1. JNC 8 2014 Evidence-Based Guideline for the Management of
High Blood Pressure in Adults
Dr. Asif Mehmood R.Ph
Pharm. D

2. HTN patients estimated by 2025
Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide1
972 million
Number of
people with HTN
worldwide in 20001
60%
Increase in the
number of adults with
HTN globally by 20251
10%
Percent of all global
healthcare spending
attributable to high
blood pressure2
1.6 Billion
HTN patients estimated by 2025
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet Jan 15-21;365(9455):
2. Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7):
$370 billion
Annual worldwide cost of hypertension2
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet Jan 15-21;365(9455): Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7):

3. EU Prevalence of Hypertension ~81 Million Adults have elevated Blood Pressure
Patients with HTN
Diagnosed HTN
Treated HTN
EU Patients with HTN 81.0M
Diagnosed HTN 78%
Treated HTN 68%
Uncontrolled HTN 38%
Resistant HTN 9% - $7.2M
Uncontrolled HTN
Lloyd-Jones D: Circulation 2010;121:e46 – e215
Persell SD: Hypertension 2011;57:
HTN=Hypertension

4. Hypertension in Pakistan
% age of Pakistani adults with HTN
18%
%age of Pakistani above 45 years of age
33%
are only adequately controlled HTN Cases.
12.5%
Time to take some serious action
Fahad Saleem et al; Br J Gen Pract June 1; 60(575): 449–450. doi: /bjgp10X502182

5. HTN leads to an increased risk of death from stroke and heart disease8x
Cardiovascular Mortality Risk 4x 2x
Hypertension is a serious health issue
Hypertension significantly increases ones risk of CV mortality
For every 20mm Hg, one doubles their CV mortality risk
CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2
Systolic BP / Diastolic BP (mmHg)
Chobanian et al. Hypertension 2003;42: ; 2Lancet 2002;360:

6. Risk Factors for Cardiovascular Disease
Smoking
Hyperlipidaemia
High salt intake
Homocysteinaemia
Lack of exercise
Obesity
Diabetes
Alcohol >4pints of beer/day
Genetic

7. Accurate Reading of Blood Pressure
Cuff bladder encircle >80% 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

8. Questions Guiding the Evidence Review

9. Question-1 Specific BP thresholds for Improvement in health outcomes?
Start of antihypertensive pharmacologic therapy
Improvement in health outcomes?
1) > 160 mm Hg
2) > 150 mm Hg
3) > 140 mm Hg
4) > 130 mm Hg

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

11. Question-3 Do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on
Specific health outcomes

12. Level of Recommendation Strength 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;():. doi: /jama

13. JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi: /jama
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.

14. JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi: /jama
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.

15. JNC 8 (2014 Hypertension Guideline Management Algorithm)3
JAMA. 2013;():. doi: /jama
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)
Full
JAMA. 2013;():. doi: /jama
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. Strategies to Dose of Antihypertensive Drugs
Start one drug, titrate to maximum dose, and then add a second drug
Start one drug and then add a second drug before achieving maximum dose of the initial drug
Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination A B C

18. Recommendations for Management of Hypertension
JNC-8
2014 Guideline for Management of High Blood Pressure

19. 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 <150 mm Hg and goal DBP <90 mmHg.
(Strong Recommendation – Grade A)

20. 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, <140mmHg) and treatment is well tolerated and without adverse effects on health or quality of life.
(Expert Opinion – Grade E)

21. Recommendation 2 In the general population <60 years
Initiate pharmacologic treatment to lower BP at DBP 90mmHg
Treatment goal DBP<90mmHg.
For ages years
Strong Recommendation – Grade A
For ages years
Expert Opinion – Grade E

22. Recommendation 3 In the general population <60 years
Initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHg
Treatment goal SBP <140mmHg.
(Expert Opinion – Grade E)

23. 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 SBP<140mmHg and goal DBP<90mmHg.
(Expert Opinion – Grade E)

24. Recommendation 5 In the population aged ≥18years with diabetes
Initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHg or DBP ≥ 90mmHg
Treatment goal SBP <140mmHg and DBP <90mmHg.
(Expert Opinion –Grade E)

25. 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

26. 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)

27. 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

28. 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)

29. Comparison of Current Recommendations With JNC 7 Guidelines

30. JNC 8 (2014 Hypertension Guideline)
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

31. JNC 8 (2014 Hypertension Guideline)
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

32. JNC 7 vs JNC 8 Treatment Goals
JNC 8 (2014 Hypertension Guideline)
Separate treatment goals defined for
“uncomplicated”hypertension
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

33. JNC 7 vs JNC 8 Lifestyle recommendations
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

34. JNC 8 (2014 Hypertension Guideline)
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

35. JNC 7 vs JNC 8 Scope of topics
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

36. JNC 7 vs JNC 8 Review process prior to publication
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

37. Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension
Population
Goal BP,
mm Hg
Initial Drug Treatment Options
JNC 8
2014 Hypertension
guideline
General ≥60 y
<150/90
Nonblack: thiazide-type diuretic, ACEI, ARB, or CCB
General <60 y
<140/90
Black: thiazide-type diuretic or CCB
Diabetes
Thiazide-type diuretic, ACEI, ARB, or CCB
CKD
ACEI or ARB
NICE 2011
General <80 y
<55 y: ACEI or ARB
General ≥80 y
≥55 y or black: CCB
KDIGO 2012
CKD no proteinuria
≤140/90
CKD + proteinuria
≤130/80
JAMA. 2013;():. doi: /jama

38. THANK YOU!!
For Your Valuable Time