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Access to the full guideline and additional resources are available at the following link: https://www.healthquality.va.gov/guidelines/CD/htn/ Sidebar 1: Office Blood Pressure Measurement AOBP (preferred) Fully automated machine programmed to wait five minutes and record the average of three measurements separated by at least 30 seconds Standard Technique (alternative) Use a properly calibrated and validated sphygmomanometer Use an average of 2 readings Sidebar 2: Confirm Diagnosis If the follow-up clinic blood pressure value is 130 mm Hg SBP or 90 mm Hg DBP, make diagnosis of HTN without further testing Consider HBPM or ABPM to inform the diagnosis in select patients (see Recommendation 4 in the full CPG) If blood pressure is <130 mm Hg SBP and <90 mm Hg DBP, yet there is evidence of target organ damage, which may suggest the presence of masked HTN, consider HBPM or ABPM to inform the diagnosis (see Recommendation 4 in the full CPG) Module B: Treatment Sidebar 5: Initiate Drug Therapy General Population Recommend one or more of the following: Thiazide-type diuretics ACEIs or ARBs* Long-acting CCBs For patients unlikely to achieve goal with monotherapy (e.g.


, patients with SBP/DBP of >20/10 mm Hg above goal), consider initiating treatment with combination therapy or monotherapy with close follow up for titration and/or addition of medications based on blood pressure response Specific Populations: For patients age 65 and over, we suggest a thiazide-type diuretic for reduction in composite cardiovascular outcomes For African American patients, we recommend against using ACEIs or ARBs as monotherapy For patients with CKD, see VA/DoD CKD CPG1 *We recommend against more than one of the following three drug classes together in the same patient: ACEIs, ARBs, or direct renin inhibitors Sidebar 3: Examples of Target Organ Damage and Comorbid Conditions* Target organ damage: stroke, MI, peripheral arterial disease, LVH, CHF, CKD, and retinopathy Comorbid conditions: CKD, dyslipidemia, diabetes, obesity/overweight, OSA, and tobacco dependence *If patient has comorbid conditions, engage relevant clinical practice guidelines, 1. See the VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. Available at: https://www.healthquality.va.gov/guidelines/CD/CKD/ 2. See the VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction. Available at: https://www.healthquality.va.gov/guidelines/CD/lipids/ 3. See the VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Available at: https://www.healthquality.va.gov/guidelines/CD/diabetes/ 4. See the VA/DoD Clinical Practice Guideline for Screening and Management of Obesity and Overweight.


See the VA/DoD Clinical Practice Guideline for Screening and Management of Obesity and Overweight. Available at: https://www.healthquality.va.gov/guidelines/CD/obesity/ Sidebar 4: Goals for Blood Pressure Systolic Goal (see Recommendations 6 8 in the full CPG) <130 mm Hg If less stringent goal is desired per clinical judgment and/or patient preference, aim for at least: <150 mm Hg among patients age 60 and over <140 mm Hg for patients age 60 and over with type 2 diabetes Diastolic Goal (see Recommendation 9 in the full CPG) <90 mm Hg for patients age 30 and above Obtain office blood pressure (see Sidebar 1) 1 Adult in healthcare system Go to Module B, Yes Return after acute episode resolved (typically within 4 weeks) Yes Yes Yes No No Assess the need for and implement lifestyle modification, then follow up for adherence (e.g., diet, exercise, weight loss, alcohol moderation) Screen blood pressure periodically; address other CV risk factors (including healthy diet and physical activity); in patients with known or suspected target organ damage (see Sidebar 3), consider possibility of masked HTN (consider HBPM or ABPM) No Yes Obtain history and physical and assess for target organ damage and comorbid conditions (see Sidebar 3); consider baseline testing (e.g., basic metabolic panel, urinalysis, EKG, A1c, other tests) as appropriate Yes Evaluate as indicated; consider referral Yes Initiate treatment (go to Module B) When measured properly (see Appendix G in the full CPG), is SBP 120 mm Hg or DBP 80 mm Hg? Is the patient currently being treated for HTN? Confirm diagnosis of HTN by measuring blood pressure after 1 4 weeks (see Sidebar 2); is diagnosis confirmed? Does patient have an acute injury or illness? Is secondary cause suspected? No Is SBP 130 mm Hg or DBP 90 mm Hg?


No Is SBP 130 mm Hg or DBP 90 mm Hg? No Is the patient s blood pressure at or below goal? 17 Determine blood pressure goal (see Sidebar 4) Initiate treatment if drug na ve or optimize existing therapy (see Sidebar 5) Yes Consider offering and/or adjusting HBPM with co- interventions (tailored medication titration, education, and/or lifestyle counseling No Follow up periodically; reassess preferences Follow up regularly (e.g., monthly) until: Blood pressure is at goal Treatment regimen is optimized (see Sidebar 6) Comorbid conditions and/or other patient preferences direct otherwise No Follow up annually or more frequently as dictated by comorbid conditions (to include lab monitoring, if indicated) Yes Implement SDM to assess patient values and preferences; assess the need for and implement lifestyle modification Is the patient willing to engage in pharmacotherapy?


, monthly) until: Blood pressure is at goal Treatment regimen is optimized (see Sidebar 6) Comorbid conditions and/or other patient preferences direct otherwise No Follow up annually or more frequently as dictated by comorbid conditions (to include lab monitoring, if indicated) Yes Implement SDM to assess patient values and preferences; assess the need for and implement lifestyle modification Is the patient willing to engage in pharmacotherapy? Patient refuses pharmacotherapy; consider nurse-led and dietitian-led interventions to improve blood pressure control Patient appropriate for HTN treatment The Diagnosis and Management of Hypertension in the Primary Care Setting Module A: Screening and Diagnosis VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 Sidebar 6: Optimize Treatment Assess adherence Consider evaluating for interfering substances (some prescription medications, NSAIDs, alcohol, recreational drugs) Consider evaluating and addressing contributing lifestyle factors Optimize treatment (refer to Appendix F, Table F-1 in the full CPG) Titrate initial drug Add another agent from a different class Reevaluate diagnosis (resistant HTN, secondary causes of HTN) Consider specialty consultation for patients with resistant HTN Consider co-interventions to enhance management of HTN and improve blood pressure (pharmacist-led, nurse-led, dietitian-led) DASH Diet Protocol Nutrient Recommended Intake Saturated fat 6% of total calories Total fat 27% of total calories Carbohydrate 55% of total calories Dietary fiber 30 grams/day Protein 18% of total calories Cholesterol 150 mg/day Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain Mediterranean Diet Protocol Food Item Goal Recommended Items Olive oil 4 tbsp per day Tree nuts and peanuts 3 servings per week Fresh fruits including natural fruit juices 3 servings per day Vegetables 2 servings per day Seafood (primarily fatty fish) 3 servings per week Legumes 3 servings per week Sofritoa 2 servings per week White meat In place of red meat Wine with meals 7 glasses per week, for those who drinkb Discouraged Items Soda drinks <1 drink per day Commercial baked goods, sweets, pastriesc <3 servings per week Spread fats <1 serving per day Red and processed meats <1 serving per day Guidance Conducting Home Blood Pressure Measurement Preparation Have an empty bladder; rest quietly, without talking or texting, in seated position with back supported for at least five minutes Position Sit with back supported; keep both feet flat on the floor Cuff should be on bare arm; directly above the bend of the arm, pulled taut Center of the bladder of the cuff (commonly marked on the cuff) should be placed over the arterials pulsation of the patient s bare upper arm The arm with the cuff should be supported on a flat surface Number of readings Take 2 readings at least 1 minute apart in the morning before any antihypertensive medications and 2 readings at least 1 minute apart in the evening before bed for a total of 4 readings Duration of monitoring Preferred monitoring period is 7 days; a minimum period of 3 days may be sufficient, ideally in the period immediately before the next appointment Analyzing readings For each monitoring period, average all of the readings If the first day of readings is excluded, as sometimes recommended, the minimum of preferred periods of HBPM should be 4 and 8 days, respectively Guidance Conducting Office Blood Pressure Measurement Properly prepare the patient Have the patient relax, sitting in a chair with feet flat on floor and back supported for 3 5 minutes without talking or moving around before recording the first reading Avoid caffeine, exercise, and smoking for 30 minutes before measurement Ensure that the patient has emptied his/her bladder The patient nor the observer should talk during rest period or the measurement Remove clothing covering the location of cuff placement Sitting on an examining table does not fulfill these criteria Use proper technique (attended or unattended, fully AOBP measurement is preferred) Use a validated upper-arm cuff measurement device that has been calibrated Support the patient s arm (e.g.


, resting on a desk) Position the middle of cuff on the patient s upper arm, level with the right atrium Use the correct cuff size so that the bladder encircles 75 100% of the upper arm Take proper measurements needed At the first visit, record blood pressure in both arms; use the arm that gives the higher reading for subsequent readings (if consistently 10 15 mm Hg higher) Separate repeated measurements by 30 seconds Properly document accurate blood pressure readings Record SBP and DBP Note the time of most recent blood pressure medication taken before measuring Use average readings Average 2 readings for the visit blood pressure For initial documentation of the patient s blood pressure, use an average of the visit readings from 2 occasions to estimate the individual s blood pressure Provide blood pressure readings to patient Provide patients their SBP/DBP readings both verbally and in writing; help the patient interpret the results For more information about blood pressure measurements, see Appendix G and Appendix H in the full CPG.


For a video with instructions on measuring blood pressure at home, please click on the Home Blood Pressure Monitoring video available at this link: https://www.healthquality.va.gov/guidelines/CD/htn/ Abbreviations: A1c: glycated hemoglobin; ABPM: ambulatory blood pressure monitoring; ACEI: angiotensin-converting enzyme inhibitor; AOBP: automated office blood pressure; ARB: angiotensin II receptor blockers; AV: atrioventricular; CCB: calcium channel blocker; CHF: chronic heart failure; CKD: chronic kidney disease; cm: centimeter; CPG: clinical practice guideline; CV: cardiovascular; DASH: Dietary Approaches to Stop Hypertension; DBP: diastolic blood pressure; DHP: dihydropyridine; DoD: Department of Defense; EKG: electrocardiogram; HBPM: home blood pressure monitoring; Hg: mercury; HTN: hypertension; IR: immediate release; K+: potassium; LV: left ventricular; LVH: left ventricular hypertrophy; mg: milligram; MI: myocardial infarction; ml: milliliter; mm: millimeter; NSAIDs: nonsteroidal anti-inflammatory drugs; OSA: obstructive sleep apnea; SBP: systolic blood pressure; SDM: shared decision making; SR: sustained release; tbsp: tablespoon; VA: Department of Veterans Affairs a Sofrito is a sauce made with tomato and onion, and often includes garlic, herbs, and olive oil b Recommended wine volume per glass: 100 mL for women, 150 mL for men c Commercial baked goods, sweets, and pastries included cakes, cookies, biscuits, and custard, and did not include those that are homemade Select Antihypertensive Therapyb Select Medicationb Usual Dosage Range Comments Thiazide- Type Diuretics Chlorthalidone 12.5 25 mg daily May cause hyperuricemia/ gout Monitor K+ levels Hydrochlorothiazide 25 50 mg dailyc ACEIs Lisinopril 10 40 mg daily Avoid in pregnancy Do not use if history of angioedema Monitor K+ and kidney function ARBs Losartan (daily or divided Avoid in pregnancy Monitor K+ and kidney function Valsartan 30 320 mg daily Long-acting CCBs: DHP CCBs Amlodipine 2.5 10 mg daily May cause ankle edema, dizziness, flushing, headache, constipation Nifedipine SR 30 120 mg daily Long-acting CCBs: Non- DHP CCBs Verapamil SR (daily or divided Verapamil may cause constipation; contraindicated in 2nd or 3rd degree AV block; severe LV dysfunction Diltiazem SR 120 540 mg daily Diltiazem may decrease sinus rate; contraindicated in 2nd or 3rd degree AV block; use with caution in LV dysfunction a For complete drug information, review the manufacturer s prescribing information b Drug classes recommended as primary pharmacologic therapy for HTN for reduction in composite CV outcomes; selected medications include those listed on the VA National Formulary and DoD Basic Core Formulary; refer to the full HTN CPG for treatment recommendations and additional medications information c Hydochlorothiazide 12.5 mg may be considered as an initial dose with titration recommended to 25 50 mg daily; refer to Recommendation 25 and associated discussion in the full HTN CPG for further information


2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; Cheryl Dennison-Himmelfarb, RN, ANP, PhD; Joel Handler, MD; Daniel T. Lackland, DrPH; Michael L. LeFevre, MD, MSPH; Thomas D. MacKenzie, MD, MSPH; Olugbenga Ogedegbe, MD, MPH, MS; Sidney C. Smith Jr, MD; Laura P. Svetkey, MD, MHS; Sandra J. Taler, MD; Raymond R. Townsend, MD; Jackson T. Wright Jr, MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion.


There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. Published online December 18, 2013. Editorials Author Audio Interview at jama.com Supplemental content at jama.com Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Paul A. James, MD, University of Iowa, 200 Hawkins Dr, 01286-D PFP, Iowa City, IA 52242-1097 (paul-james@uiowa .edu).


Corresponding Author: Paul A. James, MD, University of Iowa, 200 Hawkins Dr, 01286-D PFP, Iowa City, IA 52242-1097 (paul-james@uiowa .edu). Clinical Review & Education Special Communication H ypertensionremainsoneofthemostimportantprevent- able contributors to disease and death. Abundant evi- dencefromrandomizedcontrolledtrials(RCTs)hasshown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension.1-3 Clinical guide- linesareattheintersectionbetweenresearchevidenceandclinical actions that can improve patient outcomes. The Institute of Medi- cineReportClinicalPracticeGuidelinesWeCanTrustoutlinedapath- way to guideline development and is the approach that this panel aspired to in the creation of this report.4 The panel members appointed to the Eighth Joint National Committee (JNC 8) used rigorous evidence-based methods, developing Evidence Statements and recommendations for blood pressure (BP) treatment based on a systematic review of the lit- erature to meet user needs, especially the needs of the primary care clinician. This report is an executive sum- mary of the evidence and is designed to provide clear recommendations for all clinicians. Major differ- ences from the previous JNC report are summarized in Table 1. The complete evidence summary and detailed description of the evidence review and methods are pro- vided online (see Supplement). The Process The panel members appointed to JNC 8 were selected from more than 400 nominees based on expertise in hypertension (n = 14), primary care (n = 6), including geriatrics (n = 2), cardiology (n = 2), nephrology (n = 3), nursing (n = 1), pharmacology (n = 2), clinical trials (n = 6), evidence-based medicine (n = 3), epidemiology (n = 1), informatics (n = 4), and the development and implementa- tion of clinical guidelines in systems of care (n = 4). The panel also included a senior scientist from the National In- stituteofDiabetesandDigestiveandKidneyDiseases(NIDDK),ase- nior medical officer from the National Heart, Lung, and Blood Insti- tute(NHLBI),andaseniorscientistfromNHLBI,whowithdrewfrom authorship prior to publication.


The panel also included a senior scientist from the National In- stituteofDiabetesandDigestiveandKidneyDiseases(NIDDK),ase- nior medical officer from the National Heart, Lung, and Blood Insti- tute(NHLBI),andaseniorscientistfromNHLBI,whowithdrewfrom authorship prior to publication. Two members left the panel early intheprocessbeforetheevidencereviewbecauseofnewjobcom- mitmentsthatpreventedthemfromcontinuingtoserve.Panelmem- bers disclosed any potential conflicts of interest including studies evaluated in this report and relationships with industry. Those with conflicts were allowed to participate in discussions as long as they declaredtheirrelationships,buttheyrecusedthemselvesfromvot- ingonevidencestatementsandrecommendationsrelevanttotheir relationships or conflicts. Four panel members (24%) had relation- shipswithindustryorpotentialconflictstodiscloseattheoutsetof the process. In January 2013, the guideline was submitted for external peer review by NHLBI to 20 reviewers, all of whom had expertise in hypertension, and to 16 federal agencies. Reviewers also had expertise in cardiology, nephrology, primary care, pharmacology, research (including clinical trials), biostatistics, and other impor- tant related fields. Sixteen individual reviewers and 5 federal agencies responded. Reviewers comments were collected, col- lated, and anonymized. Comments were reviewed and discussed by the panel from March through June 2013 and incorporated into a revised document. (Reviewers comments and suggestions, and responses and disposition by the panel are available on request from the authors.) Questions Guiding the Evidence Review This evidence-based hypertension guideline focuses on the pan- tified through a modified Delphi technique.5 Nine recommenda- tionsaremadereflectingthesequestions.Thesequestionsaddress thresholds and goals for pharmacologic treatment of hypertension and whether particular antihypertensive drugs or drug classes im- proveimportanthealthoutcomescomparedwithotherdrugclasses. macologictherapyatspecificBPthresholdsimprovehealthout- comes? 2. In adults with hypertension, does treatment with antihyperten- sive pharmacologic therapy to a specified BP goal lead to im- provements in health outcomes? 3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on spe- cific health outcomes?


In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on spe- cific health outcomes? The Evidence Review The evidence review focused on adults aged 18 years or older with hypertension and included studies with the following prespecified subgroups:diabetes,coronaryarterydisease,peripheralarterydis- ease, heart failure, previous stroke, chronic kidney disease (CKD), proteinuria,olderadults,menandwomen,racialandethnicgroups, and smokers. Studies with sample sizes smaller than 100 were ex- cluded, as were studies with a follow-up period of less than 1 year, because small studies of brief duration are unlikely to yield enough health-relatedoutcomeinformationtopermitinterpretationoftreat- ment effects. Studies were included in the evidence review only if theyreportedtheeffectsofthestudiedinterventionsonanyofthese important health outcomes: Overall mortality, cardiovascular disease (CVD) related mortality, CKD-related mortality Myocardial infarction, heart failure, hospitalization for heart fail- ure, stroke Coronary revascularization (includes coronary artery bypass sur- gery, coronary angioplasty and coronary stent placement), other revascularization (includes carotid, renal, and lower extremity re- vascularization) End-stage renal disease (ESRD) (ie, kidney failure resulting in di- alysis or transplantation), doubling of creatinine level, halving of glomerular filtration rate (GFR). The panel limited its evidence review to RCTs because they are lesssubjecttobiasthanotherstudydesignsandrepresentthegold standard for determining efficacy and effectiveness.6 The studies ACEI angiotensin-converting enzyme inhibitor ARB angiotensin receptor blocker BP blood pressure CCB calcium channel blocker CKD chronic kidney disease CVD cardiovascular disease ESRD end-stage renal disease GFR glomerular filtration rate HF heart failure Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E2 JAMA Published online December 18, 2013 jama.com in the evidence review were from original publications of eligible RCTs. These studies were used to create evidence tables and sum- mary tables that were used by the panel for their deliberations (see Supplement).


These studies were used to create evidence tables and sum- mary tables that were used by the panel for their deliberations (see Supplement). Because the panel conducted its own systematic re- view using original studies, systematic reviews and meta-analyses of RCTs conducted and published by other groups were not in- cluded in the formal evidence review. through December 31, 2009. The search strategy and PRISMA dia- gram for each question is in the online Supplement. To ensure that excluded from consideration, 2 independent searches of PubMed and CINAHL between December 2009 and August 2013 were con- ductedwiththesameMeSHtermsastheoriginalsearch.Threepanel members reviewed the results. The panel limited the inclusion cri- teria of this second search to the following. (1) The study was a ma- not meet strict inclusion criteria because it included nonhyperten- sive participants. SPS3 would not have changed our conclusions/ recommendations because the only significant finding supporting ticentered. (4) The study met all the other inclusion/exclusion cri- teria. The relatively high threshold of 2000 participants was used becauseofthemarkedlylowereventratesobservedinrecentRCTs such as ACCORD, suggesting that larger study populations are neededtoobtaininterpretableresults.Additionally,allpanelmem- bers were asked to identify newly published studies for consider- ation if they met the above criteria. No additional clinical trials met the previously described inclusion criteria. Studies selected were rated for quality using NHLBI s standardized quality rating tool (see Supplement) and were only included if rated as good or fair. An external methodology team performed the literature re- view, summarized data from selected papers into evidence tables, and provided a summary of the evidence. From this evidence re- view, the panel crafted evidence statements and voted on agree- ment or disagreement with each statement. For approved evi- dence statements, the panel then voted on the quality of the evidence (Table 2).


For approved evi- dence statements, the panel then voted on the quality of the evidence (Table 2). Once all evidence statements for each critical question were identified, the panel reviewed the evidence state- ments to craft the clinical recommendations, voting on each rec- ommendationandonthestrengthoftherecommendation(Table3). For both evidence statements and recommendations, a record of the vote count (for, against, or recusal) was made without attribu- tion. The panel attempted to achieve 100% consensus whenever possible,butatwo-thirdsmajoritywasconsideredacceptable,with theexceptionofrecommendationsbasedonexpertopinion,which required a 75% majority agreement to approve. Results (Recommendations) The following recommendations are based on the systematic evi- dence review described above (Box). Recommendations 1 through 5 address questions 1 and 2 concerning thresholds and goals for BP treatment. Recommendations 6, 7, and 8 address question 3 con- cerning selection of antihypertensive drugs. Recommendation 9 is asummaryofstrategiesbasedonexpertopinionforstartingandadd- ingantihypertensivedrugs.Theevidencestatementssupportingthe recommendations are in the online Supplement. Table 1.


Recommendation 9 is asummaryofstrategiesbasedonexpertopinionforstartingandadd- ingantihypertensivedrugs.Theevidencestatementssupportingthe recommendations are in the online Supplement. Table 1. Comparison of Current Recommendations With JNC 7 Guidelines Topic JNC 7 2014 Hypertension Guideline Methodology Nonsystematic literature review by expert committee including a range of study designs Recommendations based on consensus Critical questions and review criteria defined by expert panel with input from methodology team Initial systematic review by methodologists restricted to RCT evidence Subsequent review of RCT evidence and recommendations by the panel according to a standardized protocol Definitions Defined hypertension and prehypertension Definitions of hypertension and prehypertension not addressed, but thresholds for pharmacologic treatment were defined Treatment goals Separate treatment goals defined for uncomplicated hypertension and for subsets with various comorbid conditions (diabetes and CKD) Similar treatment goals defined for all hypertensive populations except when evidence review supports different goals for a particu- lar subpopulation Lifestyle recommendations Recommended lifestyle modifications based on literature review and expert opinion Lifestyle modifications recommended by endorsing the evidence- based Recommendations of the Lifestyle Work Group Drug therapy Recommended 5 classes to be considered as initial therapy but rec- ommended thiazide-type diuretics as initial therapy for most pa- tients without compelling indication for another class Specified particular antihypertensive medication classes for patients with compelling indications, ie, diabetes, CKD, heart failure, myocar- dial infarction, stroke, and high CVD risk Included a comprehensive table of oral antihypertensive drugs in- cluding names and usual dose ranges Recommended selection among 4 specific medication classes (ACEI or ARB, CCB or diuretics) and doses based on RCT evidence Recommended specific medication classes based on evidence review for racial, CKD, and diabetic subgroups Panel created a table of drugs and doses used in the outcome trials Scope of topics Addressed multiple issues (blood pressure measurement methods, patient evaluation components, secondary hypertension, adherence to regimens, resistant hypertension, and hypertension in special populations) based on literature review and expert opinion Evidence review of RCTs addressed a limited number of questions, those judged by the panel to be of highest priority.


Review process prior to publication Reviewed by the National High Blood Pressure Education Program Coordinating Committee, a coalition of 39 major professional, pub- lic, and voluntary organizations and 7 federal agencies Reviewed by experts including those affiliated with professional and public organizations and federal agencies; no official sponsorship by any organization should be inferred Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; JNC, Joint National Committee; RCT, randomized controlled trial 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E3 In the general population aged 60 years or older, initiate pharma- mm Hg or higher or diastolic blood pressure (DBP) of 90 mm Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. Strong Recommendation Grade A Corollary Recommendation In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (for example, <140 mm Hg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted.


Strong Recommendation Grade A Corollary Recommendation In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (for example, <140 mm Hg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted. Expert Opinion Grade E Recommendation 1 is based on evidence statements 1 through 3 from question 2 in which there is moderate- to high-quality evi- dence from RCTs that in the general population aged 60 years or older, treating high BP to a goal of lower than 150/90 mm Hg re- ducesstroke,heartfailure,andcoronaryheartdisease(CHD).There tion 2 that setting a goal SBP of lower than 140 mm Hg in this age group provides no additional benefit compared with a higher goal SBP of 140 to 160 mm Hg or 140 to 149 mm Hg.9,10 thatmettheeligibilitycriteriaandthateithercomparedtreatmentwith a particular goal vs no treatment or placebo or compared treatment with one BP goal with treatment to another BP goal. The trials on whichtheseevidencestatementsandthisrecommendationarebased Strengths,limitations,andotherconsiderationsrelatedtothisevidence reviewarepresentedintheevidencestatementnarrativesandclearly support the benefit of treating to a BP lower than 150 mm Hg. treated hypertensive patients aged 60 years or older in whom SBP vious guideline recommendations.12 The panel s opinion is that in these patients, it is not necessary to adjust medication to allow BP Table 3. Strength of Recommendation Grade Strength of Recommendation A Strong Recommendation There is high certainty based on evidence that the net benefita is substantial. B Moderate Recommendation There is moderate certainty based on evidence that the net benefit is moderate to substantial or there is high certainty that the net benefit is moderate. C Weak Recommendation There is at least moderate certainty based on evidence that there is a small net benefit.


C Weak Recommendation There is at least moderate certainty based on evidence that there is a small net benefit. D Recommendation against There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh benefits. E Expert Opinion ( There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends. )Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insuffi- cient evidence, unclear evidence, or conflicting evidence, but the committee thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. N No Recommendation for or against ( There is insufficient evidence or evidence is unclear or conflicting. )Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insuffi- cient evidence, unclear evidence, or conflicting evidence, and the committee thought no recommendation should be made. Further research is recommended in this area. The strength of recommendation grading system used in this guideline was developed by the National Heart, Lung, and Blood Institute s (NHLBI s) Evidence-Based Methodology Lead (with input from NHLBI staff, external methodology team, and guideline panels and work groups) for use by all the NHLBI CVD guideline panels and work groups during this project. Additional details regarding the strength of recommendation grading system are available in the online Supplement. a Net benefit is defined as benefits minus the risks/harms of the service/intervention. Table 2.


a Net benefit is defined as benefits minus the risks/harms of the service/intervention. Table 2. Evidence Quality Rating Type of Evidence Quality Ratinga Well-designed, well-executed RCTs that adequately represent populations to which the results are applied and directly assess effects on health outcomes Well-conducted meta-analyses of such studies Highly certain about the estimate of effect; further research is unlikely to change our confidence in the estimate of effect High RCTs with minor limitations affecting confidence in, or applicability of, the results Well-designed, well-executed non randomized controlled studies and well-designed, well-executed observational studies Well-conducted meta-analyses of such studies Moderately certain about the estimate of effect; further research may have an impact on our confidence in the estimate of effect and may change the estimate Moderate RCTs with major limitations Non randomized controlled studies and observational studies with major limitations affecting confidence in, or applicability of, the results Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports) Physiological studies in humans Meta-analyses of such studies Low certainty about the estimate of effect; further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate. Low Abbreviations: RCT, randomized controlled trial a The evidence quality rating system used in this guideline was developed by the National Heart, Lung, and Blood Institute s (NHLBI s) Evidence-Based Methodology Lead (with input from NHLBI staff, external methodology team, and guideline panels and work groups) for use by all the NHLBI CVD guideline panels and work groups during this project. As a result, it includes the evidence quality rating for many types of studies, including studies that were not used in this guideline. Additional details regarding the evidence quality rating system are available in the online Supplement.


Additional details regarding the evidence quality rating system are available in the online Supplement. Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E4 JAMA Published online December 18, 2013 jama.com ManyparticipantsinthosestudiesachievedanSBPlower than 140 mm Hg with treatment that was generally well tolerated. suggesttherewasnobenefitforanSBPgoallower were wide and did not exclude the possibility of a clinically impor- tant benefit. Therefore, the panel included a corollary recommen- dationbasedonexpertopinionthattreatmentforhypertensiondoes not need to be adjusted if treatment results in SBP lower than 140 mmHgandisnotassociatedwithadverseeffectsonhealthorqual- ity of life. While all panel members agreed that the evidence supporting nimity on the recommendation of a goal SBP of lower than 150 mm Hg. Some members recommended continuing the JNC 7 SBP goal of lower than 140 mm Hg for individuals older than 60 years based on expert opinion.12 These members concluded that the evidence than 150 mm Hg in high-risk groups, such as black persons, those withCVDincludingstroke,andthosewithmultipleriskfactors.The panelagreedthatmoreresearchisneededtoidentifyoptimalgoals of SBP for patients with high BP. In the general population younger than 60 years, initiate pharma- cologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal DBP of lower than 90 mm Hg.


In the general population younger than 60 years, initiate pharma- cologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal DBP of lower than 90 mm Hg. For ages 30 through 59 years, Strong Recommendation Grade A For ages 18 through 29 years, Expert Opinion Grade E Recommendation 2 is based on high-quality evidence from 5 DBPtrials(HDFP,Hypertension-StrokeCooperative,MRC,ANBP,and VA Cooperative) that demonstrate improvements in health out- Initiation of antihypertensive treatment at a DBP threshold of 90 Hg reduces cerebrovascular events, heart failure, and overall mor- ing patients to a goal of either 80 mm Hg or lower or 85 mm Hg or which patients were randomized to these 3 goals without statisti- cally significant differences between treatment groups in the pri- In adults younger than 30 years, there are no good- or fair- qualityRCTsthatassessedthebenefitsoftreatingelevatedDBPon health outcomes (question 1, evidence statement 14). In the ab- senceofsuchevidence,itisthepanel sopinionthatinadultsyounger than 30 years, the DBP threshold and goal should be the same as in adults 30 through 59 years of age. In the general population younger than 60 years, initiate pharma- cologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to a goal SBP of lower than 140 mm Hg. Expert Opinion Grade E Box. Recommendations for Management of Hypertension In the general population aged 60 years, initiate pharmacologic treat- ment to lower blood pressure (BP) at systolic blood pressure (SBP) 150 mm Hg or diastolic blood pressure (DBP) 90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation Grade A) Corollary Recommendation high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is welltoleratedandwithoutadverseeffectsonhealthorqualityoflife,treat- ment does not need to be adjusted.


(Strong Recommendation Grade A) Corollary Recommendation high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is welltoleratedandwithoutadverseeffectsonhealthorqualityoflife,treat- ment does not need to be adjusted. (Expert Opinion Grade E) In the general population <60 years, initiate pharmacologic treatment to 30-59 years, Strong Recommendation Grade A; For ages 18-29 years, Expert Opinion Grade E) In the general population <60 years, initiate pharmacologic treatment to Opinion Grade E) In the population aged 18 years with chronic kidney disease (CKD), ini- Opinion Grade E) SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion Grade E) In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, cal- cium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommenda- tion Grade B) In the general black population, including those with diabetes, initial anti- hypertensivetreatmentshouldincludeathiazide-typediureticorCCB.(For generalblackpopulation:ModerateRecommendation GradeB;forblack patients with diabetes: Weak Recommendation Grade C) In the population aged 18 years with CKD, initial (or add-on) antihyper- tensive treatment should include an ACEI or ARB to improve kidney out- comes.ThisappliestoallCKDpatientswithhypertensionregardlessofrace or diabetes status. (Moderate Recommendation Grade B) Themainobjectiveofhypertensiontreatmentistoattainandmaintaingoal BP.IfgoalBPisnotreachedwithinamonthoftreatment,increasethedose of the initial drug or add a second drug from one of the classes in recom- continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drugfromthelistprovided.DonotuseanACEIandanARBtogetherinthe same patient. If goal BP cannot be reached using only the drugs in recom- drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whomgoalBPcannotbeattainedusingtheabovestrategyorfortheman- agement of complicated patients for whom additional clinical consulta- tion is needed.


Referral to a hypertension specialist may be indicated for patients in whomgoalBPcannotbeattainedusingtheabovestrategyorfortheman- agement of complicated patients for whom additional clinical consulta- tion is needed. (Expert Opinion Grade E) 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E5 Recommendation 3 is based on expert opinion. While there is high-quality evidence to support a specific SBP threshold and goal found insufficient evidence from good- or fair-quality RCTs to sup- port a specific SBP threshold or goal for persons younger than 60 years. In the absence of such evidence, the panel recommends an SBP treatment threshold of 140 mm Hg or higher and an SBP treat- ment goal of lower than 140 mm Hg based on several factors. First,intheabsenceofanyRCTsthatcomparedthecurrentSBP age group, there was no compelling reason to change current rec- ommendations.Second,intheDBPtrialsthatdemonstratedtheben- to have achieved SBPs of lower than 140 mm Hg with treatment. It isnotpossibletodeterminewhethertheoutcomebenefitsinthese trials were due to lowering DBP, SBP, or both. Third, given the rec- ommended SBP goal of lower than 140 mm Hg in adults with dia- general population younger than 60 years may facilitate guideline implementation. In the population aged 18 years or older with CKD, initiate pharma- of 90 mm Hg or higher and treat to goal SBP of lower than 140 mm Hg and goal DBP lower than 90 mm Hg. Expert Opinion Grade E Based on the inclusion criteria used in the RCTs reviewed by the panel, this recommendation applies to individuals younger than 70 years with an estimated GFR or measured GFR less than and in people of any age with albuminuria defined as greater than 30 mg of albumin/g of creatinine at any level of GFR. question 2.


Expert Opinion Grade E Based on the inclusion criteria used in the RCTs reviewed by the panel, this recommendation applies to individuals younger than 70 years with an estimated GFR or measured GFR less than and in people of any age with albuminuria defined as greater than 30 mg of albumin/g of creatinine at any level of GFR. question 2. In adults younger than 70 years with CKD, the evidence is insufficient to determine if there is a benefit in mortality, or car- diovascularorcerebrovascularhealthoutcomeswithantihyperten- dence statement 15). There is evidence of moderate quality dem- onstrating no benefit in slowing the progression of kidney disease from treatment with antihypertensive drug therapy to a lower BP goal (for example, <130/80 mm Hg) compared with a goal of lower than 140/90 mm Hg (question 2, evidence statement 16). Three trials that met our criteria for review addressed the effect of antihypertensive drug therapy on change in GFR or time to development of ESRD, but only one trial addressed cardiovas- cular disease end points. Blood pressure goals differed across the trials, with 2 trials (AASK and MDRD) using mean arterial pressure and different targets by age, and 1 trial (REIN-2) using only DBP None of the trials showed that treatment to a lower BP goal (for example, <130/80 mm Hg) significantly lowered kidney or cardiovascular disease end points compared with a goal of lower than 140/90 mm Hg.


Blood pressure goals differed across the trials, with 2 trials (AASK and MDRD) using mean arterial pressure and different targets by age, and 1 trial (REIN-2) using only DBP None of the trials showed that treatment to a lower BP goal (for example, <130/80 mm Hg) significantly lowered kidney or cardiovascular disease end points compared with a goal of lower than 140/90 mm Hg. For patients with proteinuria (>3 g/24 hours), post hoc analy- sis from only 1 study (MDRD) indicated benefit from treatment to a lower BP goal (<130/80 mm Hg), and this related to kidney out- Although post hoc observational analyses of data from this trial and others suggested benefit from the lower goal at lower levels of proteinuria, this result was not seen in the primary analyses or in AASK or REIN-2 (question 2, evidence statement Based on available evidence the panel cannot make a recom- mendation for a BP goal for people aged 70 years or older with GFR less than 60 mL/min/1.73m2 . The commonly used estimating equations for GFR were not developed in populations with signifi- cant numbers of people older than 70 years and have not been validated in older adults. No outcome trials reviewed by the panel included large numbers of adults older than 70 years with CKD. Further, the diagnostic criteria for CKD do not consider age-related decline in kidney function as reflected in estimated GFR. Thus, when weighing the risks and benefits of a lower BP goal for people aged 70 years or older with estimated GFR less than 60 mL/min/ , antihypertensive treatment should be individualized, tak- ing into consideration factors such as frailty, comorbidities, and albuminuria.


Thus, when weighing the risks and benefits of a lower BP goal for people aged 70 years or older with estimated GFR less than 60 mL/min/ , antihypertensive treatment should be individualized, tak- ing into consideration factors such as frailty, comorbidities, and albuminuria. macologic treatment to lower BP at SBP of 140 mm Hg or higher or DBP of 90 mm Hg or higher and treat to a goal SBP of lower than 140 mm Hg and goal DBP lower than 90 mm Hg. Expert Opinion Grade E Syst-Eur, and UKPDS) that treatment to an SBP goal of lower than in adults with diabetes and hypertension.23-25 No RCTs addressed whether treatment to an SBP goal of lower than 140 mm Hg com- outcomesinadultswithdiabetesandhypertension.Intheabsence of such evidence, the panel recommends an SBP goal of lower than based on expert opinion, consistent with the BP goals in recom- hypertension.UseofaconsistentBPgoalinthegeneralpopulation younger than 60 years and in adults with diabetes of any age may facilitateguidelineimplementation.ThisrecommendationforanSBP goal of lower than 140 mm Hg in patients with diabetes is also sup- portedbytheACCORD-BPtrial,inwhichthecontrolgroupusedthis goal and had similar outcomes compared with a lower goal.7 The panel recognizes that the ADVANCE trial tested the ef- fects of treatment to lower BP on major macrovascular and micro- vascular events in adults with diabetes who were at increased risk of CVD, but the study did not meet the panel s inclusion criteria be- causeparticipantswereeligibleirrespectiveofbaselineBP,andthere were no randomized BP treatment thresholds or goals.26 The panel also recognizes that an SBP goal of lower than 130 mmHgiscommonlyrecommendedforadultswithdiabetesandhy- pertension.


Expert Opinion Grade E Syst-Eur, and UKPDS) that treatment to an SBP goal of lower than in adults with diabetes and hypertension.23-25 No RCTs addressed whether treatment to an SBP goal of lower than 140 mm Hg com- outcomesinadultswithdiabetesandhypertension.Intheabsence of such evidence, the panel recommends an SBP goal of lower than based on expert opinion, consistent with the BP goals in recom- hypertension.UseofaconsistentBPgoalinthegeneralpopulation younger than 60 years and in adults with diabetes of any age may facilitateguidelineimplementation.ThisrecommendationforanSBP goal of lower than 140 mm Hg in patients with diabetes is also sup- portedbytheACCORD-BPtrial,inwhichthecontrolgroupusedthis goal and had similar outcomes compared with a lower goal.7 The panel recognizes that the ADVANCE trial tested the ef- fects of treatment to lower BP on major macrovascular and micro- vascular events in adults with diabetes who were at increased risk of CVD, but the study did not meet the panel s inclusion criteria be- causeparticipantswereeligibleirrespectiveofbaselineBP,andthere were no randomized BP treatment thresholds or goals.26 The panel also recognizes that an SBP goal of lower than 130 mmHgiscommonlyrecommendedforadultswithdiabetesandhy- pertension. However, this lower SBP goal is not supported by any RCT that randomized participants into 2 or more groups in which Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E6 JAMA Published online December 18, 2013 jama.com treatment was initiated at a lower SBP threshold than 140 mm Hg or into treatment groups in which the SBP goal was lower than 140 mmHgandthatassessedtheeffectsofalowerSBPthresholdorgoal onimportanthealthoutcomes.TheonlyRCTthatcomparedanSBP treatment goal of lower than 140 mm Hg with a lower SBP goal and assessed the effects on important health outcomes is ACCORD-BP, which compared an SBP treatment goal of lower than 120 mm Hg with a goal lower than 140 mm Hg.7 There was no difference in the primary outcome, a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.


However, this lower SBP goal is not supported by any RCT that randomized participants into 2 or more groups in which Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E6 JAMA Published online December 18, 2013 jama.com treatment was initiated at a lower SBP threshold than 140 mm Hg or into treatment groups in which the SBP goal was lower than 140 mmHgandthatassessedtheeffectsofalowerSBPthresholdorgoal onimportanthealthoutcomes.TheonlyRCTthatcomparedanSBP treatment goal of lower than 140 mm Hg with a lower SBP goal and assessed the effects on important health outcomes is ACCORD-BP, which compared an SBP treatment goal of lower than 120 mm Hg with a goal lower than 140 mm Hg.7 There was no difference in the primary outcome, a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. There were also no dif- ferences in any of the secondary outcomes except for a reduction in stroke. However, the incidence of stroke in the group treated to lower than 140 mm Hg was much lower than expected, so the ab- solute difference in fatal and nonfatal stroke between the 2 groups was only 0.21% per year. The panel concluded that the results from ACCORD-BP did not provide sufficient evidence to recommend an SBP goal of lower than 120 mm Hg in adults with diabetes and hy- pertension. The panel similarly recommends the same goal DBP in adults with diabetes and hypertension as in the general population (<90 mm Hg). Despite some existing recommendations that adults with diabetesandhypertensionshouldbetreatedtoaDBPgoaloflower than 80 mm Hg, the panel did not find sufficient evidence to sup- port such a recommendation. For example, there are no good- or fair-qualityRCTswithmortalityasaprimaryorsecondaryprespeci- fied outcome that compared a DBP goal of lower than 90 mm Hg with a lower goal (evidence statement 21).


For example, there are no good- or fair-qualityRCTswithmortalityasaprimaryorsecondaryprespeci- fied outcome that compared a DBP goal of lower than 90 mm Hg with a lower goal (evidence statement 21). IntheHOTtrial,whichisfrequentlycitedtosupportalowerDBP goal, investigators compared a DBP goal of 90 mm Hg or lower vs a goal of 80 mm Hg or lower.19 The lower goal was associated with a of the study population that was not prespecified. As a result, the evidence was graded as low quality. Another commonly cited study to support a lower DBP goal is which had a BP goal of lower than 150/85 mm Hg in the more-intensivelytreatedgroupcomparedwithagoaloflowerthan 180/105 mm Hg in the less-intensively treated group. UKPDS did showthattreatmentinthelowergoalBPgroupwasassociatedwith asignificantlylowerrateofstroke,heartfailure,diabetes-relatedend points,anddeathsrelatedtodiabetes.However,thecomparisonin UKPDS was a DBP goal of lower than 85 mm Hg vs lower than105 mm Hg; therefore, it is not possible to determine whether treat- ment to a DBP goal of lower than 85 mm Hg improves outcomes compared with treatment to a DBP goal of lower than 90 mm Hg. In addition, UKPDS was a mixed systolic and diastolic BP goal study (combined SBP and DBP goals), so it cannot be determined if the benefits were due to lowering SBP, DBP, or both. In the general nonblack population, including those with diabetes, initialantihypertensivetreatmentshouldincludeathiazide-typedi- uretic, calcium channel blocker (CCB), angiotensin-converting en- zyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Moderate Recommendation Grade B For this recommendation, only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed; placebo-controlled RCTs were not included.


Moderate Recommendation Grade B For this recommendation, only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed; placebo-controlled RCTs were not included. However, the evidence review was informed by major placebo-controlled hypertension trials, includ- ing 3 federally funded trials (VA Cooperative Trial, HDFP, and SHEP), that were pivotal in demonstrating that treatment of hypertension with antihypertensive medications reduces cardio- vascular or cerebrovascular events and/or mortality.3,13,18 These trials all used thiazide-type diuretics compared with placebo or usual care as the basis of therapy. Additional evidence that BP lowering reduces risk comes from trials of -blocker vs and CCB vs placebo.1 Each of the 4 drug classes recommended by the panel in rec- cardiovascular,cerebrovascular,andkidneyoutcomes,withoneex- ception: heart failure. Initial treatment with a thiazide-type di- uretic was more effective than a CCB or ACEI (question 3, evidence statements 14 and 15), and an ACEI was more effective than a CCB (question 3, evidence statement 1) in improving heart failure out- comes.Whilethepanelrecognizedthatimprovedheartfailureout- comeswasanimportantfindingthatshouldbeconsideredwhense- lecting a drug for initial therapy for hypertension, the panel did not conclude that it was compelling enough within the context of the overallbodyofevidencetoprecludetheuseoftheotherdrugclasses for initial therapy. The panel also acknowledged that the evidence supported BP control, rather than a specific agent used to achieve thatcontrol,asthemostrelevantconsiderationforthisrecommen- dation.


The panel also acknowledged that the evidence supported BP control, rather than a specific agent used to achieve thatcontrol,asthemostrelevantconsiderationforthisrecommen- dation. The panel did not recommend -blockers for the initial treat- ment of hypertension because in one study use of -blockers re- sulted in a higher rate of the primary composite outcome of cardio- vascular death, myocardial infarction, or stroke compared to use of an ARB, a finding that was driven largely by an increase in stroke Intheotherstudiesthatcom- performed similarly to the other drugs (question 3, evidence state- ment 8) or the evidence was insufficient to make a determination (question 3, evidence statements 7, 12, 21, 23, and 24). -Blockers were not recommended as first-line therapy be- cause in one study initial treatment with an -blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic (question 3, evi- dence statement 13).29 There were no RCTs of good or fair quality dual 1- + -blocking agents (eg, carvedilol), vasodilating -block- rect vasodilators (eg, hydralazine), aldosterone receptor antago- nists(eg,spironolactone),peripherallyactingadrenergicantagonists (reserpine), and loop diuretics (eg, furosemide) (question 3, evi- mendedasfirst-linetherapy.Inaddition,noeligibleRCTswereiden- tified that compared a diuretic vs an ARB, or an ACEI vs an ARB. ONTARGET was not eligible because hypertension was not re- quired for inclusion in the study.30 Similar to those for the general population, this recommenda- tion applies to those with diabetes because trials including partici- pants with diabetes showed no differences in major cardiovascular or cerebrovascular outcomes from those in the general population (question 3, evidence statements 36-48). 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E7 The following important points should be noted. First, many people will require treatment with more than one antihyperten- sive drug to achieve BP control.


First, many people will require treatment with more than one antihyperten- sive drug to achieve BP control. While this recommendation ap- pliesonlytothechoiceoftheinitialantihypertensivedrug,thepanel agents (recommendation 9). Second, this recommendation is spe- cific for thiazide-type diuretics, which include thiazide diuretics, chlorthalidone, and indapamide; it does not include loop or potas- sium-sparing diuretics. Third, it is important that medications be dosedadequatelytoachieveresultssimilartothoseseenintheRCTs (Table 4). Fourth, RCTs that were limited to specific nonhyperten- sivepopulations,suchasthosewithcoronaryarterydiseaseorheart failure,werenotreviewedforthisrecommendation.Therefore,rec- ommendation 6 should be applied with caution to these popula- tions. Recommendations for those with CKD are addressed in rec- ommendation 8. In the general black population, including those with diabetes, ini- tial antihypertensive treatment should include a thiazide-type di- uretic or CCB. Forgeneralblackpopulation:ModerateRecommendation GradeB For black patients with diabetes: Weak Recommendation Grade C tion 3. In cases for which evidence for the black population was the sameasforthegeneralpopulation,theevidencestatementsforthe general population apply to the black population. However, there are some cases for which the results for black persons were differ- ent from the results for the general population (question 3, evi- dence statements 2, 10, and 17). In those cases, separate evidence statements were developed. This recommendation stems from a prespecified subgroup analysis of data from a single large trial (ALLHAT) that was rated In that study, a thiazide-type diuretic was shown to be more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACEI in the black patient subgroup, which included large numbers of diabetic and nondiabetic participants (question 3, evidence statements 10, 15 and 17). Therefore, the recommendation is to choose thiazide- type diuretics over ACEI for black patients.


Therefore, the recommendation is to choose thiazide- type diuretics over ACEI for black patients. Although a CCB was less effective than a diuretic in preventing heart failure in the black subgroup of this trial (question 3, evidence statement 14), there were no differences in other outcomes (cerebrovascular, CHD, combined cardiovascular, and kidney outcomes, or overall mortal- ity) between a CCB and a diuretic (question 3, evidence state- and CCBs are recommended as first-line therapy for hypertension in black patients. The panel recommended a CCB over an ACEI as first-line therapy in black patients because there was a 51% higher rate (relative risk, 1.51; 95% CI, 1.22-1.86) of stroke in black persons in ALLHAT with the use of an ACEI as initial therapy compared with use of a CCB (question 3, evidence statement 2).32 The ACEI was also less effective in reducing BP in black individuals compared with the CCB (question 3, evidence statement 2).32 There were no outcome studies meeting our eligibility criteria that compared diuretics or CCBs vs -blockers, ARBs, or other renin-angiotensin system inhibitors in black patients. Therecommendationforblackpatientswithdiabetesisweaker than the recommendation for the general black population be- causeoutcomesforthecomparisonbetweeninitialuseofaCCBcom- pared to initial use of an ACEI in black persons with diabetes were not reported in any of the studies eligible for our evidence review. Table 4. Evidence-Based Dosing for Antihypertensive Drugs Antihypertensive Medication Initial Daily Dose, mg Target Dose in RCTs Reviewed, mg No. of Doses per Day ACE inhibitors Angiotensin receptor blockers -Blockers Calcium channel blockers Thiazide-type diuretics Abbreviations: ACE, angiotensin-converting enzyme; RCT, randomized controlled trial. a Current recommended evidence-based dose that balances efficacy and safety is 25-50 mg daily.


a Current recommended evidence-based dose that balances efficacy and safety is 25-50 mg daily. Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E8 JAMA Published online December 18, 2013 jama.com Therefore,thisevidencewasextrapolatedfromfindingsintheblack port comes from a post hoc analysis of black participants in ALL- However,thisstudydidnotmeetthecriteriaforour reviewbecauseitwasaposthocanalysis.Thisrecommendationalso doesnotaddressblackpersonswithCKD,whoareaddressedinrec- ommendation 8. In the population aged 18 years or older with CKD and hyperten- sion, initial (or add-on) antihypertensive treatment should include anACEIorARBtoimprovekidneyoutcomes.ThisappliestoallCKD patients with hypertension regardless of race or diabetes status. Moderate Recommendation Grade B 32) that treatment with an ACEI or ARB improves kidney outcomes for patients with CKD. This recommendation applies to CKD pa- tients with and without proteinuria, as studies using ACEIs or ARBs showed evidence of improved kidney outcomes in both groups. This recommendation is based primarily on kidney outcomes because there is less evidence favoring ACEI or ARB for cardiovas- cular outcomes in patients with CKD. Neither ACEIs nor ARBs im- proved cardiovascular outcomes for CKD patients compared with (IDNT)didshowimprovementinheartfailureoutcomeswithanARB compared with a CCB, but this trial was restricted to a population with diabetic nephropathy and proteinuria (question 3, evidence There are no RCTs in the evidence review that di- rectlycomparedACEItoARBforanycardiovascularoutcome.How- ever, both are renin-angiotensin system inhibitors and have been shown to have similar effects on kidney outcomes (question 3, evi- dence statements 31-32). Recommendation 8 is specifically directed at those with CKD and hypertension and addresses the potential benefit of specific drugs on kidney outcomes.


Recommendation 8 is specifically directed at those with CKD and hypertension and addresses the potential benefit of specific drugs on kidney outcomes. The AASK study showed the benefit of an ACEI on kidney outcomes in black patients with CKD and pro- Additional trials that support the benefits of ACEI or ARB therapy did not meet our inclusion criteria because they were not re- stricted to patients with hypertension.35,36 Direct renin inhibitors arenotincludedinthisrecommendationbecausetherewerenostud- ies demonstrating their benefits on kidney or cardiovascular out- comes. Thepanelnotedthepotentialconflictbetweenthisrecommen- dation to use an ACEI or ARB in those with CKD and hypertension and the recommendation to use a diuretic or CCB (recommenda- tion 7) in black persons: what if the person is black and has CKD? To answerthis,thepanelreliedonexpertopinion.Inblackpatientswith CKD and proteinuria, an ACEI or ARB is recommended as initial therapy because of the higher likelihood of progression to ESRD.21 In black patients with CKD but without proteinuria, the choice for initialtherapyislessclearandincludesathiazide-typediuretic,CCB, ACEI, or ARB. If an ACEI or ARB is not used as the initial drug, then an ACEI or ARB can be added as a second-line drug if necessary to achieve goal BP. Because the majority of patients with CKD and hy- pertension will require more than 1 drug to achieve goal BP, it is an- ticipatedthatanACEIorARBwillbeusedeitherasinitialtherapyor as second-line therapy in addition to a diuretic or CCB in black pa- tients with CKD. CKD, but there is no evidence to support renin-angiotensin system inhibitor treatment in those older than 75 years. Although treat- ment with an ACEI or ARB may be beneficial in those older than 75 years, use of a thiazide-type diuretic or CCB is also an option for in- dividuals with CKD in this age group.


Although treat- ment with an ACEI or ARB may be beneficial in those older than 75 years, use of a thiazide-type diuretic or CCB is also an option for in- dividuals with CKD in this age group. Use of an ACEI or an ARB will commonly increase serum creati- nine and may produce other metabolic effects such as hyperkale- mia, particularly in patients with decreased kidney function. Al- thoughanincreaseincreatinineorpotassiumleveldoesnotalways require adjusting medication, use of renin-angiotensin system in- hibitorsintheCKDpopulationrequiresmonitoringofelectrolyteand serum creatinine levels, and in some cases, may require reduction in dose or discontinuation for safety reasons. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treat- ment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using the drugs in recommendation 6 because of a contraindica- tion or the need to use more than 3 drugs to reach goal BP, anti- hypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. Expert Opinion Grade E a perceived need for further guidance to assist in implementation of recommendations 1 through 8.


Expert Opinion Grade E a perceived need for further guidance to assist in implementation of recommendations 1 through 8. Recommendation 9 is based on strategies used in RCTs that demonstrated improved patient out- comesandtheexpertiseandclinicalexperienceofpanelmembers. Thisrecommendationdiffersfromtheotherrecommendationsbe- cause it was not developed in response to the 3 critical questions using a systematic review of the literature. The Figure is an algo- rithm summarizing the recommendations. However, this algo- rithmhasnotbeenvalidatedwithrespecttoachievingimprovedpa- tient outcomes. How should clinicians titrate and combine the drugs recom- mended in this report? There were no RCTs and thus the panel relied on expert opinion. Three strategies (Table 5) have been used in RCTs of high BP treatment but were not compared with each other. Based on the evidence reviewed for questions 1 through 3 and on the expert opinion of the panel members, it is not known if one of the strategies results in improved cardiovas- cular outcomes, cerebrovascular outcomes, kidney outcomes, or mortality compared with an alternative strategy. There is not likely to be evidence from well-designed RCTs that compare these 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E9 Figure. 2014 Hypertension Guideline Management Algorithm Adult aged 18 years with hypertension Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dose combination. Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). For strategy C, titrate doses of initial medications to maximum. Reinforce medication and lifestyle adherence.


For strategy C, titrate doses of initial medications to maximum. Reinforce medication and lifestyle adherence. Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). Reinforce medication and lifestyle adherence. Add additional medication class (eg, -blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management. Continue current treatment and monitoring.b Black All races Nonblack Age 60 years Blood pressure goal SBP <150 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Age <60 years Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg All ages Diabetes present No CKD Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg All ages CKD present with or without diabetes At goal blood pressure? No Yes At goal blood pressure? No Yes At goal blood pressure? No Yes Yes No Initiate thiazide-type diuretic or CCB, alone or in combination. Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination.a Initiate ACEI or ARB, alone or in combination with other drug class.a Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD). Implement lifestyle interventions (continue throughout management). Diabetes or CKD present General population (no diabetes or CKD) At goal blood pressure? SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker. a ACEIs and ARBs should not be used in combination. b If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan.


b If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan. Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure E10 JAMA Published online December 18, 2013 jama.com strategies and assess their effects on important health outcomes. There may be evidence that different strategies result in more rapid attainment of BP goal or in improved adherence, but those are intermediate outcomes that were not included in the evi- dence review. Therefore, each strategy is an acceptable pharma- cologic treatment strategy that can be tailored based on indi- vidual circumstances, clinician and patient preferences, and drug tolerability. With each strategy, clinicians should regularly assess BP, encourage evidence-based lifestyle and adherence interven- tions, and adjust treatment until goal BP is attained and main- tained. In most cases, adjusting treatment means intensifying therapy by increasing the drug dose or by adding additional drugs to the regimen. To avoid unnecessary complexity in this report, the hypertension management algorithm (Figure) does not explicitly define all potential drug treatment strategies. Finally,panelmemberspointoutthatinspecificsituations,one antihypertensive drug may be replaced with another if it is per- ceived not to be effective or if there are adverse effects. Limitations This evidence-based guideline for the management of high BP in adults is not a comprehensive guideline and is limited in scope be- tions (Table 1). Clinicians often provide care for patients with nu- merous comorbidities or other important issues related to hypertension, but the decision was made to focus on 3 questions considered to be relevant to most physicians and patients. Treat- ment adherence and medication costs were thought to be beyond the scope of this review, but the panel acknowledges the impor- tance of both issues.


Treat- ment adherence and medication costs were thought to be beyond the scope of this review, but the panel acknowledges the impor- tance of both issues. Theevidencereviewdidnotincludeobservationalstudies,sys- tematic reviews, or meta-analyses, and the panel did not conduct itsownmeta-analysisbasedonprespecifiedinclusioncriteria.Thus, information from these types of studies was not incorporated into the evidence statements or recommendations. Although this may be considered a limitation, the panel decided to focus only on RCTs because they represent the best scientific evidence and because therewereasubstantialnumberofstudiesthatincludedlargenum- bers of patients and met our inclusion criteria. Randomized con- trolled trials that included participants with normal BP were ex- cluded from our formal analysis. In cases in which high-quality evidencewasnotavailableortheevidencewasweakorabsent,the panelreliedonfair-qualityevidence,panelmembers knowledgeof thepublishedliteraturebeyondtheRCTsreviewed,andpersonalex- perience to make recommendations. The duration of the guideline developmentprocessfollowingcompletionofthesystematicsearch may have caused the panel to miss studies published after our lit- erature review. However, a bridge search was performed through August 2013, and the panel found no additional studies that would have changed the recommendations. Many of the reviewed studies were conducted when the over- all risk of cardiovascular morbidity and mortality was substantially higher than it is today; therefore, effect sizes may have been over- estimated. Further, RCTs that enrolled prehypertensive or nonhy- pertensiveindividualswereexcluded.Thus,ourrecommendations do not apply to those without hypertension. In many studies fo- cused on DBP, participants also had elevated SBP so it was not pos- sibletodeterminewhetherthebenefitobservedinthosetrialsarose from lowering DBP, SBP, or both. In addition, the ability to compare studiesfromdifferenttimeperiodswaslimitedbydifferencesinclini- cal trial design and analytic techniques.


In addition, the ability to compare studiesfromdifferenttimeperiodswaslimitedbydifferencesinclini- cal trial design and analytic techniques. While physicians use cost, adherence, and often observational data to make treatment decisions, medical interventions should wheneverpossiblebebasedfirstandforemostongoodsciencedem- onstratingbenefitstopatients.Randomizedcontrolledtrialsarethe gold standard for this assessment and thus were the basis for pro- vidingtheevidenceforourclinicalrecommendations.Althoughad- verse effects and harms of antihypertensive treatment docu- mented in the RCTs were considered when the panel made its decisions, the review was not designed to determine whether therapy-associated adverse effects and harms resulted in signifi- cantchangesinimportanthealthoutcomes.Inaddition,thisguide- line was not endorsed by any federal agency or professional soci- ety prior to publication and thus is a departure from previous JNC reports. The panel anticipates that an objective assessment of this reportfollowingpublicationwillallowopendialogueamongendors- Table 5. Strategies to Dose Antihypertensive Drugs Strategy Description Details A Start one drug, titrate to maximum dose, and then add a second drug If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum recommended dose to achieve goal BP If goal BP is not achieved with the use of one drug despite titration to the maximum recommended dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the maximum recommended dose of the second drug to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB.


Strategies to Dose Antihypertensive Drugs Strategy Description Details A Start one drug, titrate to maximum dose, and then add a second drug If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum recommended dose to achieve goal BP If goal BP is not achieved with the use of one drug despite titration to the maximum recommended dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the maximum recommended dose of the second drug to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP B Start one drug and then add a second drug before achieving maximum dose of the initial drug Start with one drug then add a second drug before achieving the maximum recommended dose of the initial drug, then titrate both drugs up to the maximum recommended doses of both to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination.


Titrate the third drug up to the maximum recommended dose to achieve goal BP C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination. Some committee members recommend starting therapy with 2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose. Abbreviations: ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic blood pressure; SBP, systolic blood pressure. 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E11 ing entities and encourage continued attention to rigorous meth- ods in guideline development, thus raising the standard for future guidelines. Discussion The recommendations based on RCT evidence in this guideline dif- fer from recommendations in other currently used guidelines sup- guidelines recommended treatment to lower BP goals in patients with diabetes and CKD based on observational studies.12 Recently, several guideline documents such as those from the American Dia- betesAssociationhaveraisedthesystolicBPgoalstovaluesthatare Other guidelines such as those of the European Society of Hyper- tension also recommend a systolic BP goal of lower than 150 mm Hg, albeit in patients older than 80 years (not 60 years as recom- Thischanginglandscapeisunderstand- ablegiventhelackofclearRCTevidenceinmanyclinicalsituations.


Discussion The recommendations based on RCT evidence in this guideline dif- fer from recommendations in other currently used guidelines sup- guidelines recommended treatment to lower BP goals in patients with diabetes and CKD based on observational studies.12 Recently, several guideline documents such as those from the American Dia- betesAssociationhaveraisedthesystolicBPgoalstovaluesthatare Other guidelines such as those of the European Society of Hyper- tension also recommend a systolic BP goal of lower than 150 mm Hg, albeit in patients older than 80 years (not 60 years as recom- Thischanginglandscapeisunderstand- ablegiventhelackofclearRCTevidenceinmanyclinicalsituations. History of JNC 8 The panel was originally constituted as the Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treat- ment of High Blood Pressure (JNC 8). In March 2008 NHLBI sent letters inviting the co-chairs and committee members to serve on JNC 8. The charge to the committee was as follows: The JNC 8 will review and synthesize the latest available scientific evidence, up- dateexistingclinicalrecommendations,andprovideguidancetobusy primary care clinicians on the best approaches to manage and con- trol hypertension in order to minimize patients risk for cardiovas- cular and other complications. The committee was also asked to identify and prioritize the most important questions for the evi- dence review. In June 2013, NHLBI announced its decision to dis- continue developing clinical guidelines including those in process, instead partnering with selected organizations that would develop Importantly, participation in this process re- quired that these organizations be involved in producing the final content of the report. The panel elected to pursue publication in- dependentlytobringtherecommendationstothepublicinatimely manner while maintaining the integrity of the predefined process. This report is therefore not an NHLBI sanctioned report and does not reflect the views of NHLBI. Conclusions Itisimportanttonotethatthisevidence-basedguidelinehasnotre- nition from JNC 7 remains reasonable. The relationship between naturallyoccurringBPandriskislineardowntoverylowBP,butthe benefitoftreatingtotheselowerlevelswithantihypertensivedrugs is not established.