1. Putting the 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults Into Practice
Title Slide Layout
Moderator
James A. Underberg, MD
Clinical Assistant Professor of Medicine
New York University School of Medicine
Director, Bellevue Hospital Lipid Clinic
New York University Center for Prevention of Cardiovascular Disease
New York City

2. Louis Kuritzky, MD Raymond R. Townsend, MD Panelists
Clinical Assistant Professor
University of Florida
Gainesville, Florida
Raymond R. Townsend, MD
Professor of Medicine
Perelman School of Medicine Philadelphia, Pennsylvania
Title Slide Layout

3. Report From the Panel Members Appointed to the JNC 8
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults
Report From the Panel Members Appointed to the JNC 8
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; 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
James PA, et al. JAMA. 2014;311: [1]

4. Questions to the JNC 8 Panel
At what level should you treat BP?
To what level should it be treated?
How do you do that?

5. Target Audience for JNC 8
“Statements and recommendations for [BP] treatment based on a systematic review of the literature to meet user needs, especially the needs of the primary care clinician.”
James PA, et al. JAMA. 2014;311: [1]

6. Focus of the Recommendations
Age
Diabetic
Black/nonblack
Chronic kidney disease (CKD)

7. Age Recommendations, JNC 2014
18 years old and younger: Not considered
30 years old and younger: We have little to no data
30 to 59 years old: In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at a DBP of 90 mm Hg and treat to a goal DBP lower than 90 mm Hg. Strong Recommendation: Grade A
60 years old: In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at an SBP of 150 mm Hg or higher or a DBP of 90 mm Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. Strong Recommendation: Grade A
80 years old: Based on HYVET
James PA, et al. JAMA. 2014;311: [1]

8. JNC Panel Recommendation for Patients With Diabetes and Hypertension
In the population aged 18 years and older with diabetes, initiate pharmacologic treatment to lower BP at an SBP of 140 mm Hg or a DBP of 90 mm Hg and treat to a goal of SBP lower than 140 mm Hg and goal DBP lower than 90 mm Hg. Expert Opinion: Grade E
James PA, et al. JAMA. 2014;311: [1]

9. ACCORD Mean Number of Medications Prescribed
Time, y 1 2 3 4 5 6 7 8
Intensive therapy group
3.2
3.4
3.5
Standard therapy group
1.9
2.1
2.2
2.3
ACCORD Primary Outcome
Intensive Therapy, %
Standard Therapy, %
208 (1.87)
237 (2.09)
No permission needed
ACCORD Study Group. N Engl J Med. 2010;362: [6]

10. JNC Panel Recommendation for Patients With CKD
In the population aged 18 years with CKD, initiate pharmacologic treatment to lower BP at an SBP of 140 mm Hg or a DBP of 90 mm Hg and treat to goal of an SBP lower than 140 mm Hg and a goal DBP lower than 90 mm Hg. Expert Opinion: Grade E
James PA, et al. JAMA. 2014;311: [1]

11. JNC Recommendation for Nonblack Patients
In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include
Thiazide-type diuretic
Calcium channel blocker (CCB)
Angiotensin-concerting enzyme (ACE) inhibitor
Angiotensin receptor blocker (ARB)
Moderate Recommendation: Grade B
James PA, et al. JAMA. 2014;311: [1]

12. ALLHAT
Outcomes in Hypertensive Black Patients Treated With Chlorthalidone, Amlodipine, and Lisinopril
6-Year Rate per 100 Persons
Chlorthalidone
Amlodipine
Lisinopril
Outcome
No.
Rate (SE)
Total randomized
5369
3213
3210
CHD
(nonfatal MI + fatal CHD)
400
9.6 (0.5)
243
9.5 (0.6)
260
10.3 (0.7)
All-cause mortality
821
17.9 (0.6)
481
17.0 (0.8)
520
18.0 (0.8)
Cardiovascular mortality
362
8.1 (0.5)
215
8.4 (0.6)
224
Combined CHD
655
15.2 (0.6)
407
15.8 (0.8)
444
17.3 (0.8)
Combined CVD
1211
26.8 (0.7)
767
28.4 (1.0)
836
31.1 (1.0)
Stroke
257
6.0 (0.4)
145
5.7 (0.5)
212
8.0 (0.6)
End-stage renal disease 93
2.3 (0.3) 65
2.7 (0.4) 71
3.1 (0.4)
Cancer
417
9.4 (0.5)
245
9.8 (0.7)
254
9.9 (0.7)
Hospitalized for gastrointestinal bleeding
282
8.9 (0.5)
169
8.6 (0.7)
209
11.1 (0.8)
Wright JT, et al. JAMA. 2005;293(13): [17]

13. JNC Recommendation for Black Patients
In the general black population, including those with diabetes, initial antihypertensive treatment should include
Thiazide-type diuretic
CCB
For the general black population:
Moderate Recommendation: Grade B
For black patients with diabetes:
Weak Recommendation: Grade C
No permission needed
James PA, et al. JAMA. 2014;311: [1]

14. Recommendations for Hypertension Management
Recommendation 1: In the general population aged 60 years, initiate pharmacologic treatment to lower BP at systolic BP (SBP)150 mm Hg or diastolic BP (DBP) 90 mm Hg and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. (Strong Recommendation : Grade A) Corollary Recommendation: In the general population aged 60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without 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 90 mm Hg and treat to a goal DBP lower than 90 mm Hg. (For ages 30 to 59 years, Strong Recommendation : Grade A; for ages 18 to 29 years, Expert Opinion: Grade E) Recommendation 3: In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at SBP to 140 mm Hg and treat to a goal SBP lower than 140 mm Hg. (Expert Opinion : Grade E) Recommendation 4: In the population aged 18 years with CKD, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E) Recommendation 5: In the population aged 18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to a goal SBP lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E)
I recommend that this slide be split into 2 slides for legibility.
Please clarify: “not reached within of the initial drug or add a second drug.”
James PA, et al. JAMA. 2014;311: [1]

15. Recommendations for Hypertension Management (cont)
Recommendation 6: In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, CCB, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation: Grade B) Recommendation 7: In the 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) 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. This applies to all patients with CKD 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 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. 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 who additional clinical consultation is needed. (Expert Opinion : Grade E)
I recommend that this slide be split into 2 slides for legibility.
Please clarify: “not reached within of the initial drug or add a second drug.”
James PA, et al. JAMA. 2014;311: [1]

16. JNC Management Guideline Algorithm
Adult aged 18 years and older who have hypertension
Implement lifestyle interventions (continue throughout management)
Set BP goal and initiate BP-lowering medication on the basis of age, diabetes status, and CKD
General population (no diabetes or CKD) Diabetes or CKD present
Age ≥ 60 years Age < 60 years
All ages/with CKD/ with or without diabetes
All ages/with diabetes/no CKD
BP goal
SBP < 150 mm Hg DBP < 90 mm Hg
BP goal
SBP < 140 mm Hg DBP < 90 mm Hg
BP goal
SBP < 140 mm Hg DBP < 90 mm Hg
BP goal
SBP < 140 mm Hg DBP < 90 mm Hg
Nonblack Black
All races
Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination
Initiate thiazide-type diuretic or CCB, alone or in combination
Initiate thiazide-type diuretic or CCB, alone or in combination
Select a drug treatment titration strategy
Maximize first medication before adding second or
Add second medication before reaching maximum dose of first medication or
Start with 2 medication classes separately or as fixed-done combination
At goal BP? No
Reinforce medication and lifestyle adherence
For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB
(use medication class not previously selected and avoid combined use of ACEI and ARB).
For strategy C, titrate doses of initial medications to maximum.
No permission needed
At goal BP? No
Yes
Reinforce medication and lifestyle adherence
Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).
At goal BP? No
Reinforce medication and lifestyle adherence
Add additional medication class (eg, beta-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management.
At goal BP?
James PA, et al. JAMA. 2014;311: [1]
Continue current treatment and monitoring

17. ASCOT Summary of All End Points
Primary Nonfatal MI (including silent) + fatal CHD
Secondary Nonfatal MI (excluding silent) + fatal CHD
Total coronary end point Total cardiovascular event and procedures All-cause mortality Cardiovascular mortality Fatal and nonfatal stroke Fatal and nonfatal heart failure
Tertiary Silent MI
Unstable angina Chronic stable angina Peripheral arterial disease Life-threatening arrhythmias New-onset diabetes mellitus New-onset renal impairment
Post hoc
Primary end point + coronary revascularization procedures
CV death + MI + stroke
Unadjusted hazard ratio (95% CI)
0.90 ( )
0.87 ( )
0.87 ( )
0.84 ( )
0.89 ( )
0.76 ( )
0.77 ( )
0.84 ( )
1.27 ( )
0.68 ( )
0.98 ( )
0.65 ( )
1.07 ( )
070 ( )
0.85 ( )
0.86 ( )
0.84 ( )
No permission
Please verify range:
Please write out “revasc procs.”
0.50
0.70
1.00
1.45
2.00
Amlodipine  perindopril better
Atenolol  thiazide better
Dahlöf B. Lancet. 2005;366: [18]

18. Strategies for Reaching BP Goal
Start 1 drug, titrate to maximum dose, and then add a second drug
Start 1 drug and then add a second drug before achieving maximum dose of the initial drug
No permission
Begin with 2 drugs at the same time either as 2 separate pills or as a single pill combination
James PA, et al. JAMA. 2014;311: [1]

19. Abbreviations
ACCORD = Action to Control Cardiovascular Risk in Diabetes ACE = angiotensin-converting enzyme ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ARB = angiotensin receptor blockers ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial BP = blood pressure CCB = calcium channel blocker CHADS = congestive heart failure, hypertension, age, diabetes mellitus, and stroke CHD = coronary heart disease CI = confidence interval CKD = chronic kidney disease DBP = diastolic blood pressure HYVET = Hypertension in the Very Elderly Trial JNC 8 = Eighth Joint National Committee MI = myocardial infarction SBP = systolic blood pressure

20. References
1. James PA, Oparil S, Carter BL, et al 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: Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289: Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358: Mancia G, Fagard R, Narkiewicz K, et al ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:

21. References (cont)
6. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362: Hebert LA, Kusek JW, Greene T, et al. Effects of blood pressure control on progressive renal disease in blacks and whites. Modification of Diet in Renal Disease Study Group. Hypertension. 1997;30(3 Pt 1): Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288: Ruggenenti P, Perna A, Loriga G, et al; REIN-2 Study Group. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365: ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT). NCT Accessed March 14, 2014.

22. References (cont)
11. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168: Wright Jr JT, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View. Ann Intern Med [Epub ahead of print] 13. Dahlöf B, Devereux RB, Kjeldsen SE, et al; LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359: Poulter NR, Wedel H, Dahlöf B, et al; ASCOT Investigators. Role of blood pressure and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). Lancet. 2005;366:

23. References (cont)
15. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Diuretic versus alpha-blocker as first-step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42: Wright JT Jr, Dunn JK, Cutler JA, et al; ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293: Dahlöf B, Sever PS, Poulter NR, et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366: