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JNC-8 New Guidelines…Finally
Let the controversies begin
Eric D Peterson, MD, MPH
Director of DCRI
Feb, 2014
http://www.dcri.duke.edu/research/coi.jsp
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2
• Affects 1 billion people worldwide
• US – about 1 in 3 adults
– 73 million have hypertension (SBP >140/90)
• A 55yo normotensive person has up to a 90% lifetime
risk of developing hypertension (Vasan 2001)
• Number one reason listed for office visits
• Causes/contributes to 457,000 admissions per year
• A leading cause/contributor to death (MI, stroke,
vascular disease)
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 3
• “The greatest danger to a man with high blood pressure
lies in its discovery, because then some fool is certain to
try and reduce it.”- J.H. Hay, 1931.
• “Hypertension may be an important compensatory
mechanism which should not be tampered with, even
were it certain that we could control it.” Paul Dudley
White, 1937.
How Aggressive to Treat Hypertension
Some Early Views on the Controversy
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 4
Stroke and IHD Mortality vs Systolic BP by Age
Mortality
(Floatingabsoluteriskand95%CI)
Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Stroke
Age at risk
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Ischemic Heart Disease
Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Age at risk:
40-49 years
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Lancet. 2002;360:1903-1913
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 5
BP Reductions as Small as 2 mmHg Reduce
the Risk of CV Events by Up to 10%
▶ Meta-analysis of 61 prospective, observational studies
▶ 1 million adults
▶ 12.7 million person-years
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
2 mmHg
increase in
mean SBP
10% increase in
risk of stroke
mortality
7% increase in
risk of ischemic
heart disease
mortality
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 6
Benefits of Treating Hypertension: RCT
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
Heart failure Stroke Cardiovascular
death
Riskreduction(%)
↓ 50%
↓ 40%
↓ 20%
Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 7
Lifestyle Modifications
Goal blood pressure <140/90 mm Hg
<130/80 mm Hg with diabetes or chronic kidney disease*
Initial drug choices
Without Compelling indications
Stage 1 Hypertension
(SBP 140-159 DBP 90-99 )
Diuretics for most; may
consider ACE inhibitor,
ARB, beta blocker, CCB or
combination
Stage 2 hypertension
(SBP ≥ 160 or DBP ≥ 100)
2-drug combination for
most (Diuretic +ACE, ARB,
beta blocker, or CCB)
With compelling indications
Drug(s) for compelling
indications
Diuretics, ACE inhibitor,
ARB, beta blocker, CCB as
needed
* Released in 2003
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 8
NHLBI Drops Out of
Guidelines Business
JNC-8 Significantly
Delayed
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 9
James et al JAMA December 13 2014
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 10
James et al JAMA December 13 2014
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 11
James et al JAMA December 13 2014
JNC-8 Hypertension Treatment Choices
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 12
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 13
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 14
The Evidence for Targets: JATOS Study
• 2200 pts per arm
• Baseline BP 170/90
• Target
<150 mild vs. <140 strict
• Drugs:
– Ca++blocker 50-60%
– Ace 30-40%
– Alpha blocker 15%
– Diuretic 15%
• Follow-up 2 yrs
Hypertens Res. 2008;31(12):2115-2127
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 15
JATOS Results
Hypertens Res. 2008;31(12):2115-2127
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 16
The Evidence for Targets: VALISH Trial
Hypertension. 2010;56(2):196-202
• 1630 pts per arm
• Baseline BP 170/80
• Target
Mild <150, strict <140
• Drugs:
– Valsartan 100%
– Ca++ blacker 30%
– Diuretic 10-15%
• Median Follow-up 3 yrs
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 17
Hypertension. 2010;56(2):196-202
VALISH Trial
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 18
RCTs Evaluating SBP Targets
in those Aged < 60
“Does the absence of evidence lead to
the conclusion of evidence of absence?”
JNC-8 authors concluded:
- Yes for those >60
- No for those <60
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 19
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 20
Guidelines, Performance Measures and Policy
• Guideline:
– In past: practical advice on a course of action
– Have become: RCT-based, rigorous
• Performance Measures:
– Distillation of guidelines:
• Use strict criteria to define what should and must
be done to avoid a quality concern
– Often applied to public reporting or financial
incentives
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 21
BP Treatment Targets Have Risks Both Ways
• If one votes to keep all at 140/90
– PM’s and incentives may encourage over-treatment
• Worse symptoms, falls, costs in elderly
• If one votes to move to 150/90 in elderly
– Risk of under-treatment
• Despite existing guideline goals/PM’s, <50%
of public reaches goal!
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 22
JNC-8 Implications for US
All US Adults Ages 18-59 Ages 60+
JNC 7: HTN 66.6 32.8 33.8
Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%)
JNC 8: HTN 60.8 30.8 30.0
Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 23
Major Findings
• Currently: 66.7 million in US have hypertension,
– of which 39.9% met guideline targets.
• Using JNC 8: 60.8 million in US have hypertension,
– of which 56.4% have controlled blood pressure.
• In 60+, switching to JNC-8
– improves BP control rates from 34.3% to 60.8%
– reclassifying 13.6 million with previously
uncontrolled BP now seen as under control
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 24
Conclusions
• Hypertension: common, costly and modifiable
• Interpretation of existing evidence is challenging
– Determining the optimal threshold will require
more RCTs.
• In interim: My view:
– Aim for 140/90 but allow for individualization
– What’s your take?

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The Hypertension Guidelines JNC 8

  • 1. JNC-8 New Guidelines…Finally Let the controversies begin Eric D Peterson, MD, MPH Director of DCRI Feb, 2014 http://www.dcri.duke.edu/research/coi.jsp
  • 2. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2 • Affects 1 billion people worldwide • US – about 1 in 3 adults – 73 million have hypertension (SBP >140/90) • A 55yo normotensive person has up to a 90% lifetime risk of developing hypertension (Vasan 2001) • Number one reason listed for office visits • Causes/contributes to 457,000 admissions per year • A leading cause/contributor to death (MI, stroke, vascular disease)
  • 3. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 3 • “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.”- J.H. Hay, 1931. • “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” Paul Dudley White, 1937. How Aggressive to Treat Hypertension Some Early Views on the Controversy
  • 4. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 4 Stroke and IHD Mortality vs Systolic BP by Age Mortality (Floatingabsoluteriskand95%CI) Usual Systolic BP (mm Hg) 50-59 years 60-69 years 70-79 years 80-89 years Stroke Age at risk 256 128 64 32 16 8 4 2 1 0 120 140 160 180 Ischemic Heart Disease Usual Systolic BP (mm Hg) 50-59 years 60-69 years 70-79 years 80-89 years Age at risk: 40-49 years 256 128 64 32 16 8 4 2 1 0 120 140 160 180 Lancet. 2002;360:1903-1913
  • 5. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 5 BP Reductions as Small as 2 mmHg Reduce the Risk of CV Events by Up to 10% ▶ Meta-analysis of 61 prospective, observational studies ▶ 1 million adults ▶ 12.7 million person-years Prospective Studies Collaboration. Lancet. 2002;360:1903-1913 2 mmHg increase in mean SBP 10% increase in risk of stroke mortality 7% increase in risk of ischemic heart disease mortality
  • 6. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 6 Benefits of Treating Hypertension: RCT -100 -90 -80 -70 -60 -50 -40 -30 -20 -10 0 Heart failure Stroke Cardiovascular death Riskreduction(%) ↓ 50% ↓ 40% ↓ 20% Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996
  • 7. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 7 Lifestyle Modifications Goal blood pressure <140/90 mm Hg <130/80 mm Hg with diabetes or chronic kidney disease* Initial drug choices Without Compelling indications Stage 1 Hypertension (SBP 140-159 DBP 90-99 ) Diuretics for most; may consider ACE inhibitor, ARB, beta blocker, CCB or combination Stage 2 hypertension (SBP ≥ 160 or DBP ≥ 100) 2-drug combination for most (Diuretic +ACE, ARB, beta blocker, or CCB) With compelling indications Drug(s) for compelling indications Diuretics, ACE inhibitor, ARB, beta blocker, CCB as needed * Released in 2003
  • 8. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 8 NHLBI Drops Out of Guidelines Business JNC-8 Significantly Delayed
  • 9. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 9 James et al JAMA December 13 2014
  • 10. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 10 James et al JAMA December 13 2014
  • 11. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 11 James et al JAMA December 13 2014 JNC-8 Hypertension Treatment Choices
  • 12. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 12
  • 13. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 13
  • 14. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 14 The Evidence for Targets: JATOS Study • 2200 pts per arm • Baseline BP 170/90 • Target <150 mild vs. <140 strict • Drugs: – Ca++blocker 50-60% – Ace 30-40% – Alpha blocker 15% – Diuretic 15% • Follow-up 2 yrs Hypertens Res. 2008;31(12):2115-2127
  • 15. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 15 JATOS Results Hypertens Res. 2008;31(12):2115-2127
  • 16. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 16 The Evidence for Targets: VALISH Trial Hypertension. 2010;56(2):196-202 • 1630 pts per arm • Baseline BP 170/80 • Target Mild <150, strict <140 • Drugs: – Valsartan 100% – Ca++ blacker 30% – Diuretic 10-15% • Median Follow-up 3 yrs
  • 17. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 17 Hypertension. 2010;56(2):196-202 VALISH Trial
  • 18. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 18 RCTs Evaluating SBP Targets in those Aged < 60 “Does the absence of evidence lead to the conclusion of evidence of absence?” JNC-8 authors concluded: - Yes for those >60 - No for those <60
  • 19. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 19
  • 20. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 20 Guidelines, Performance Measures and Policy • Guideline: – In past: practical advice on a course of action – Have become: RCT-based, rigorous • Performance Measures: – Distillation of guidelines: • Use strict criteria to define what should and must be done to avoid a quality concern – Often applied to public reporting or financial incentives
  • 21. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 21 BP Treatment Targets Have Risks Both Ways • If one votes to keep all at 140/90 – PM’s and incentives may encourage over-treatment • Worse symptoms, falls, costs in elderly • If one votes to move to 150/90 in elderly – Risk of under-treatment • Despite existing guideline goals/PM’s, <50% of public reaches goal!
  • 22. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 22 JNC-8 Implications for US All US Adults Ages 18-59 Ages 60+ JNC 7: HTN 66.6 32.8 33.8 Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%) JNC 8: HTN 60.8 30.8 30.0 Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)
  • 23. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 23 Major Findings • Currently: 66.7 million in US have hypertension, – of which 39.9% met guideline targets. • Using JNC 8: 60.8 million in US have hypertension, – of which 56.4% have controlled blood pressure. • In 60+, switching to JNC-8 – improves BP control rates from 34.3% to 60.8% – reclassifying 13.6 million with previously uncontrolled BP now seen as under control
  • 24. All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 24 Conclusions • Hypertension: common, costly and modifiable • Interpretation of existing evidence is challenging – Determining the optimal threshold will require more RCTs. • In interim: My view: – Aim for 140/90 but allow for individualization – What’s your take?