Download JNC 8 2014 Evidence-Based Guidelines for the Management of

JNC 8
2014 Evidence-Based Guidelines
for the Management of High
Blood Pressure in Adults
April 22, 2016
Connie Tien
Daniel Kim
Jeffrey Hughes
Michelle Di Fiore
Ola Lafi
Table of Contents
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Why Do We Treat Hypertension?
Blood Pressure Treatment Goals
Initial Therapy
Strength of Recommendation
Recommendation 1
Corollary Recommendation
Recommendation 2
Recommendation 3
Recommendation 4
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Recommendation 5
Recommendation 6
Recommendation 7
Recommendation 8
Recommendation 9
Evidence Based Dosing for
Antihypertensive Drugs
• Hypertension Guideline
Management Algorithm
• Sources
Why Do We Treat Hypertension?
• Hypertension can lead to:
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Myocardial infarction
Stroke
Renal failure
Death
Blood Pressure Treatment Goals
• Persons 60 years or older without diabetes or CKD
• BP < 150/90 (based on strong evidence)
• Persons less than 60 years of age, with diabetes, and/or with CKD
• BP <140/90 (based on expert opinion)
Initial Therapy
• Non-black persons
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Angiotensin-converting enzyme inhibitor (ACEI)
Angiotensin receptor blocker (ARB)
Calcium channel blocker (CCB)
Thiazide-type diuretic
• Black persons (including those with diabetes)
• CCB
• Thiazide-type diuretic
• Chronic kidney disease (regardless of race or diabetes status)
• ACEI or ARB as initial or add-on antihypertensive therapy
Strength of Recommendation
Recommendation 1
In the general population aged ≥60 years, initiate treatment at systolic
blood pressure (SBP) ≥150 or diastolic blood pressure (DBP) ≥90 and
treat to a goal SBP <150 and DBP <90.
Strong Recommendation – Grade A
Corollary Recommendation
In the general population aged ≥60 years, if treatment results in lower
achieved SBP (e.g. SBP <140) and treatment is well tolerated 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 <60 years, initiate treatment at DBP ≥90 and
treat to a goal DBP <90.
For ages 30-59 years, Strong Recommendation – Grade A
For ages 18-29 years, Expert Opinion – Grade E
Recommendation 3
In the general population <60 years, initiate treatment at SBP ≥140 and
treat to a goal SBP<140.
Expert Opinion – Grade E
Recommendation 4
In the population aged ≥18 with chronic kidney disease (CKD), initiate
treatment at SBP ≥140 or DBP ≥90 and treat to goal SBP <140 and DBP
<90.
Expert Opinion – Grade E
Based on the inclusion criteria used in the randomized controlled trials (RCTs) reviewed by the panel, this
recommendation applies to individuals <70 years with an estimated GFR or measured GFR <60 and in
people of any age with albuminuria defined as >30 mg of albumin/g of creatinine at any level of GFR.
Recommendation 5
In the population aged ≥18 years with diabetes, initiate treatment at
SBP ≥140 or DBP ≥90 and treat to a goal SBP <140 and DBP <90.
Expert Opinion – Grade E
Recommendation 6
In the 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
RCTs that were limited to specific nonhypertensive populations, such as those with coronary artery
disease (CAD) or heart failure (HF) were not reviewed for this recommendation. Therefore,
recommendation 6 should be applied with caution to these populations.
For more details regarding why other drug classes were not recommended for initial therapy please see
the notes for this slide.
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
For more information regarding why the other drug classes were not recommended as initial therapy for black
persons please see the notes for this slide.
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 CKD patients with hypertension
regardless of race or diabetes status.
Moderate Recommendation – Grade B
Recommendation 9
• The main objective of 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.
• The clinician should continue to assess BP and adjust the treatment regimen until
the goal BP is reached.
• If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the
list provided in recommendation 6.
• If goal BP cannot be reached using on 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
Figure continued on following slide.
Sources
• James PA, Oparil S, Carter BL, et al. 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.
Question #1
A 43 yo M is evaluated during a routine physical examination. He has
no current symptoms and no PMH. FH is notable for DM and HTN in 2
1st degree relatives. He takes no meds.
On physical exam, initial BP is 144/86; repeat measurement after 5
minutes of rest are 136/86 and 134/88. BMI is 32. The remainder of
the exam is normal.
Labs show normal Cr and plasma glucose levels.
In addition to lifestyle modifications, which of the
following is the most appropriate next step in the
management of this patient’s blood pressure?
A: Initiate a low dose ACE inhibitor
B: Initiate low dose chlorthalidone
C: Order ambulatory BP monitoring
D: Recheck blood pressure in 1 year
In addition to lifestyle modifications, which of the
following is the most appropriate next step in the
management of this patient’s blood pressure?
A: Initiate a low dose ACE inhibitor
B: Initiate low dose chlorthalidone
C: Order ambulatory BP monitoring
D: Recheck blood pressure in 1 year
Answer
• Although JNC 8 did not address pre-hypertension, JNC 7 defined it as
SBP 120-139 or DBP 80-89 in the absence of pre existing disease
• Lifestyle modifications:
• Low salt diet, DASH diet, exercise regimen
• Follow-up: annual visits.
• Answer A &B: although there is increased risk of stroke, CV dx, and
development of HTN, ACE inhibitor has not been shown to reduce the
risk.
• Answer C: Ambulatory BP monitoring records BP periodically during
normal activities. Indicated for “white-coat” HTN, masked HTN, or
confirm poor response to antihypertensive medications.
Question 89
A 57 yo African American M is evaluated for treatment of newly
diagnosed HTN. History is notable for HLD, which is treated with
moderate-dose simvastatin.
On exam, BP 151/94, HR 72, BMI 28. Remainder of exam is
unremarkable.
Labs show Cr 1.0, fasting glucose 104, and K+ 4.5. A urine dipstick
demonstrates no blood or protein.
In addition to recommending lifestyle
modifications, which of the following is the most
appropriate initial anti-hypertensive therapy for
this patient?
A: Amlodipine
B: Diltiazem
C: HCTZ
D: Lisinopril
In addition to recommending lifestyle
modifications, which of the following is the most
appropriate initial anti-hypertensive therapy for
this patient?
A: Amlodipine
B: Diltiazem
C: HCTZ
D: Lisinopril
Answer:
• Patient is African American with stage 1 HTN. Thiazide diuretics and
CCB alone or in combo are recommended by JNC 8.
• Patient is on moderate dose statin that uses CYP3A4 pathway which
can be inhibited by CCB and can cause increased statin myopathy, so
thiazide diuretic would be more appropriate.
• REMEMBER: African Americans have less BP response to reninangiotensin system agents despite similar plasma renin activity.
• ACE inhibitor is not indicated
Question 98
A 60 yo woman is evaluated during a follow-up visit for HTN. History is also
notable for HLD. She tolerates her medications well except for minor pedal
edema since starting her anti-hypertensive medication. She is active and
plays tennis 3x/wk. Current medications are amlodipine 5mg/d and
rosuvastatin.
On exam, the average of 2 BP readings is 152/86 which is consistent with
measurements she has obtained at home for 3 months. HR 64, BMI 22.
Trace pedal edema is noted.
Labs show normal chemistry panel and urine dipstick shows no protein.
Which of the following is the most
appropriate next step in management?
A: Add Lisinopril
B: Add metoprolol
C: Increase amlodipine to 10mg/d
D: Continue current regimen
Which of the following is the most
appropriate next step in management?
A: Add Lisinopril
B: Add metoprolol
C: Increase amlodipine to 10mg/d
D: Continue current regimen
Answer
• Patient has stage 1 hypertension and JNC 8 recommends BP goal <150/90 for
patients >60 yo.
• She has no evidence of CV or kidney dx and is not frail and has a longer
expected lifetime than the general population of this age, cautious stepped care
for lower blood pressure goals is reasonable.
• Increasing dose of 1 agent is less effective in reducing BP then addition of 2nd
agent at low dose, also avoids the risk of SIDE EFFECTS
• Beta blocker is not indicated for the initial Rx of HTN
• ACCOMPLISH trial demonstrated benefit of combo therapy with CCB and ACE
inhibitor in reducing cardiovascular events compared to using a thiazide and
ACE inhibitor
Question 19
A 48 yo woman is evaluated during a follow up visit for newly diagnosed
HTN, confirmed by multiple measurements at home and in the office. PMH
of HLD for which she is taking atorvastatin. Lifestyle modifications have
been recommended.
On exam, BP 160/92, HR 64, BMI 32. Remainder of exam unremarkable.
Labs show Cr 1.1mg/dL, fasting glucose 114 and K+ 4.0, urine dipstick
demonstrates no blood or protein.
Which of the following is most likely to be
effective in controlling this patient’s HTN?
A: Amlodipine
B: Lisinopril
C: Losartan
D: Lisinopril and amlodipine
E: Losartan and lisinopril
Which of the following is most likely to be
effective in controlling this patient’s HTN?
A: Amlodipine
B: Lisinopril
C: Losartan
D: Lisinopril and amlodipine
E: Losartan and lisinopril
Answer
• Combination therapy with ACE inhibitor and amlodipine is appropriate with
stage 2 HTN
• Stage 2: SBP > 160 or DBP >100
• Single agent is unlikely to control BP who are >20/10mmg Hg above target BP.
• Combo of 2 agents at moderate doses is more successful at achieving goal than
1 at maximal dose
• Combos supported by JNC 8
• Thiazide w/ ACE inhibitor or ARB
• CCB w/ ACE inhibitor or ARB
• ACCOMPLISH trial demonstrated benefit of combo therapy with CCB and ACE
inhibitor in reducing cardiovascular events compared to using a thiazide and
ACE inhibitor
• ACE and ARB should not be used in combination
Question 10
A 51 yo M is evaluated during a follow up visit for management of newly
diagnosed hypertension and diabetes. He started a program of lifestyle
modifications for his DM, but hasn’t started anti-hypertensive medication. He
currently takes no meds.
On exam, BP 148/92, HR 76, BMI 33. The remainder of the exam was normal.
Labs show Cr 1.5, K+4.2, urine dipstick with no hematuria or proteinuria and
spot urine protein-creatinine ratio 50mg/g
Which of the following is the most appropriate
anti-hypertensive treatment for this patient?
A: HCTZ
B: Lisinopril
C: Lisinopril and amlodipine
D: Lisinopril and HCTZ
E: Lisinopril and losartan
Which of the following is the most appropriate
anti-hypertensive treatment for this patient?
A: HCTZ
B: Lisinopril
C: Lisinopril and amlodipine
D: Lisinopril and HCTZ
E: Lisinopril and losartan
Answer:
• Patient has Stage 1 HTN, DM, and CKD.
• Regardless of DM status, ACEi/ARB have protective effect on kidney
and is recommended by JNC8 with goal <140/90
• Recommendations for more aggressive BP goals <130/80 in this
population have ben tempered by the lack of efficacy in reducing
mortality and increase adverse events.