hypertension update:- JNC 8 guidelines

1. Hypertension Update: JNC8
Dr. Mansij Biswas
SYR, Dept. of Pharmacology & Therapeutics
Seth GS Medical College & KEM Hospital

2. “The greatest danger to
a man with high blood pressure
lies in its discovery because then
some fool is certain to try his hand
and reduce it”
Hay J, “A british medical association lecture on the significance of a raised blood pressure,” British
Medical Journal, vol. 2, no. 3679, pp. 43–47, 1931
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3. At a glance…
 Eighth Joint National Committee
 Evidence- based Guidelines
 Not just JNC 7 “Renovated” BUT “Demolished &
Reconstructed”
 Destination is important and not the journey!!
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4. Introduction:
 Hypertension remains one of the most important preventable
contributors to disease and death
 Guidelines are at the intersection between research evidence and
clinical actions that can improve patient outcomes
 The panel members appointed to the JNC 8 used evidence-based
methods, developing statements and recommendations for high
blood pressure management
 Recommendations are based on a systematic review of literature
to meet the need of the primary care physicians
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5. Hypertension (HTN) is a major public health concern, affecting
26% of adults worldwide
People with HTN
worldwide in 2000
972 million
Increase in the
number of adults with
HTN globally by 2025
60%
Percentage of all global
healthcare spending
attributable to treat high
blood pressure
10%
Annual worldwide cost of
treating hypertension
$370 billion
1.6 Billion
HTN patients estimated
by 2025
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23.
Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.

6. Questions Guiding the Evidence Review
 Guideline focuses on the panel’s most debated questions
related to high BP management.
 These questions address:
 Thresholds and goals for treatment of hypertension
 Whether particular antihypertensive drugs or drug classes
improve important health outcomes compared with others
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7. Questions Guiding the Evidence Review
① In adults with hypertension, does initiating antihypertensive
pharmacologic therapy at specific BP thresholds improve
health outcomes? Threshold
② In adults with hypertension, does treatment with
antihypertensive pharmacologic therapy to a specified BP goal
lead to improvement in health outcome? Goal
③ In adults with hypertension, do various antihypertensive drugs
or drug classes differ in comparative benefits and harms on
specific health outcome? Impact of drugs
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8. Process:
>400 nominees
Members selected
Guidelines first draft - January 2013
Reviewed by 20 (16) reviewers and 16 (5) federal agencies -
February 2013
Revised document - June 2013
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9. Population Criteria:
• Adults ≥ 18 years with HTN
• Subgroups-
• DM
• CAD, PAD
• HF
• Previous h/o Stroke
• CKD, Proteinuria
• Older adults (>70 years of age)
• Men/Women
• Racial/ethnic groups
• Smokers
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10. Outcomes considered:
• Mortality: overall, CVD related, CKD related
• MI, HF (hospitalization due to HF), stroke
• Revascularization: Coronary (CABG,
Angioplasty, Stent placement), others
(carotid, renal, lower extremity)
• ESRD (resulting in dialysis or transplant),
doubling Creatinine level, halving GFR
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11. Trials:
 Only RCTs (well executed or with minor limitations
only- rated as ‘good’ or ‘fair’)
 Period January 1, 1966 to December 31, 2009
 Secondary search: (with same MeSH terms)
 PubMed & CINAHL
 December 2009 – August 2013
 Major study in HTN (like ACCORD), ≥ 2000
subjects, multi-centric, met inclusion/exclusion
criteria
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12. Collation:
• Literature review & Data tabulation by external methodology
team
• Evidence summarized
• Evidence statements crafted
• Voting
 Agree/disagree with each evidence statement
 Quality of evidence (high, moderate or low)
• Clinical recommendations crafted
• Voting
 Agree/disagree with recommendation
 Strength of recommendation
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13. 09/08/14
Copyright © 2012 American Medical Association. All rights reserved.
JAMA. 2013; doi:10.1001/jama.2013.284427
13

14. Recommendations:
 Recommendations 1-5:
Threshold and goals for HTN treatment
 Recommendations 6-8:
Selection of anti-HTN drugs
 Recommendation 9:
Summary of strategies (expert opinion)
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15. Recommendation 1:
General population aged 60 years or older:
SBP ≥150 mm Hg
Or
DBP ≥ 90mm Hg
Goal of Treatment:
SBP <150 mm Hg
OR
DBP of < 90mm Hg.
Initiate Treatment at:
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16. Recommendation 1: Corollary
General population aged ≥60years
 Treatment does not need to be adjusted
IF
Pharmacologic treatment for high BP results in lower
achieved SBP (<140mmHg) and treatment is well
tolerated and without adverse effects on health or quality
of life

17. Recommendation 2:
General population < 60 years:
Initiate Treatment at: DBP ≥ 90mm Hg
Goal of Treatment: DBP of < 90mm Hg
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18. Recommendation 3:
General population < 60 years:
SBP ≥ 140 mm Hg
Initiate Treatment at:
Goal of Treatment: SBP of < 140 mm Hg
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19. Recommendation 4:
Population aged 18 years or older with CKD:
Initiate Treatment at:
SBP ≥ 140 mm Hg
Or
DBP ≥ 90 mm Hg
Goal of Treatment:
SBP < 140 mm Hg
Or
DBP < 90 mm Hg
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20. Recommendation 5:
Population aged 18 years or older with diabetes:
Initiate Treatment at:
SBP ≥ 140 mm Hg
Or
DBP ≥ 90 mm Hg
Goal of Treatment:
SBP < 140 mm Hg
Or
DBP < 90 mm Hg
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21. Recommendation 6:
In General non black population, including those with
diabetes, initial anti-HTN therapy should include any of the
following:
 Thiazide-type diuretic
 Calcium channel blocker (CCB)
 Angiotensin-converting enzyme inhibitor (ACEI)
 Angiotensin receptor blocker (ARB)
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22. Recommendation 7:
In general black population, including those with
diabetes, initial antihypertensive treatment should
include:
 Thiazide-type diuretic
OR
 Calcium channel blocker (CCB)
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23. Recommendation 8:
Population aged 18 years or more with CKD ± DM
 Initial (or add-on) antihypertensive treatment should include an
ACEI or ARB to improve kidney outcomes
 This applies to all CKD patients with hypertension regardless of
race or diabetes status
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24. Recommendation 9:
 The main aim is to attain and maintain a goal BP
 If goal BP is not reached within a month of treatment:
 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
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25. Recommendation 9: contd…
 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 contraindication or due to adverse reactions or the need
to use more than 3 drugs to reach goal BP: Anti- HTN drugs from
other classes can be used
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26. Strategies to Dose Antihypertensive Drugs
Figure Legend:
09/08/14
Copyright © 2012 American Medical Association. All rights reserved.
JAMA. 2013; doi:10.1001/jama.2013.284427
26

27. Recommendation 9: contd…
 For patients in whom goal BP cannot be attained using the
above strategy
OR
 The management of complicated patients for whom
additional clinical consultation is needed
 Referral to a hypertension specialist may be indicated
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28. JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi:1 09/08/14 28 0.1001/jama.2013.284427

29. JNC 8 (2014 Hypertension Guideline Management Algorithm)
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30. JNC 8 (2014 Hypertension Guideline Management Algorithm)
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30

31. Copyright © 2012 American Medical Association. All rights
reserved. JAMA. 2013; doi:10.1001/jama.2013.284427
Figure Legend:
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32. JNC 7
 Nonsystematic literature
review by expert committee
including a range of study
designs
 Recommendations based on
consensus
JNC 8
 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
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33. JNC 7
 Defined hypertension and
prehypertension
JNC 8
 Definitions of hypertension and
prehypertension not addressed
 But thresholds for
pharmacologic treatment were
defined
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34. JNC 7
 Separate treatment goals
defined for
 “uncomplicated” hypertension
 Subsets with various comorbid
conditions (diabetes and CKD)
JNC 8
 Similar treatment goals defined
for all hypertensive populations
 Except when evidence review
supports different goals for a
particular subpopulation
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35. JNC 7
 Recommended lifestyle
modifications based on
literature review and expert
opinion
JNC 8
 Lifestyle modifications
recommended by endorsing the
evidence based
recommendations of the
Lifestyle Work Group
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36. JNC 7
 Recommended 5 classes to be considered
as initial therapy
 Recommended thiazide-type diuretics as
initial therapy for most patients without
compelling indication for another class
 Specified particular antihypertensive
medication classes for patients with
compelling indications, ie, diabetes,
CKD, heart failure, myocardial
infarction, stroke, and high CVD risk
 Included a comprehensive table of oral
antihypertensive drugs including names
and usual dose ranges
JNC 8
 Recommended selection among 4
specific medication classes
 ACEI or ARB, CCB or diuretics
 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
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37. JNC 7
 Addressed multiple issues
 blood pressure measurement
methods
 Patient evaluation components
 Secondary hypertension
 Adherence to regimens
 Resistant hypertension
 Hypertension in special
populations
 Based on literature review and
expert opinion
JNC 8
 Addressed a limited number of
questions, those judged by the
panel to be of highest priority.
 Evidence review of RCTs
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38. JNC 7
 Reviewed by the National High
Blood Pressure Education
Program
 Coordinating Committee
 a coalition of 39 major professional
 Public and voluntary
organizations and 7 federal
agencies
JNC 8
 Reviewed by experts including
those affiliated with
 Professional
 Public organizations
 Federal agencies
 No official sponsorship by any
organization should be inferred
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39. 09/08/14 JAMA. 2013;():. 39 doi:10.1001/jama 2013.28442

40. Limitations:
 Focused to address 3 specific questions: clinicians often provide
care for patients with numerous co-morbidities
 Treatment adherence and medication costs were thought to be
beyond the scope of this guideline
 Did not include observational studies or systematic reviews and
did not perform its own meta-analysis
 Many of the reviewed studies were conducted when the overall
CV morbidity and mortality were much higher than today- effect
size might have been over-estimated
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41. Conclusion:
 Guidelines Offer clinicians an analysis of what is known and not
known about BP treatment thresholds, goals and drug treatment
strategies.
 Provides evidence-based recommendations for the management
of high BP.
 Should meet the clinical needs of most patients.
 However, these recommendations are not a substitute for clinical
judgment and decisions must be carefully considered and
incorporate the clinical characteristics of each individual.
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42. ANIMATED SLIDE