JNC 8

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JNC 8

• 2014 Evidence-Based Guideline for the Management
  of
• High Blood Pressure in Adults

Dr. Asif Mehmood R.Ph Pharm. D
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Hypertension (HTN) is a major public health
concern, affecting 26 of adults worldwide1
Number of people with HTN worldwide in 20001
972 million
60
Increase in the number of adults with HTN
globally by 20251
Percent of all global healthcare spending
attributable to high blood pressure2
10
1.6 Billion HTN patients estimated by 2025
Annual worldwide cost of hypertension2
370 billion
1. Kearney PM, Whelton M, Reynolds K, Muntner P,
Whelton PK, He J. Global burden of hypertension
analysis of worldwide data. Lancet. 2005 Jan
15-21365(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.
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EU Prevalence of Hypertension81 Million Adults
have elevated Blood Pressure
81M Patients with HTN
Diagnosed HTN
Treated HTN
Uncontrolled HTN
Lloyd-Jones D Circulation 2010121e46
e215 Persell SD Hypertension 2011571076-1080
HTNHypertension
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Hypertension in Pakistan
Time to take some serious action
Fahad Saleem et al Br J Gen Pract. 2010 June 1
60(575) 449450. doi 10.3399/bjgp10X502182
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HTN leads to an increased risk of death from
stroke and heart disease
8x
Cardiovascular Mortality Risk
4x
2x
Systolic BP / Diastolic BP (mmHg)
CV mortality risk doubles for every 20 mmHg
increase in systolic blood pressure.1,2
Chobanian et al. Hypertension 2003421206-1252
2Lancet 20023601903-1913
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Hyperactive Sympathetic Nervous System Drives
Hypertension
Peripheral Vascular Resistance
Cardiac Output
Kidney Effects - Sodium Volume Retention
- Decreased Renal Blood Flow due to
Vasoconstriction - RAS Activity
Cardiac Effects - LV Hypertrophy - Systolic
HF - HFpEF - Arrhythmia
Renal Function
Efferent from the brain
Afferent to the brain
Doumas et al. Am J Cardiol 2010105570-576,
Cleveland Clinic Journal of Medicine 2012 79
501-10
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Risk Factors for Cardiovascular Disease

• Smoking
• Hyperlipidaemia
• High salt intake
• Homocysteinaemia
• Lack of exercise
• Obesity
• Diabetes
• Alcohol gt4pints of beer/day
• Genetic

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Accurate Reading of Blood Pressure
Cuff bladder encircle gt80 pts arm
sphygmomanometer
Deflate 2-3mm per second
Siting comfortably Back supported Legs
uncrossed Upper arm bared
Arm at heart level
SBP INACCURATELY HIGH IF patient is supine,
crossed legs, arm below the heart, arm
unsupported, undersized cuff.
AHA guidelines
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Questions Guiding the Evidence Review
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Question-1

• Specific BP thresholds for
• Start of antihypertensive pharmacologic therapy
• Improvement in health outcomes?
• 1) gt 160 mm Hg
• 2) gt 150 mm Hg
• 3) gt 140 mm Hg
• 4) gt 130 mm Hg

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Question-2

• Does a specified BP goal lead to improvements in
  health outcomes?
• 1) 130/80 mm Hg in a diabetic
• 2) lt 140/90 in an 84 year old female
• 3) lt 140/90 in a patient with CKD
• 4) lt 120/80 in a 38 year old male

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Question-3

• Do various antihypertensive drugs or drug classes
• differ in comparative benefits and harms on
• Specific health outcomes

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Level of Recommendation
Grade Strength of Recommendation
A Strong Recommendation
B Moderate Recommendation
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.
JAMA. 2013(). doi10.1001/jama.2013.284427
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JNC 8 (2014 Hypertension Guideline Management
Algorithm)
1
JAMA. 2013(). doi10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm
SBP indicates systolic blood pressure DBP,
diastolic blood pressure ACEI,
angiotensin-converting enzyme ARB, angiotensin
receptor blocker and CCB, calcium channel
blocker.aACEIs and ARBs should not be used in
combination.bIf blood pressure fails to be
maintained at goal, reenter the algorithm where
appropriate based on the current individual
therapeutic plan.
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JNC 8 (2014 Hypertension Guideline Management
Algorithm)
2
JAMA. 2013(). doi10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm
SBP indicates systolic blood pressure DBP,
diastolic blood pressure ACEI,
angiotensin-converting enzyme ARB, angiotensin
receptor blocker and CCB, calcium channel
blocker.aACEIs and ARBs should not be used in
combination.bIf blood pressure fails to be
maintained at goal, reenter the algorithm where
appropriate based on the current individual
therapeutic plan.
16
JNC 8 (2014 Hypertension Guideline Management
Algorithm)
3
JAMA. 2013(). doi10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm
SBP indicates systolic blood pressure DBP,
diastolic blood pressure ACEI,
angiotensin-converting enzyme ARB, angiotensin
receptor blocker and CCB, calcium channel
blocker.aACEIs and ARBs should not be used in
combination.bIf blood pressure fails to be
maintained at goal, reenter the algorithm where
appropriate based on the current individual
therapeutic plan.
17
JNC 8 (2014 Hypertension Guideline Management
Algorithm)
Full
JAMA. 2013(). doi10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm
SBP indicates systolic blood pressure DBP,
diastolic blood pressure ACEI,
angiotensin-converting enzyme ARB, angiotensin
receptor blocker and CCB, calcium channel
blocker.aACEIs and ARBs should not be used in
combination.bIf blood pressure fails to be
maintained at goal, reenter the algorithm where
appropriate based on the current individual
therapeutic plan.
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Strategies to Dose of Antihypertensive Drugs
A
B
C
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Strategies to Dose of Antihypertensive Drugs
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Recommendations for Management of Hypertension

• JNC-8
• 2014 Guideline for Management of High Blood
  Pressure

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Recommendation 1

• In the general population aged 60 years
• Initiate pharmacologic treatment to lower blood
  pressure (BP) at systolic blood pressure (SBP)150
  mmHg or diastolic blood pressure (DBP)90mmHg
• Treatment goal SBP lt150 mm Hg and goal DBP lt90
  mmHg.
• (Strong Recommendation Grade A)

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Recommendation 1 Corollary Recommendation

• In the general population aged 60years
• Treatment does not need to be adjusted
• if pharmacologic treatment for high BP results in
  lower achieved SBP (eg, lt140mmHg) and treatment
  is well tolerated and without adverse effects on
  health or quality of life.
• (Expert Opinion Grade E)

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Recommendation 2

• In the general population lt60 years
• Initiate pharmacologic treatment to lower BP at
  DBP 90mmHg
• Treatment goal DBPlt90mmHg.
• For ages 30-59 years
• Strong Recommendation Grade A
• For ages 18-29 years
• Expert Opinion Grade E

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Recommendation 3

• In the general population lt60 years
• Initiate pharmacologic treatment to lower BP at
  SBP 140mmHg
• Treatment goal SBP lt140mmHg.
• (Expert Opinion Grade E)

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Recommendation 4

• In the population aged 18 years with chronic
  kidney disease (CKD)
• Initiate pharmacologic treatment to lower BP at
  SBP 140mmHg or DBP 90mmHg
• Treatment goal SBPlt140mmHg and goal DBPlt90mmHg.
• (Expert Opinion Grade E)

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Recommendation 5

• In the population aged 18years with diabetes
• Initiate pharmacologic treatment to lower BP at
  SBP 140mmHg or DBP 90mmHg
• Treatment goal SBP lt140mmHg and DBP lt90mmHg.
• (Expert Opinion Grade E)

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Recommendation 6

• General nonblack population, including those with
  diabetes
• Initial antihypertensive treatment should
  include
• A thiazide-type diuretic, calcium channel blocker
  (CCB), angiotensin-converting enzyme inhibitor
  (ACEI), or angiotensin receptor blocker (ARB).
• Moderate Recommendation Grade B

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Recommendation 7

• General black population, including those with
  diabetes
• Initial antihypertensive treatment should include
  a thiazide-type diuretic or CCB.
• For general black population
• Moderate Recommendation Grade B
• For black patients with diabetes
• Weak Recommendation Grade C)

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Recommendation 8

• In the population aged 18 years with CKD
• Initial (or add-on) antihypertensive treatment
• Should include an ACEI or ARB to improve kidney
  outcomes.
• Applies to all CKD patients with hypertension
  regardless of race or diabetes status.
• Moderate Recommendation Grade B

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Recommendation 9

• The main objective of hypertension treatment is
  to attain and maintain 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
  recommendation6 (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 only the drugs
  in recommendation
• 6 because of a contraindication or the need to
  use more than 3
• drugs to reach goal BP, antihypertensive 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)

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Comparison of Current Recommendations With JNC 7
Guidelines
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JNC 7 vs JNC 8 Methodology

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• 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

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JNC 7 vs JNC 8 Definitions

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• Defined hypertension and prehypertension

• Definitions of hypertension and prehypertension
  not addressed
• But thresholds for pharmacologic treatment were
  defined

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JNC 7 vs JNC 8 Treatment Goals

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• Separate treatment goals defined for
• uncomplicatedhypertension
• 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 particular subpopulation

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JNC 7 vs JNC 8 Lifestyle recommendations

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• Recommended lifestyle modifications
• Based on literature review and expert opinion

• Lifestyle modifications recommended by endorsing
  the evidence based Recommendations of the
  Lifestyle Work Group

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JNC 7 vs JNC 8 Drug therapy

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• 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

• 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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JNC 7 vs JNC 8 Scope of topics

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• 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

• Addressed a limited number of questions
• Those judged by the panel to be of highest
  priority.
• Evidence review of RCTs

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JNC 7 vs JNC 8 Review process prior to
publication

• JNC 7

• JNC 8 (2014 Hypertension Guideline)

• 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

• 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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Guideline Comparisons of Goal BP and Initial Drug
Therapy for Adults With Hypertension
JAMA. 2013(). doi10.1001/jama.2013.284427
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Guideline Comparisons of Goal BP and Initial Drug
Therapy for Adults With Hypertension
Guideline Population Goal BP, mm Hg Initial Drug Treatment Options
JNC 8 2014 Hypertension guideline General 60 y lt150/90 Nonblack thiazide-type diuretic, ACEI, ARB, or CCB
General lt60 y lt140/90 Black thiazide-type diuretic or CCB
Diabetes lt140/90 Thiazide-type diuretic, ACEI, ARB, or CCB
CKD lt140/90 ACEI or ARB
NICE 2011 General lt80 y lt140/90 lt55 y ACEI or ARB
General 80 y lt150/90 55 y or black CCB
KDIGO 2012 CKD no proteinuria 140/90 ACEI or ARB
CKD proteinuria 130/80
JAMA. 2013(). doi10.1001/jama.2013.284427
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