Hey what’s going on guys? Today I want to talk about hypertension. Specifically, I want to talk about the changes made which JNC-8 when compared to JNC-7. The big question is are we going to study from JNC-7 when it comes to board reviews or are we going to start studying from JNC-8?
The problem is JNC-8 was published in 2013 making it obsolete from any reviewable books that you’re going to go over as of today. This also means that JNC-8 questions or answers will probably not be on your board exams. The reason being,is it takes time to write for board exams. They have to go through this peer review process and finally they get put onto the exam as a test first, then they get published as an actual question that counts.
However, that doesn’t mean that you should not study for JNC-8. The reason being, if you have any questions on your board exam or the PANCE that is referencing JNC-7, they will more than likely throw that question out.
If you’re studying for your board exams that means that very soon you will be out in clinical practice, and in clinical practice you should be going by the most current guidelines. This means you should be practicing based on JNC-8. So, for those reasons, I would stick to studying what’s most current and I would stick to studying JNC-8 for your board and for clinical practice.
So let’s go over some of the changes made with JNC-8 guidelines. Alright, so the first thing you need to know is they have higher cut off values. For all adults that are otherwise healthy, you’re still going to have a cutoff value of 140/90. That has not changed.
The difference is patients with chronic kidney disease and diabetes have bumped up their cutoff values; it used to be 130/80. They found that there was no benefit in keeping these patients with the lower blood pressure. Therefore, they bumped their cutoff values to 140/90. So, patients with chronic kidney disease and diabetes have a cutoff value of 140/90.
Patients over 60 have an even higher cutoff value still. They have a value of 150/90 now. Again, they found that there was no benefit in keeping these patients at a lower blood pressure and there was actually probably an increase risk in probable reactions based on trials that were done. So, for that reason, if you’re over 60 you have a cutoff value of 150/90. However, if you’re over 60 and you have chronic kidney disease or diabetes you’re going to be bumped back down to 140/90. This is still a higher cutoff value than the 130/80 previously designated.
They actually they found that in patients over 60, it was more important to control the diastolic blood pressure as opposed to the systolic. That might also be true in patients over 60, however, the consensus was systolic is more important to control if you’re over 60.
Just a little aside, really irrelevant because you’re going to be using both cutoff values and the higher of the 2 numbers is what you’re going to be shooting to decrease. But, just a little aside for you guys to be aware.
Now, as far as treatment goes, this has also changed. It used to be that in JNC-7 the first line treatment for all adults, healthy adults, was hydrochlorothiazide. Well, they found that you don’t need to start with hydrochlorothiazide, other acceptable first line agents are going to be an ACE or an ARB – you’re never going to combine the two, you will never combine an ACE inhibitor with an ARB – or calcium channel blocker, preferably amlodipine.
Some quick adverse reactions for these medications because you’re going to need to be aware of these. Hydrochlorothiazide can cause hyperglycemia, hyperuricemia, and hypercalcemia. It can cause hypokalemia and hyponutremia. So, be aware of those electrolyte imbalances.
ACE and ARBs will worsen GFR and can cause hyperkalemia, however, ACE inhibitors are indicated in patients with chronic kidney disease or diabetes who have impaired renal function, right? So just know that there is a transient increase in creatinine and a transient drop in GFR that should be reversed after a week of treatment. So, far that reason, anybody that has any type of impaired kidney function should have a repeat creatinine and a repeat potassium after a week of initiating treatment to make sure that it is in fact transient.
Calcium channel blockers – a very common side-effect is going to be peripheral edema; know that this is dose dependent. So, know that all this might not happen with 2.5mgs, but if you increase that dose to 10mgs and you start to see swelling, it’s more than likely due to amlodipine, so you probably need to titrate that dose back. If you have heart failure, know that it can also cause pulmonary edema.
These are some adverse reactions that you need to be aware of because they will be tested on your boards. Patients with African decent should probably stay away from ACE inhibitors, simply because they’re probably not as effective as initiating a calcium channel blocker or hydrochlorothiazide.
Now the goal of treatment should be to reach your blood pressure goal in one month. JNC-7 guidelines weren’t too clear as to how long it should take, JNC-8 makes it a little bit clearer, you have one month to get to your goal. Alright guys so that was it, we touched on the difference between JNC-8 and JNC-7.
Keep up to date, keep current, know the most current guidelines, you will not be faulted for speaking on the most current guidelines when it comes to your exam, and in fact it’s going to be beneficial.