David Antecol, M.D., FACC, FASH, FRCP(C) Specialist in Clinical Hypertension (American Society of Hypertension) Disclosures: None.

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA, 2014;311(5):507-520.

Paul A. James, MD; Suzanne Oparil, MD; Barry L Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; Cheryl Dennison-Himmelfarb, RN, ANP, PhD; Joel Handler, MD; Daniel T. Lackland, DrPH; Michael L. LeFevre,MD, MSPH; Thomas D. MacKenzie,MD, MSPH; Olugbenga Ogedegbe,MD, MPH, MS; Sidney C. Smith Jr, MD; Laura P. Svetkey,MD, MHS; Sandra J. Taler, MD; Raymond R. Townsend, MD; Jackson T.Wright Jr,MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH

JAMA 2014 Hypertension Guidelines Adult age >18 years with hypertension. Lifestyle interventions throughout management. Evidence-based (RCT)& Expert Opinion

Questions Guiding the Evidence Review This evidence-based hypertension guideline focuses on the panel’s 3 highest- Ranked questions related to high BP management identified. Nine recommendations are made reflecting these questions. These questions address thresholds and goals for pharmacologic treatment of hypertension and whether particular antihypertensive drugs or drug classes improve important health outcomes compared with other drug classes.

The Institute of Medicine Report Clinical Practice Guidelines We Can Trust outlined a pathway to guideline development and is the approach that this panel aspired to in the creation of this report.

Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Recommendation 1 In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at SBP >150 mmHg or DBP >90 mmHg and to treat to a goal of SBP <150 mmHg and DBP <90 mmHg. Strong recommendation - Grade A

Corollary Recommendation In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved systolic BP and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted. Expert Opinion - Grade E

Recommendation 2 In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at DBP of >90 mmHg and treat to goal DBP <90 mmHg. Ages 30-59 years, Strong Recommendation - Grade A Ages 18-29 years, Expert Opinion - Grade E

Recommendation 3 In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP >140 mmHg and treated to goal of SBP <140 mmHg Expert Opinion - Grade E

Recommendation 4 Chronic Kidney Disease Initiate pharmacologic treatment to lower BP at SBP >140 mmHg or DBP >90 mmHg and treat to a goal of SBP <140 mmHg and goal DBP <90 mmHg. Expert Opinion - Grade E

Recommendation 5 Diabetes Initiate pharmacologic treatment to lower BP at SBP >140 mmHg or DBP >90 mmHg and treated to goal of SBP <140 mmHg and goal DBP <90 mmHg. Expert Opinion - Grade E

Treatment threshold & goal BP summary General population >60 years (no CKD, no DM) Pharmacologic treatment threshold >150/90 Goal BP <150/90 General population <60 years or DM or CKD Pharmacologic treatment threshold >140/90 Goal BP <140/90

Antihypertensive agents Thiazide-type diuretics ACEI ARB CCB Avoid combined use of ACEI and ARB BB not 1st, 2nd, or 3rd line

Recommendation 6 General nonblack population (including DM): Initial antihypertensive treatment should include a thiazide-type diuretic, a calcium channel blocker (CCB), angiotensin converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Moderate Recommendation - Grade B

Recommendation 7 General black population (including DM), initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Moderate Recommendation - Grade B (general black patients without DM) Weak Recommendation - Grade C (black patients with DM)

Initial Drug Treatment Choices (no CKD) Nonblack Black Thiazide-type diuretic ACEI ARB CCB Thiazide-type diuretic CCB

Recommendation 8 CKD: Initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. Applies to all CKD patient's with hypertension regardless of race or diabetes status. Moderate Recommendation - Grade B

Recommendation 9 The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not achieved within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendations 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. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use and ACEI and an ARB together in the same patient.

Recommendation 9 If goal BP cannot be reached using only the drugs in recommendation 6 (thiazide-type diuretic, CCB, ACEI or ARB) 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 further management of complicated patients for whom additional clinical consultation is needed. Expert Opinion - Grade E

Drug treatment strategy A. Maximize first medication before adding second or B. Add a second medication before reaching maximum dose of first medication C. Start with 2 medication classes separately or as fixed-dose combination

Not at goal BP Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate antihypertensive agent (thiazide-type diuretic or ACEI or ARB or CCB). Use medication class not previously selected. For strategy C, titrate doses of initial medications to maximum. i.e., maximize 2-drug combination before adding a third drug Avoid combined use of ACEI and ARB.

Not at BP goal with 2-drug regimen Reinforce medication and lifestyle adherence. Add and titrate third agent (thiazide-type diuretic or ARB or ACEI or CCB). Use medication class not previously selected. Avoid combined use of ACEI and ARB

Not at goal BP with 3-drug regimen Reinforce medication and lifestyle adherence. Add additional medication class (e.g., beta blocker, aldosterone antagonist, or others) AND/OR refer to physician with expertise in hypertension management.

American Society of Hypertension http://www.ash-us.org/ Specialist in Clinical Hypertension Directory search

Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg In Patient's Age 60 or Older: The Minority Review. Annals of Internal Medicine. April 1, 2014, 160 (7): 499-504.

The Minority View Five of the JNC 8 members published a separate report which disagreed with the recommendation of increasing target systolic BP from 140 to 150 mmHg for the general population >60 years old without diabetes or CKD. 1. Increasing target systolic BP will reduce intensity of antihypertensive treatment in a large population at risk for cardiovascular disease. 2. The higher systolic BP goal would applied to some groups with high CVD risk (e.g., African-Americans; multiple CVD risk factors other than DM or CKD; those with clinical CVD). 3. Insufficient evidence supporting systolic BP target increase from 140-150 mmHg. 4. Higher SBP goal may reverse decades long decline in CVD, especially stroke mortality. 5. Not in alignment with European Society of Hypertension, Canadian Hypertension Education Program, National Institute for Health in Clinical Excellence (NICE), American College of Cardiology/American Heart Association.

SPRINT, Systolic Blood Pressure Intervention Trial not included