2014 evidence-based guidelines for the management of high blood pressure in adults paul a. james,...

2014 evidence-based guidelinesfor the management

of high blood pressure in adults

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, MS; 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

Report from the panel members appointed to the Eighth Joint National Committee (JNC 8)

JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.

Questions guiding the JNC8 review

This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management. They address thresholds, goals for pharmacologic treatment, and whether particular antihypertensive drugs or drug classes improve important health outcomes compared to others.

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

2.In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?

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


The answers to these three questions are reflected in 9 recommendations

Recommendation 1 (Strong recommendation)

Recommendation 2 (Strong recommendation)

Recommendation 3 (Expert opinion)

General population ≥60 years

SBP ≥150 mm Hgor DBP ≥90 mm Hg

SBP <150 mm Hgand DBP <90 mm Hg

General population <60 years DBP ≥90 mm Hg DBP <90 mm Hg

General population <60 years SBP ≥140 mm Hg SBP <140 mm Hg

Recommendations (1/3)


GoalsBP thresholds



Recommendation 6 (Moderate recommendation)

Population with CKD ≥18 years



Population with diabetes ≥18 years



General nonblack population (with diabetes)

Thiazide-type diuretic,calcium channel blocker (CCB),angiotensin-converting enzyme inhibitor (ACEI),or angiotensin receptor blocker (ARB)



GoalsBP thresholds

Initial treatment

CKD: chronic kidney disease





General (with diabetes) black population

Thiazide-type diuretic,or calcium channel blocker (CCB)

Population with CKD ≥18 years

Angiotensin-converting enzyme inhibitor (ACEI),or angiotensin receptor blocker (ARB)

Goal BP not reachedwithin a month of treatment

Increase the dose of the initial drug,or add a second drug (from the list provided)

Goal BP not reachedwith 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


Initial treatments

Initial or add-on treatments

Non control strategies

Conclusions

• This JNC8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from JNC 7 reasonable.

• It offers clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies to achieve those goals.

• However these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

2014 evidence-based guidelines for the management of high blood pressure in adults paul a. james,...

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