JNC 8 _Dr. Mansij Biswas

Hypertension Update: JNC8Dr. Mansij Biswas

SYR, Dept. of Pharmacology & TherapeuticsSeth GS Medical College & KEM Hospital

“The greatest danger toa man with high blood pressure lies in its discovery because then some fool is certain to try his hand and reduce it”

Hay J, “A british medical association lecture on the significance of a raised blood pressure,” British Medical Journal, vol. 2, no. 3679, pp. 43–47, 1931

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At a glance…

Eighth Joint National Committee

Evidence- based Guidelines

Not just JNC 7 “Renovated” BUT “Demolished &

Reconstructed”

Destination is important and not the journey!!

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Introduction:

Hypertension remains one of the most important preventable

contributors to disease and death

Guidelines are at the intersection between research evidence and

clinical actions that can improve patient outcomes

The panel members appointed to the JNC 8 used evidence-based

methods, developing statements and recommendations for high

blood pressure management

Recommendations are based on a systematic review of literature

to meet the need of the primary care physicians

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Hypertension (HTN) is a major public health concern, affecting

26% of adults worldwide

People with HTN

worldwide in 2000972 million

Increase in the

number of adults with

HTN globally by 2025

60%

Percentage of all global

healthcare spending

attributable to treat high

blood pressure

10%

Annual worldwide cost of

treating hypertension$370 billion

Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23.

Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.

1.6 Billion

HTN patients estimated

by 2025

Questions Guiding the Evidence Review

Guideline focuses on the panel’s most debated questions

related to high BP management.

These questions address:

Thresholds and goals for treatment of hypertension

Whether particular antihypertensive drugs or drug classes

improve important health outcomes compared with others

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① In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Threshold

② In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvement in health outcome? Goal

③ In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcome? Impact of drugs

Questions Guiding the Evidence Review

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Process:

>400 nominees

Members selected

Guidelines first draft - January 2013

Reviewed by 20 (16) reviewers and 16 (5) federal agencies -February 2013

Revised document - June 2013

09/08/14 8

Population Criteria:

• Adults ≥ 18 years with HTN

• Subgroups-

• DM

• CAD, PAD

• HF

• Previous h/o Stroke

• CKD, Proteinuria

• Older adults (>70 years of age)

• Men/Women

• Racial/ethnic groups

• Smokers

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Outcomes considered:

• Mortality: overall, CVD related, CKD related

• MI, HF (hospitalization due to HF), stroke

• Revascularization: Coronary (CABG,

Angioplasty, Stent placement), others

(carotid, renal, lower extremity)

• ESRD (resulting in dialysis or transplant),

doubling Creatinine level, halving GFR

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Trials:

Only RCTs (well executed or with minor limitations

only- rated as ‘good’ or ‘fair’)

Period January 1, 1966 to December 31, 2009

Secondary search: (with same MeSH terms)

PubMed & CINAHL

December 2009 – August 2013

Major study in HTN (like ACCORD), ≥ 2000

subjects, multi-centric, met inclusion/exclusion

criteria09/08/14 11

Collation:

• Literature review & Data tabulation by external methodology team

• Evidence summarized

• Evidence statements crafted

• Voting

Agree/disagree with each evidence statement

Quality of evidence (high, moderate or low)

• Clinical recommendations crafted

• Voting

Agree/disagree with recommendation

Strength of recommendation09/08/14 12

09/08/14Copyright © 2012 American Medical Association. All rights reserved.

JAMA. 2013; doi:10.1001/jama.2013.28442713

Recommendations:

Recommendations 1-5:

Threshold and goals for HTN treatment

Recommendations 6-8:

Selection of anti-HTN drugs

Recommendation 9:

Summary of strategies (expert opinion)

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General population aged 60 years or older:

Recommendation 1:

SBP ≥150 mm Hg

Or

DBP ≥ 90mm Hg

Goal of Treatment: SBP <150 mm Hg

OR

DBP of < 90mm Hg.

Initiate Treatment at:

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Recommendation 1: Corollary

General population aged ≥60years

Treatment does not need to be adjusted

IF

Pharmacologic treatment for high BP results in lower

achieved SBP (<140mmHg) and treatment is well

tolerated and without adverse effects on health or quality

of life

General population < 60 years:

Recommendation 2:

Initiate Treatment at: DBP ≥ 90mm Hg

Goal of Treatment: DBP of < 90mm Hg

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General population < 60 years:

Recommendation 3:

SBP ≥ 140 mm Hg

Goal of Treatment: SBP of < 140 mm Hg


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Population aged 18 years or older with CKD:

Recommendation 4:


SBP ≥ 140 mm Hg

Or

DBP ≥ 90 mm Hg

Goal of Treatment: SBP < 140 mm Hg

Or

DBP < 90 mm Hg

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Population aged 18 years or older with diabetes:

Recommendation 5:

Initiate Treatment at: SBP ≥ 140 mm Hg

Or

DBP ≥ 90 mm Hg

Goal of Treatment: SBP < 140 mm Hg

Or

DBP < 90 mm Hg

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Recommendation 6:

In General non black population, including those with

diabetes, initial anti-HTN therapy should include any of the

following:

Thiazide-type diuretic

Calcium channel blocker (CCB)

Angiotensin-converting enzyme inhibitor (ACEI)

Angiotensin receptor blocker (ARB)

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Recommendation 7:

In general black population, including those with

diabetes, initial antihypertensive treatment should

include:

Thiazide-type diuretic

OR

Calcium channel blocker (CCB)

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Recommendation 8:

Population aged 18 years or more with CKD ± DM

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

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Recommendation 9:

The main aim is to attain and maintain a 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

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Recommendation 9: contd…

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 due to adverse reactions or the need

to use more than 3 drugs to reach goal BP: Anti- HTN drugs from

other classes can be used

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Strategies to Dose Antihypertensive Drugs

Figure Legend:

09/08/14Copyright © 2012 American Medical Association. All rights reserved.

JAMA. 2013; doi:10.1001/jama.2013.28442726

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

Recommendation 9: contd…

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JNC 8 (2014 Hypertension Guideline Management Algorithm)

JAMA. 2013;():. doi:10.1001/jama.2013.28442709/08/14 28


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JNC 7

Nonsystematic literature

review by expert committee

including a range of study

designs

Recommendations based on

consensus

JNC 8

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

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JNC 7

Defined hypertension and

prehypertension

JNC 8

Definitions of hypertension and

prehypertension not addressed

But thresholds for

pharmacologic treatment were

defined

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JNC 7

Separate treatment goals

defined for

“uncomplicated” hypertension

Subsets with various comorbid

conditions (diabetes and CKD)

JNC 8

Similar treatment goals defined

for all hypertensive populations

Except when evidence review

supports different goals for a

particular subpopulation

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JNC 7

Recommended lifestyle

modifications based on

literature review and expert

opinion

JNC 8

Lifestyle modifications

recommended by endorsing the

evidence based

recommendations of the

Lifestyle Work Group

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JNC 7

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

JNC 8

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

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JNC 7

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

JNC 8

Addressed a limited number of

questions, those judged by the

panel to be of highest priority.

Evidence review of RCTs

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JNC 7

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

JNC 8

Reviewed by experts including

those affiliated with

Professional

Public organizations

Federal agencies

No official sponsorship by any

organization should be inferred

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09/08/14 JAMA. 2013;():. doi:10.1001/jama 2013.2844239

Limitations:

Focused to address 3 specific questions: clinicians often provide

care for patients with numerous co-morbidities

Treatment adherence and medication costs were thought to be

beyond the scope of this guideline

Did not include observational studies or systematic reviews and

did not perform its own meta-analysis

Many of the reviewed studies were conducted when the overall

CV morbidity and mortality were much higher than today- effect

size might have been over-estimated

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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 be carefully considered and

incorporate the clinical characteristics of each individual.

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ANIMATED SLIDE

JNC 8 _Dr. Mansij Biswas

Health & Medicine

Transcript of JNC 8 _Dr. Mansij Biswas