Update Hypertension

Guideline

JNC 8

Hypertension Background
Hypertension (HTN) affects approximately 1
billion individual worldwide
HTN 1 in 3 adults in US, Europe, Australia,
many Asia countries
HTN is the most common condition seen in
primary care and leads to MI, stroke, renal
failure, and death if not detected early and
treated appropriately
Control of BP leads to reduction in events heart
failure (~50%), CVD (~40%), MI (~20-25%)
-

2014 evidence based guideline for the management of

HBP in Adults Report from JNC 8
HTN news, january 2014 opus 35

 Patients want to be assured that BP

treatment will reduce their disease burden,
while clinicians want guidance on HTN
management using the best scientific
evidence
Clinical guidelines are at the intersection
between research evidence and clinical
actions that can improve patient outcomes
-

2014 evidence based guideline for

the management of HBP in Adults
Report from JNC 8
HTN news, january 2014 opus 35

JNC
CE
NI

NH
LBI

ES C

A
D
A

/
A
AH C
AC

HYPERTENSION
GUIDELINES

H
S
J

TN da
H a
n
a
C

ASH/I
SH
IS
HI
B

NKF

CLASSIFICATION
HYPERTENSION
BP
Norma
l
Pre HT

SBP

DBP

<120 and <80

or
120- or 80-89
139
or
14090-99
159

Stg 2

160

BP

SBP

DBP

Optimal

<120

and <80

<130 and <85

6
C
N
High J
Nml
130-139 or 85-89
Normal

HT stg 1

140-159 or 90-99

HT stg 2

160-179 or 100-109

HT stg 3

180

or

110

DBP

<120 and <80

Normal

and./o80-84
120-129
r
130-139
85-89

HT stg 1

140-159

HT stg 2

160-179

HT stg 3

180

ISH

100

SBP

Optimal
High
Normal

JNC
7

Stg 1

BP

ES 90-99
C

100-109
110

140 and <90

JNC 8
No definition of HT

JNC 8
A new guideline for the management of HTN
developed by the Eighth Joint National Committee
(JNC 8)
The JNC committee for HTN was appointed by
NHLBI to provide guidance for clinician on the
best approaches to manage and control high BP
The JNC 8 guideline authors simplified a
complicated recommendation for follow up in
patients with HTN
The panel limited its evidence review to RCTs
less subject to bias than other study design

The Process
Literature review 1/1/1966
12/31/2009
Inclusion Criteria
(1)The study was a major study in HTN
(2)The study had at least 2000
participants
(3)The study was multicentered
(4)The study met all the other
inclusion/exclusion criteria.
9
Recommendatio
ns

JNC 8
The evidence-based recommendations for the
management of high BP, with different BP goals and
treatments recommended for patients based on age,
race/ethnicity, kidney function and diabetes status
3 question threshold to start and goals for
pharmacologic treatment, which drugs will improve
health outcome
Definitions of HTN and pre HTN not addressed, but
thresholds for pharmacologic treatment were
defined

Type of Evidence
Well designed and conducted RCT
Highly certain about the estimate
of effect
RCT minor limitations
Well designed and well conducted
observasional studies
Moderately certain about the
estimate of effect
RCTs with major limitations
Non randomized controlled studies
and observational studies with
major limitations
Physiological studies, meta analysis
Low certainty about the estimate of
effect

Quality
Rating
HIGH

MODERATE

LOW

Stron
g
Reco
mmen
datio
Moderate
n

Recommendation

Weak Recommendation

Recommendation against
Expert Opinion
No Recommendation for or against

D
E
N

Recommendation
Recommendation 1

Strength of
Recommendation

Population aged 60 yrs, initiate

pharmacologic treatment at SBP150
mmHg, DBP90 mmHg
HYVET,

Grade A
Sys-Eur,
SHEP,
VALISH, CARDIO-

JATOS,
SIS

Corollary Recommendation
Population
aged
60
yrs,
if
pharmacologic treatment for BP
results in lower achieved (<140/90)
and treatment is well tolerated and
without adverse effect on health or
quality of life, treatment doesnt need
to adjusted

Grade E

Recommendation 2
Population aged <60 yrs, initiate Grade
pharmacologic treatment to lower BP Grade
at DBP90 mmHg and treat to a goal HDFP,

A (30-59 yrs)
E (18-29 yrs)
HT-Stroke

Comparison of Strict and Mild BP

Control In Elderly Hypertensives
(JATOS Trial)
Japanese Trial to Assess Optimal Systolic Blood Pressure in
Elderly Hypertensive Patients
Study Question

What is the optimal SBP in elderly hypertensive

patients?

Design

Per protocol analysis of strict treatment

(achieved SBP < 132.3 mmHg; n= 1191) vs mild
treatment (achieved ABP <146.7; n= 1531)

Subjects

Elderly (65-85 yrs) HTN treated w/ Felonidipine

Mean Follow up

2 years

Primary Outcome

Cardiovascular disease and renal failure

Conclusion

Strict treatment for elderly HTN pts may have

little effect in enhancing suppression of the
onset of CV events as compared w/ mild
treatment
Hypertens Res, 2010
Nov;33 (11): 1124-8

Recommendation
Recommendation 3
Population aged <60 yrs, initiate
pharmacologic treatment to lower BP
at SBP at 140 mmHg and treat to a
goal SBP<140 mmHg

Strength of
Recommendation
Grade E

Recommendation 4
Population aged 18 yrs with CKD,
initiate pharmacologic treatment to
lower BP at SBP of 140 mmHg or
DBP of 90 mmHg and treat to goal
SBP of <140 mmHg and goal DBP
<90 mmHg

Grade E
AASK, MDRD, REIN-2

Recommendation 5
Population aged 18 with DM, initiate
pharmacologic treatment to lower at
BP of SBP 140 mmHg or DBP 90
mmHg, and the goal SBP<140 and
DBP <90

Grade E
SHEP, Syst-Eur, UKPDS,
ACCORD, ADVANCE,
HOT

Intensive BP Control In
Hypertensive CKD
(AASK Collaborative Group)

African American Study of Kidney Disease and Hypertension

Study Question

Intensive BP control retards the progression of

CKD among black people

Design

Randomized trial and Cohort phase target SBP

<130 mmHg

Subjects

1094 black pts w/ hypertensive CKD

F/U

8.8-12.2 yrs

Primary Outcome

Progression CKD (doubling Cr, ESRD or death)

Achieved BP

Trial phase: 130/78 V 141/86

Cohort phase: 131/78 Vs 134/78

HR (primary
Outcome)

0.91; p = 0.27
0.73; p = 0.01 for pts w/ protein cr ratio >0.22

Conclusion

Intensive BP control had no effect on CKD

progression in hypertensive CKD
NEJM 2010;363:918-29

REIN-2
Ramipril Efficacy In Nephropathy Study-2
Study Question

More intensive BP lowering vs less intensive BP

lowering strategies

Design

Randomized controlled trial

Subjects

338 pts Non DM proteinuric nephropathies receiving

Felodipine or placebo on background th/ w/ ACEI
(Ramipril)

F/U

36 months

Primary Outcome ESRD

Achieved BP

Intensified (130/80), conventional diastolic <90

HR (primary
Outcome)

Median follow-up of 19 months (IQR 1235), 38/167 (23%) patients

assigned to intensified blood-pressure control and 34/168 (20%)
allocated conventional control progressed to end-stage renal disease
(hazard ratio 100 [95% CI 061164]; p=099).
The Lancet,365,

Conclusion

Intensified BP control didnt improve the outcome

939-46

Action to Control Cardiovascular Risk in

Diabetes (ACCORD )Trial
Study Question

Does targeting SBP <120 Vs <140 reduce

major CV events in T2 DM at high risk of CV
events?

Design

Randomized

Subjects

N = 4733 T2 DM pts

Mean F/U

4.7 yrs

Primary Outcome

Non fatal MI, non fatal CVD, or CV death

Achieved SBP 1 yrs

119.3 Vs 133.5 mmHg

Rate of Primary
Outcome

1.87% Vs 2.09% (HR w/ intensive th/; o

0.88;95% CI 0.73-1.06; p = 0.20)

Rate of Any Death

1.28% Vs 1.19% (HR 1.07, 95% CI 0.85-1.35; p

= 0.55)

Rate of CVD

0.32% Vs 0.53% (HR 0.59; 95% CI 0.39-0.89; P

= 0.01)

Serious adverse events 3.3% Vs 1.3% (p 0.001)

Conclusion

Target SBP <120 compared <140 didnt

reduce the rate ofNEJM
fatal
and non fatal CV
2010;362; 1575-85
events

Recommendation
Recommendation 6
In non black population, including with
DM, initial anti HTN treatment should
include a thiazide type diuretic, CCB,
ACEI or ARB

Strength of
Recommendation
Grade B
VA-cooperative, HDFP,
SHEP

Recommendation 7
In black population, including those
with DM, initial anti HT treatment
should include thiazide-type diuretic
or CCB

Grade B ( No DM)
Grade C ( DM)
ALLHAT

Recommendation 8
Population aged 18 with CKD and
HTN, initial (or add on) anti HTN
treatment should include an ACEI or
ARB to improve kidney outcomes. This
applies to all CKD patients with HTN

Grade B
IDNT, AASK

The Antihypertensive and Lipid Lowering

Treatment to Prevent Heart Attack (ALLHAT)
Study Question

Determine whether occurrence of fatal CHD or

non fatal MI is lower for high risk hypertensive
pts treated with CCB (amlodipine), ACEI
(lisinopril), alpha blocker (doxazosin) compared
w/ diuretic (chlorthalidone)

Design

Randomized, double blind, multicentre

Subjects

N = 42.418 high risk hypertensive pts 55 yrs

Mean F/U

8 yrs

Primary Outcome

Composite of fatal CHD or nonfatal MI

Other predefined
endpoint

All cause mortality, stroke, combined CHD/CVD,

renal

Conclusion

Chlorthalidone better control SBP

There was no difference in risk for CHD
death/non fatal MI
In secondary end points, chlorthalidone was
associated with lower risk for stroke,
combined CVD, HF (compared lisinopril), HF
(compared amlodipine)
Thiazide type diuretic should be the drugs

BP Targets In CKD: Proteinuria

as an Effect Modifier
3 RCT

MDRD, AASK, REIN-2

MDRD and AASK trial also post trial
observational follow up

Subjects

2272 participants
Mostly no DM, all trial with subgroup
analysis by baseline proteinuria levels

F/U

2 to 4 year

Primary outcome

Renal outcomes (not CVD)

Conclusion

There is no conclusive evidence

favoring a BP target <125/75 to
130/80 rather than <140/90
A lower target may be beneficial in
persons with proteinuria >300-1000
mg/d

Recommendation

Strength of
Recommendat
ion

Recommendation 9
The main objective of HTN treatment is to
attain and maintain goal BP
If goal BP isnt reached in 1
month,
increase the dose or add a 2nd drug 6
classes (thiazide-type diuretic, CCB, ACEI,
or ARB)
If goal BP cannot be reached with 2 drugs,
add and titrate a 3rd drug from the list
provided. Do not use an ACEI and an
ARB together
If goal BP cannot be reached using only the
drugs in recommendation 6 because of a
contraindication or need >3 drugs, antiHT
drugs from other classes can be used
Referral to a hypertension specialist may

Grade E

Strategies to Dose Antihypertensive Drugs

Strategie
Description
s
Start 1 drug tritate
A

Details

to maximum, and
then add 2nd drug

If goal BP isnt achieved tritate

1st drug until maximum dose
before add 2nd or 3rd drugs

Start 1 drug and

then add 2nd drug
before achiving max
dose

Add 2nd drug before 1st achievied

max dose. If goal BP isnt
achieved add 3rd drugs and
titrate until max dose

Begin with 2 drugs

(separate or single
combination)

Initiate with 2 drugs

Some committee
recommended:
2 drugs SBP >160 and/or
DBP >100, or if SBP >20
mmHg above goal and/or
DBP >10 mmHg
If goal BP isnt achieved (2
drugs), add 3rd drug and
titrate it

Lifestyle Modification

JNC
8

JNC
7

Guideli
ne
2014 HT
Guidelin
e

Populatio
n
General 60
y
General <60
y
DM

Goal
BP

Initial drugs

<150/90 Non Black: thiazide type

diuretic, ACEI, ARB or ARB
<140/90 Black: thiazide type-diuretic or
<140/90 CCB
Thiazide type diuretic, ACEI,
<140/90 ARB or CCB
ACEI or ARB

CKD

ESH/ESC

CHEP

General (non
elderly)
General
elderly <80
y
General 80
y
DM
CKD (no
proteinemia)
CKD +
proteinemia

General <80 y

<140/90

Bocker, diuretic, CCB, ACEI, ARB

<150/90
<150/90
<140/85
<140/90

ACEI or ARB
ACEI or ARB

<130/90

<140/90

Thiazide, Blocker (<60y), ACEI

(nonblack) or ARB

Guidelin Population
e
DM
ADA
DM and
KDIGO

Goal BP

130/80

CKD alb exc

<30 mg/d
DM and
CKD alb
exc >30
mg/d

Initial drugs

<140/80

ACEI or ARB

140/90

ACEI or ARB

NICE

General <80 y
General 80 y

<140/90
<150/90

<55 y; ACEI or ARB

55 y or black; CCB

ISHIB

Black, lower
risk
TOD or CVD
risk

<135/85
<130/80

Diuretic or CCB

JNC 7

General
CKD
DM

<140/90
<130/80
<130/80

ACEI or ARB

Under JNC 8, in all cases, targets BP should

be reached within a month of starting
treatment either by increasing the dose or by
using a combination drugs
In patients 60 yrs who do not have DM or
CKD, the goal BP level is <150/90 mm Hg
In
pts
18
59
yrs
without
major
comorbidities, and in patient 60 yrs
without DM, CKD, or both, the new goal BP is
<140/90 mm Hg
JNC 8 panel recommended thiazide-type
diuretics as initial therapy for most patients
(include newly diagnosed HTN)

JNC 8 also recommend lifestyle interventions

include use of the DASH eating plan, weight
loss, reduction in sodium intake to <2.4
gr/day, and at least 30 minutes of aerobic
activity most days of the week
Under the JNC 8 guidelines, patients would
receive a dosage adjustment and combinations
of the 4 first-line & later line therapies
ACEI/ARB, CCB, and thiazide-type diuretic
The JNC 8 does not recommend -blockers and
-blockers as 1st therapy due to 1 trial that
showed a higher rate of CV events with use of
B compared with use of an ARB, and another
trial in which B resulted in inferior CV
outcomes compared with use of a diuretic

When initiating therapy, patients of

African descent without CKD should use
CCBs and thiazides instead of ACE
inhibitors
ACE inhibitors and ARBs should not be
used in the same patient simultaneously

Diabete
s
Adults with DM and HTN have reduced
mortality as well as improved Cardio and
Cerebro Vascular outcomes with treatment
to a goal SBP <150 mm Hg, but no RCTs
support a goal <140/90 mm Hg. Despite
this, the panel opted for a conservative
recommendation in patients with diabetes
and hypertension, opting for a goal level
of <140/90 mm Hg in adult patients with
diabetes and hypertension rather than the
evidence based goal of <150/90 mm Hg.

CKD
No different targets for CKD with / without DM
or for DM
1 analysis showed an advantage in kidney
outcomes with target BP <130/80 (JNC 7), 2
other analyses didnt support. Another 3 trials
didnt show an advantage with the <130/80
goal over the <140/90 goal level for patients
with
ACEI CKD
& ARBs is recommended in all pts with
CKD regardless of ethnic background, either
as 1st line therapy or in addition therapy
CCBs and thiazide-type diuretics should be
used instead of ACEI and ARBs in patients >75
yrs with impaired kidney function due to the
risk of hyperkalemia, increased creatinine,
and further renal impairment

The use of ACEI or ARBs in protection of

kidney function applies to patients over
the age of 75 years
It was insufficient evidence to support a
goal blood pressure of <140/90 mm Hg in
patients over the age of 70 years with
CKD or albuminuria

Important Variables For HTN

Recommendations
BP

NICE

ESC/ES
H

ASH/I
SH

AHA/A
CC/CD
C

JNC 7

JNC 8

Definitio
n HTN

140/90
and
daytime
ABPM
135/85

140/90

140/9
0

140/9
0

Pre HT
120-139 or
80-89
Stg 1 HT
140-159 or
90-99
Stg 2 HT
160 or
100

Not
addresse
d

Drug th/
in low
risk pts
after
non
pharm
th/

160/10
0 or
daytime
ABPM
150/95

140/90

140/9
0

140/9
0

140/90

<60 y,
140/9
0
60 y,
150/9
0

Blocker

No

Yes

No

No

No

No

st

NICE

ESH/ESC

ASH/IS
H

AHA/A
CC/CD
C

JNC 7

JNC 8

Diureti
c

Chorthal
i-done
(CTD)
Indapam
ide (IND)

Thiazides
(THZ),
CTD
ND

THZ
CTD
IND

THZ

THZ

THZ
CTD
IDP

Initiate
th/
with 2
drugs

Not
mentioned

Pts w/
markedly
elevated
BP

160/90

160/10
0

160/10
0

Not
mention
ed

BP
target

<140/90 <140/90
<140/90
80 y,
Elderly
80 y,
<150/90
<80 SBP <150/90
140-150,
in fit pts
SBP
<140
Elderly
80 y
SBP 140-

<140/90

<140/90 <160/90
(<60 y)
60 y,
<150/90

NICE

ESH/ES ASH/IS AHA/AC

C
H
C/CDC
<140/9
0

<140/90

JNC 7

JNC 8

BP
target
for DM

Not
address
ed

<140/85

<130/80 <140/90

BP
target
for
CKD

Not
address
ed

CKD no
proteinur
ia
(<140/90
CKD +
proteinur
ia
<130/90

<130/8
0
(+protei
nuria)

<130/80

<130/80 <140/90

Th/ for
resiste
nt HTN

Explana
-tion

Explanation

Explana
-tion

Explanation

ExplanaNo
tion
explanation

Low
target
may be
considere
d

Thank you