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Hypertension Guidelines UpdateHow high is too high?

Gbemiga Sofowora, MBChB, FACC

Report from the Eighth Joint National Committee

• Hypertension is the most common condition seen in primary care and leads to

‒ Myocardial infarction‒ Stroke‒ Renal failure‒ Death

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Process

• 50 authors were selected from a total of 400 nominated persons and they had expertise in‒ Hypertension‒ Primary care‒ Geriatrics‒ Cardiology‒ Nephrology‒ Clinical Pharmacology ‒ Nursing

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Process

• The completed document was sent to 20 reviewers and 16 federal agencies.‒ 16 reviewers responded‒ 5 federal agencies responded

‒ Comments were reviewed and incorporated into a revised document.

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Evidence

• Randomized control trials with sample sizes > 100 and duration of follow up > 1 year

• Health outcomes‒ Overall mortality, CVD related mortality, CKD related

mortality‒ Myocardial infarction, CHF, Stroke‒ Coronary and other revascularization‒ ESRD, doubling of creatinine level, halving of GFR

• Literature review between January 1 1966 and December 31 2009 the August 2013

Date of download: 9/15/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: 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. doi:10.1001/jama.2013.284427

Evidence Quality Rating

Table Title:

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Date of download: 9/15/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: 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. doi:10.1001/jama.2013.284427

Strength of Recommendation

Table Title:

Recommendations

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Recommendation 1

• In the general population aged ≥ 60 years, initiate pharmacological treatment to lower BP at ≥150/90 mmHg and treat to lower than 150/90 mmHg

• Grade A- Strong recommendation

Recommendation 1

• There was moderate to High quality evidence that in this population, treating to a goal BP of < 150/90 mmHg reduces stroke, heart failure and coronary artery disease.

• There is also evidence (low quality) that a goal SBP <140 mmHg provided no added benefit compared with a higher goal of 140-149 mmHg

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Corollary recommendation

In the general population ≥ 60 years, if pharmacologic treatment for high BP results in lower achieved 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

Corollary recommendation

• The corollary to recommendation 1 reflects that there are many treated hypertensive patients ≥60 years in whom the SBP is currently lower than 140 mmHg, based on previous guideline recommendations.

• Not necessary to adjust medication to allow BP to increase

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Recommendation 2

• In the general population < 60 years initiate pharmacological treatment to lower BP at DBP of ≥ 90 mmHg and treat to a lower BP of < 90 mmHg

• Ages 30-59 years: Strong recommendation- Grade A

• Ages 18-29 years: Expert opinion- Grade E

Recommendation 2

‒ Based on high quality evidence from 5 DBP trials. Initiation of therapy at a DBP threshold of ≥ 90 mmHg reduces cerebrovascular events, heart failure and overall mortality

‒ No benefit treating patients to goals of < 80 mmHg or < 85 mmHg (HOT trial)

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Recommendation 3

• In the general population < 60 years, initiate pharmacologic treatment to lower BP at SBP of ≥ 140 mmHg and treat to < 140 mmHg

• Expert opinion- Grade E

Recommendation 3

• There was good evidence supporting a specific SBP goal in persons aged 60 years and above but insufficient evidence in persons younger than 60 years

• The panel recommended a goal of 140 mmHg or lower based on:‒ In the absence of studies comparing the resent standard

with a lower or higher standard, there was no need to change the current standard

‒ Given the recommended goal of 140 mmHg or lower in adults with diabetes or CKD, a similar goal may facilitate guideline implementation

‒ Also DBP trial demonstrating benefit with DBP < 90 mmHg also achieved SBP < 140 mmHg

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Recommendation 4

• In the CKD population ≥ 18 years, initiate pharmacologic treatment to lower BP at SBP of ≥ 140 mmHg or DBP of ≥ 90 mmHg and treat to a goal SBP of < 140 mmHg and goal DBP lower than 90 mmHg

• Expert opinion Grade E

Recommendation 4

• This applies to individuals < 70 years with an estimated or measured GFR < 60 mL/min/1.73 m2

• In adults < 70 years, there was insufficient evidence to determine if there was cardiovascular, cerebrovascular or overall mortality benefit to lower goal BP compared to a BP goal of < 140/90 mmHg

• There is moderate quality evidence showing no benefit in slowing kidney disease progression with a lower BP goal compared to < 140/90 mmHg

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Recommendation 5

• In the population ≥ 18 years with diabetes mellitus, initiate pharmacologic treatment to lower BP at SBP of ≥ 140 mmHg or DBP of ≥ 90 mmHg and treat to a goal SBP of < 140 mmHg and goal DBP of < 90 mmHg

• Expert opinion-Grade E

Recommendation 5

• Moderate quality evidence supporting SBP lower than 150 mmHg improves cardiovascular, cerebrovascular and overall mortality in this group

• No RCT suggesting benefit from lower target BP’s in this group

• In the absence of such hard evidence, the panel recommended a goal of <140/90 mmHg in line with recommendation 3 and felt it may facilitate guideline implementation

• ACCORD-BP compared SBP-140 mmHg with SBP < 120 mmHg and there was no difference in a composite outcome

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Recommendation 6

• In the general non-black population, including diabetics, initial antihypertensive treatment should include either of the following:‒ Thiazide diuretic‒ Calcium channel blocker (CCB)‒ Angiotensin converting enzyme inhibitor (ACEI)‒ Angiotensin receptor blocker (ARB)

• Moderate recommendation- Grade B

Recommendation 6

• Each of the 4 classes listed had comparable effects on overall mortality, as well as cardiovascular, cerebrovascular and kidney outcomes except heart failure.

• Initial treatment of hypertension with a thiazide was more effective than an ACE inhibitor or calcium channel blocker in improving heart failure outcomes. An ACEI was more effective than a calcium channel blocker

• Despite this, and considering the other body of evidence, the panel did not feel it necessary to preclude other drug classes

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Recommendation 6

• Beta blockers were not recommended for initial treatment because of a study that showed an increase in the composite endpoint of cardiovascular death, myocardial infarction or stroke compared to an ARB

• Alpha blockers were not recommended for initial treatment because of a study that showed initial treatment with an α-blocker was associated with worse cerebrovascular, cardiovascular and heart failure outcomes compared with a diuretic

Recommendation 7

• In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide type diuretic or calcium channel blocker

‒ For black population: Moderate recommendation-Grade B‒ For diabetic blacks: Weak recommendation-Grade C

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Recommendation 7

• In ALLHAT study, a thiazide diuretic was more effective in improving cerebrovascular, combined cardiovascular outcomes and heart failure compared to an ACEI in Blacks

• There were no difference in cerebrovascular, CHD, combined cardiovascular and kidney outcomes between a CCB and a diuretic

• CCB recommended over ACEI as initial therapy in Blacks because of a 51% higher rate of stroke in Blacks who used an ACEI over a CCB as initial therapy

• ACEI also less effective in reducing BP in Black individuals compared with CCB

Recommendation 8

• In the population aged ≥ 18 years with CKD and hypertension, initial or add on antihypertensive treatment should include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker to improve kidney outcomes. This applies to all patients regardless of race or diabetes status

• Moderate recommendation-Grade B

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Recommendation 8

• Improved kidney outcomes in patients with CKD but less cardiovascular benefit in these patients who use ACEI/ARB as monotherapy

• AASK showed the benefit of ACEI/ARB’s on kidney outcomes in black patients with CKD.

• In Black patients with CKD and proteinuria, an ACEI or ARB is recommended as initial therapy because of the higher likelihood of progression to ESRD

Recommendation 9

• If goal BP is not reached within a month of treatment, increase the dose of the drug or add a second drug [thiazide, CCB, ACEI or ARB]. Continue to evaluate and assess and if goal BP is still not reached, add a third drug from the list but do not prescribe an ACEI and an ARB on the same patient.

• Expert opinion Grade E

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Date of download: 8/27/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: 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. doi:10.1001/jama.2013.284427

2014 Hypertension Guideline Management AlgorithmSBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker. ACEIs 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.

Figure Legend:

End

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Date of download: 9/15/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: 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. doi:10.1001/jama.2013.284427

2014 Hypertension Guideline Management AlgorithmSBP 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.

Figure Legend:

Date of download: 9/15/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: 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. doi:10.1001/jama.2013.284427

2014 Hypertension Guideline Management AlgorithmSBP 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.

Figure Legend: