2014 Evidence-Based Guideline for the Managementof High Blood Pressure in AdultsReport From the Panel Members Appointedto the Eighth Joint National Committee (JNC 8)dr Nahar Taufiq, Sp.JP (K)

Disclosures No disclosures

HypertensionHypertension is the most common condition in primary care.

1 in 3 patients have hypertension according to NHLBI

Risk factor for MI, CVA, ARF, death

CaseA 58 year old African-American woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine micro-albumin is mildly elevated.

Case Question 1What goal BP is most appropriate for this patient?

Case Question 2What is the drug of choice to start?

HCTZAmlodipinLisinoprilLosartanCandesartanCombination therapy

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36Prevalensi Hipertensi

*

Hypertension complication

*

Blood Pressure Reduction of 2 mmHg Reduces The Risk of CV Events by 710%Meta-analysis of 61 prospective, observational studies1 million adults12.7 million person-years

Lewington et al. Lancet 2002;360:1903132 mmHg decrease in mean SBP10% reduction in risk of stroke mortality7% reduction in risk of ischaemic heart disease mortality

*Trials have shown that BP lowering can produce rapid reductions in CVD risk.In fact, even a 2 mmHg decrease in SBP would result in about a 7% lower mortality risk from ischaemic heart disease and a 10% lower mortality risk from stroke. ReferenceLewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:190313.

HYPERTENSION GUIDELINES

JNCASH/ISHESCHTN Canada

ADA

ISHIB

JSH

NHLBI

NICE

NKF

AHA/ACC

JNC 82014 Evidence-Based Guidelines for the Management of High Blood Pressure in AdultsJAMA. 2014;311(5):507-520December 18, 2013

JNC-7 Blood Pressure Classification

Blood Pressure ClassificationSystolic blood pressure(mm Hg)Diastolic blood pressure(mm Hg)Normal< 120< 80Pre-hypertension120-13980-89Stage 1 hypertension140-15990-99Stage 2 hypertension> 160> 100

JNC 8: Hypertension ManagementQuestions Guiding ReviewIn adults with HTN:

Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? [When to start therapy?]Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes? [How low should I go?]Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? [What drug do I use?]

JNC 8: Hypertension ManagementEvidence ReviewLimited to RCTsHypertensive adults > 18 years oldSample size > 100Follow-up > 1 yearReported effect of treatment on important health outcomes (mortality, MI, HF, CVA, ESRD)January 1966 to December 2009Separate criteria used of RCTs published after December 2009

JNC 8: Hypertension ManagementEvidence ReviewRCTs December 2009 August 2013

Major study in hypertensionACCORD, NEJM 2010

> 2,000 participantsMulticenteredMet all other inclusion/exclusion criteria

The ProcessLiterature review 1/1/1966 12/31/2009Inclusion Criteria HTN 2000 participants multisenterKriteria inklusi/eksklusi.

9 Recommendations

*

ACBNDE

JNC 8: Drug TreatmentThresholds and GoalsAge > 60 yoSystolic:Threshold > 150 mmHgGoal < 150 mmHgLOE: Grade A

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A

JNC 8: Drug TreatmentThresholds and GoalsAge < 60 yoSystolic:Threshold > 140 mmHgGoal < 140 mmHgLOE: Grade E

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A for ages 40-59; Grade E for ages 18-39

JNC 8: Drug TreatmentThresholds and GoalsAge > 18 yo with CKD or DMJNC 7: < 130/80 (MDRD NEJM 1994)Systolic:Threshold > 140 mmHgGoal < 140 mmHgLOE: Grade E

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade E

JNC 8: Initial Drug ChoiceAge > 18 yo with CKD and HTN (regardless of race or diabetes)Initial (or add-on) therapy should include an ACEI or ARB to improve kidney outcomesLOE: Grade BBlacks w/ or w/o proteinuriaACEI or ARB as initial therapy (LOE: Grade E)No evidence for RAS-blockers > 75 yoDiuretic is an option for initial therapy

JNC 8: Subsequent ManagementReassess treatment monthlyAvoid ACEI/ARB combinationConsider 2-drug initial therapy for Stage 2 HTN (> 160/100)Goal BP not reached with 3 drugs, use drugs from other classesConsider referral to HTN specialistLOE: Grade E

Recent HTN Guideline Statements2013 ESH/ESC Guidelines for the management of arterial hypertension.J Hypertnsion 2013;31:1281-1357.An Effective Approach to High Blood Pressure Control: A Science Advisory From the AHA, ACC, and CDC.Hypertension online November 15, 2013.Clinical Practice Guidelines for the Management of HTN in the Community A Statements by the ASH/ISH.J Hypertension 2014;32:3-15

Medical Education & Information for all Media, all Disciplines, from all over the WorldPowered by2013 ESH/ESC Guidelines for the management of arterial hypertensionThe Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357

Blood pressure goals in hypertensive patientsSBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

RecommendationsSBP goal for mostPatients at lowmoderate CV riskPatients with diabetesConsider with previous stroke or TIAConsider with CHDConsider with diabetic or non-diabetic CKD

BP goal in the elderly

Medical Education & Information for all Media, all Disciplines, from all over the WorldPowered by2013 ESH/ESC Guidelines for the management of arterial hypertensionThe Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357

Hypertension treatment for people with diabetesSBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.

RecommendationsAdditonal considerationsMandatory: initiate drug treatment in patients with SBP 160 mmHgStrongly recommended: start drug treatment when SBP 140 mmHgSBP goals for patients with diabetes:

What is the goal BP?

Comparison of RecentGuideline Statements

JNC 8ESH/ESCAHA/ACCASH/ISH>140/90Threshold>140/90 < 60 yrEldery SBP >160>140/90 150/90 >60 yrConsider SBP>140/90>150/90 >80 yr140-150 if 160/100"Markedly>160/100>160/100w/ 2 drugselevated BP"

Goal BP*ADA: < 140/80 or lower**KDIGO:

Development of JNC-83 critical questions for adults with hypertensionDoes initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes? [When to start therapy?]Does treatment with antihypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes? [How low should I go?]Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? [What drug do I use?]

James PA et al. JAMA 2014;311:507-20.

JNC-8 RecommendationsIn patients >60 years of age, start medications at blood pressure of >150/90mm Hg and treat to goal of 60 years of age, treatment does not need to be adjusted if achieved blood pressure is lower than goal and well-tolerated

James PA et al. JAMA 2014;311:507-20.

Hypertension in the ElderlyFastest growing segment of the populationPrevalence of hypertension is very highSeveral issues make managing HTN unique:Often present with isolated systolic HTNMore likely to present with comorbiditiesMany clinical trials in HTN have excluded these patients (particularly for those 80 years and older)Elderly are more susceptible to certain adverse effects (orthostatic hypotension)

JNC-8 RecommendationsIn patients 140/90mm Hg and treat to goal of 140/90mm Hg and treat to goal of

JNC-8 RecommendationsFor the non-black population (including diabetes), initial antihypertensive treatment may include a thiazide, ACEI, ARB, or CCBFor the black population (including diabetes), initial antihypertensive treatment should include a thiazide or CCBFor all patients with CKD, initial (or add-on) therapy for hypertension should include an ACEI or ARB

James PA et al. JAMA 2014;311:507-20.

JNC-8 RecommendationsInitiate therapy according to recommendationsIf BP is not at goal in one month, increase dose or add a second agent from recommended classesIf patient is still not at goal, add a third drug from recommended classesDo not use an ACEI and ARB togetherDrugs from other classes may be used if additional BP lowering is needed or if contraindications existRefer to HTN specialist whenever necessary

James PA et al. JAMA 2014;311:507-20.

Comparisons to Other GuidelinesAdapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

BP GoalJNC-7JNC-8ASH/ISHESC/ESHCHEPAge < 60

Lifestyle Modification

JNC 8

JNC 7

GuidelinePopulationGoal BPInitial drugs2014 HT GuidelineGeneral 60 y

General

GuidelinePopulationGoal BPInitial drugsADADM

* thank you

JNC 8: Initial Drug ChoiceNonblack, including DMThiazide diuretic, CCB, ACEI, ARBLOE: Grade B

Black, including DMThiazide diuretic, CCBLOE: Grade B (Grade C for diabetics)

Dissenting EditorialAnn Intern Med. January 14, 2014

5/17 authors (29%)

Insufficient evidence to increase target SBP to 150 mmHg.

Expertise vs. Scientific Evidence

**

*Trials have shown that BP lowering can produce rapid reductions in CVD risk.In fact, even a 2 mmHg decrease in SBP would result in about a 7% lower mortality risk from ischaemic heart disease and a 10% lower mortality risk from stroke. ReferenceLewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:190313.

*