Stages of hypertension according to JNC 8, and the JNC 8 target blood pressure in people over 60

Classification (JNC 7 stages, retained for reference). The textbook definition is a systolic pressure of 140 mmHg or greater and/or a diastolic pressure of 90 mmHg or greater.

What JNC 8 actually did. JNC 8 (published in JAMA, 2014) was an evidence-based panel report addressing nine questions on thresholds, targets and drug choice, deliberately restricted to randomised controlled trial evidence. It did not define stages, did not address measurement technique, secondary hypertension, lifestyle modification or resistant hypertension, and was not formally endorsed by the NHLBI.

The JNC 8 recommendation for people over 60 — the core of the question. In the general population aged 60 years and older, initiate pharmacological treatment when the blood pressure is ≥ 150/90 mmHg, and treat to a goal of below 150/90 mmHg (Grade A, strong recommendation). This relaxation of the systolic threshold from 140 to 150 mmHg was the single most controversial and most examinable element of JNC 8, and was based chiefly on HYVET, SHEP and Syst-Eur. The panel added a corollary (expert opinion): if treatment already achieves a lower systolic pressure without adverse effects on health or quality of life, treatment need not be adjusted upwards. A minority of the panel dissented, arguing the evidence was insufficient to raise the threshold above 140 mmHg.

Other JNC 8 thresholds and targets.

JNC 8 drug recommendations. In the general non-Black population, including those with diabetes, first-line treatment may be a thiazide-type diuretic, calcium channel blocker, ACE inhibitor or ARB. In the general Black population, including those with diabetes, first-line treatment should be a thiazide-type diuretic or calcium channel blocker. In chronic kidney disease of any race, an ACE inhibitor or ARB should be included for renal protection. Beta-blockers were NOT recommended as first-line therapy (based on the LIFE trial), which was another notable departure from JNC 7. Titration strategies: maximise the first drug, add a second before maximising the first, or start with two drugs.

Criticisms and the geriatric perspective. The over-60 target of 150/90 mmHg was criticised as too permissive, particularly for patients with coronary artery disease or previous stroke, and it was overturned by SPRINT (2015), which showed that targeting a systolic pressure below 120 mmHg reduced cardiovascular events and all-cause mortality, including in a prespecified subgroup aged 75 and over. The enduring, examinable geriatric principle from JNC 8 is nevertheless correct and still current: blood pressure targets in older people must be individualised and balanced against orthostatic hypotension, falls, polypharmacy, frailty and quality of life. The important practical caveat is that SPRINT measured unattended automated office blood pressure, which reads roughly 5–10 mmHg lower than conventional office measurement.

JNC 8 is now obsolete and has been superseded twice over. The 2025 AHA/ACC multisociety guideline (co-authored by the American Geriatrics Society) retires and replaces the 2017 ACC/AHA guideline and sets a universal target of below 130/80 mmHg, with encouragement to reach a systolic pressure below 120 mmHg, supported by SPRINT, STEP (in patients aged 60–80), ESPRIT and BPROAD. It also introduces the PREVENT risk calculator in place of the Pooled Cohort Equations, endorses single-pill combinations and home/ambulatory measurement, and provides explicit individualised exceptions for institutionalised patients, the frail and those with limited life expectancy. In parallel the 2024 ESC guideline introduced the intermediate category of "Elevated BP" (120–139/70–89 mmHg) and a target of 120–129 mmHg systolic where tolerated.