 60 years without diabetes or chronic kidney disease (CKD).
Five opposing JNC 8 panel members wrote the new commentary because they said the published JNC 8 guidelines did not adequately explain their concerns about changing the target systolic BP for this patient population.
Reducing the intensity of treatment
Jackson T. Wright Jr., MD, PhD, and colleagues stated three main reasons for their dissent.
First, raising the systolic BP target to 150 mm Hg “will probably reduce the intensity of antihypertensive treatment in a large population at high risk for CVD,” the authors wrote. Groups at risk include African Americans, those with hypertension and other risk factors aside from diabetes and CKD, and those with clinical CVD, they wrote.
“A target of less than 150 mm Hg would likely increase [BP] in the treated hypertensive population and would suggest that nearly half the untreated hypertensive patients in this age range remain untreated,” they wrote. They also noted that “on the basis of absolute risk, using an age threshold of 60 years to define eligibility for less aggressive treatment lacks consistency.”
Second, the authors stated that the evidence supporting the panel’s recommendation to raise the systolic BP target to 150 mm Hg in patients aged at least 60 years without diabetes or CKD was insufficient and inconsistent with the evidence supporting a systolic BP target of 140 mm Hg for those younger than 60 years and those with diabetes or CKD.
They cited results from the SHEP and HYVET trials. SHEP demonstrated benefit of treating hypertension to a systolic BP goal of between 140 mm Hg and 145 mm Hg in those aged at least 60 years. HYVET found benefit, including mortality, of treating hypertension to a systolic BP goal of less than 150 mm Hg, they wrote, noting that the treatment group in HYVET achieved a mean systolic BP of 144 mm Hg at 2 years.
Benefit without major harm
The trials “provide evidence that reducing [systolic] BP to around 140 mm Hg has substantial benefit without major harm in older persons,” Wright and colleagues wrote. In contrast, two trials cited by the panel as supportive of the 150 mm Hg target — JATOS and VALISH — were underpowered and not generalizable to groups such as African Americans, according to the authors.
They also noted that results of the FEVER trial and two meta-analyses support a systolic BP target of 140 mm Hg, but were not considered by the panel. In addition, they wrote, guidelines from Europe, Canada, the United Kingdom, the American College of Cardiology Foundation and the American Heart Association, and the American Society of Hypertension and International Society of Hypertension all support a systolic BP target of 140 mm Hg in patients younger than 80 years.
Third, the authors wrote, “The higher [systolic BP] goal in individuals aged 60 years or older may reverse the decades-long decline in CVD, especially stroke mortality.” They cited a statement from the AHA and American Stroke Association on factors influencing the decline of stroke mortality.
“We, the panel minority, believed that the evidence was insufficient to increase the [systolic] BP goal from its current level of less than 140 mm Hg because of concern that increasing the goal may cause harm by increasing the risk for CVD and partially undoing the remarkable progress in reducing [CV] mortality in Americans older than 60 years,” the authors wrote. “Because of the overall evidence, including the [randomized clinical trial] data reviewed by the panel, and the decrease in CVD mortality, we concluded that the evidence for increasing a [BP] target in high-risk populations should be at least as strong as the evidence required to decrease the recommended [BP] target.”
A reasonable alternative approach, they wrote, would have been to set a systolic BP goal of less than 150 mm Hg for frail persons aged at least 80 years.
Disclosure: One author reports financial ties with CVRx, Medtronic, Novartis, Pfizer and Sankyo. The other authors report no relevant financial disclosures.
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