1. JNC VIII Hypertension

2. Hypertension Management: JNC VIII Guidelines
Ashwani Bhatia M.D. Clinical Hypertension Specialist 2014

3. OBJECTIVES: Participants will be able to…
Discuss the basics of HTN management per JNC VIII Guidelines
State changes from JNC VII
Identify the rationale behind current blood pressure targets
Compare JNC VIII to other national and international guidelines

4. “Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately.”
Hypertension is the most common clinical condition for office visits of non-pregnant adults to physicians in the US and for use of prescription drugs.
Nearly 1 in 3 adults in the US have hypertension (approximately 73 million people).
Hypertension, or high blood pressure, is one of the nation’s leading causes of death, responsible for roughly one in six deaths among adults annually.
Despite considerable improvements in increasing awareness, treatment and control of hypertension, over half of adults with HTN do NOT have their blood pressure under control
Racial/ethnic and socioeconomic
Hypertension affects approximately 50 million individuals in the United States
and approximately 1 billion worldwide. As the population ages, the prevalence
of hypertension will increase even further unless broad and effective preventive
measures are implemented. Recent data from the Framingham Heart Study
suggest that individuals who are normotensive at age 55 have a 90 percent lifetime
risk for developing hypertension.7

5. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden as hypertension is a silent disease.
Providers want guidance on hypertension management using the best scientific evidence.

6. Introduction
Hypertension remains one of the most important preventable contributors to disease and death.
Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes.
This report highlights the Evidence-Based Guideline for the Management of High Blood Pressure in Adults.

7. “Abundant evidence from randomized controlled trials(RCTs) has shown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension.”

8. Why Changes were made:
In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? GOAL
In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? OUTCOMES
In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? MEDICAL MANAGEMENT

10. Recommendations

11. Appendix. Appendix Go A S et al. Hypertension. 2014;63:878-885
Copyright © American Heart Association, Inc. All rights reserved.

12. Lifestyle Modifications
Exercise, reduce sodium intake, lose weight, and decrease stress

13. Initiate Treatment at :
Recommendation 1
General population aged 60 years or older
SBP ≥150 mmHg Or
DBP ≥ 90mmHg
Initiate Treatment at :
SBP <150 mmHg OR
DBP of < 90mmHg.
Goal of Treatment :
In patients aged ≥60 years, initiate pharmacologic treatment if systolic BP ≥150mmHg or diastolic BP ≥90mmHg and treat to a goal systolic BP <150mmHg and goal diastolic BP <90mmHg.  (Strong Recommendation–Grade A)

14. Initiate Treatment at :
Recommendation 2
General population < 60 years
DBP ≥ 90mmHg
Initiate Treatment at :
DBP of < 90mmHg.
Goal of Treatment :
In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal DBP of lower than 90mmHg.

15. Initiate Treatment at :
Recommendation 3
General population < 60 years
SBP ≥ 140 mmHg
Initiate Treatment at :
SBP of < 140 mmHg.
Goal of Treatment :
In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to a goal SBP of lower than 140mmHg.

16. Initiate Treatment at:
Recommendation 4
Population aged 18 years or older with CKD
SBP ≥ 140 mmHg Or
DBP ≥ 90 mmHg
Initiate Treatment at:
SBP < 140 mmHg Or
DBP < 90 mmHg
Goal of Treatment :
initiate pharmacologic treatment to lower BP at SBP of 140mmHg or higher or DBP of 90mmHg or higher and treat to goal SBP of lower than 140mm Hg and goal DBP lower than 90mmHg.

17. Initiate Treatment at:
Recommendation 5
Population aged 18 years or older with diabetes
SBP ≥ 140 mmHg Or
DBP ≥ 90 mmHg
Initiate Treatment at:
SBP < 140 mmHg Or
DBP < 90 mmHg
Goal of Treatment :
the population aged 18 years or older with diabetes, initiate pharmacologic treatment to lower BP at SBP of 140mmHg or higher or DBP of 90 mm Hg or higher and treat to a goal SBP of lower than 140mmHg and goal DBP lower than 90mmHg.

18. Recommendation 6
In General Caucasian population, including those with diabetes:
Initial antihypertensive treatment should include any of the following:
A thiazide-type diuretic
Calcium channel blocker (CCB)
Angiotensin-converting enzyme inhibitor (ACEI) or
Angiotensin receptor blocker (ARB).

19. Recommendation 7
In general African American population, including those with diabetes:
Initial antihypertensive treatment should include :
Thiazide-type Diuretic
Calcium Channel Blocker

20. Population aged 18 years or older with CKD and hypertension:
Recommendation 8
Population aged 18 years or older with CKD and hypertension:
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.

21. Recommendation 9 (slide 1 of 3)
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 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.

22. Recommendation 9 (slide 2 of 3)
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 the need to use more than 3 drugs to reach goal BP:
- Antihypertensive drugs from other classes can be used.

23. Recommendation 9 (Slide 3 of 3)
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

25. Treatment Preference JNC 8 ASH/ISH AHA/ACC Published on: 18-Dec-13
JNC 8
ASH/ISH
AHA/ACC
Published on:
18-Dec-13
19-Dec-13
21-Nov-13
Target Goal
<140/90
For general patients including DM/CKD
Lower targets may be appropriate for LVD, LVH, DM, CKD
For elderly people
150/90 (≥60 yrs)
150/90(≥80 yrs)
Lower targets for the elderly
Treatment Preference
General <60 yrs
Stage 1 HTN:
Initiate Thiazide-type Diuretic or ACEI or ARB or CCB
ACEI or ARB
Thiazide for most patients
(If needed, add CCB or Thiazide-type Diuretic)
or ACEI, ARB, CCB, (or combination, if uncontrolled)
For uptitration, any possible combination from above (avoid ACEI+ARB)
Stage 2 HTN:
ACEI or ARB + CCB or Thiazide-type Diuretic
Thiazide with ACEI/ARB/CCB, or ACEI with CCB
General ≥ 60 yrs
Same as Above
CCB or Thiazide
(If needed, add ACEI or ARB)
Hypertension with Diabetes
ACEI or ARB, Thiazide, BB, CCB
If needed add CCB or Thiazide-type Diuretic
Hypertension with CKD
ACEI or ARB alone
Or in combination with other
Hypertension with CAD
BB plus ARB or ACE inhibitor
BB, ACEI
Hypertension with Stroke
ACE Inhibiitor or ARB
Thiazide, ACEI
Hypertension with HF
ARB or ACE inhibitor+BB +Diuretic +Spironolactone reglardless of BP
ACEI or ARB, BB, Aldosterone Antagonist, Thiazide

26. 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 carefully consider and incorporate the clinical characteristics of each individual.

27. THANK YOU JNC VIII in a nutshell:
Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else.
Any of 4 classes of drugs could be chosen.
Destination is important and not the journey.
No stages please.
In African American population C and D (Calcium Channel Blockers and Diuretics)
THANK YOU

28. REFERENCES: Journal of the American Medical Association, 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) {December 18, 2013} -International Society of Hypertension, WHO/ISH Hypertension guidelines - An Effective approach to High Blood pressure control. A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention