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Evidence-Based Guideline for Management of High Blood Pressure in
AdultsReport From the Panel Members Appointed to the
Eighth Joint National Committee (JNC 8)
Dr Arun kochar MD;DM;DNB Senior interventional cardiologist Fortis Hospital, Mohali
JNC 8 is not just JNC 7 “Renovated”….but 911ed and Reconstructed
Historical Comments about Hypertension
“The greatest danger to a man withhigh blood pressure lies in its discovery…….because then some fool is certain to try his hand and reduce it.” Hay, Brit Med J, 1931
Let us take a early dinner…
Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else.
Any of 4 classes of drugs could be chosen. Destination is important and not the journey. No stages please. In blacks C and D.
THANK YOU
Introduction
Hypertension remains one of the most important preventable contributors to disease and death.
Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes.
This report highlights the Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
Introduction
The panel members appointed to the JNC 8 used evidence-based methods, developing Evidence Statements and recommendations for blood pressure treatment.
Recommendations are based on a systematic review of the literature to meet needs of the primary care clinician.
This is an Executive summary of the evidence and is provides clear recommendations for all clinicians.
Date of download: 12/21/2013Copyright © 2012 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. 2013;():. doi:10.1001/jama.2013.284427
Comparison of Current Recommendations With JNC 7 Guidelines
Figure Legend:
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 have a bearing health outcomes.
1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Goals
2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvement in health outcomes? Targets
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? Impact of drugs
Questions Guiding the Evidence Review
Recommendations
Concerning thresholds and goals.
Recommendations 1 -5
General population aged 60 years or older
Recommendation 1
SBP ≥150 mmHg Or
DBP ≥ 90mmHg
Goal of Treatment :
SBP <150 mmHg OR
DBP of < 90mmHg.
Initiate Treatment at :
General population < 60 years
Recommendation 2
Initiate Treatment at : DBP ≥ 90mmHg
Goal of Treatment :
DBP of < 90mmHg.
General population < 60 years
Recommendation 3
SBP ≥ 140 mmHg
Goal of Treatment :
SBP of < 140 mmHg.
Initiate Treatment at :
Population aged 18 years or older with CKD
Recommendation 4
Initiate Treatment at:
SBP ≥ 140 mmHgOr
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHgOr
DBP < 90 mmHg
Population aged 18 years or older with diabetes
Recommendation 5
Initiate Treatment at:
SBP ≥ 140 mmHgOr
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHgOr
DBP < 90 mmHg
Concerning selection of antihypertensive drugs.
Recommendations6,7,8
Recommendation 6
In General nonblack population, including those with diabetes
Initial antihypertensive treatment should include any of the following:
A thiazide-type diuretic Calcium channel blocker (CCB) Angiotensin-converting enzyme inhibitor
(ACEI) or Angiotensin receptor blocker (ARB).
Recommendation 7
In general black population, including those with diabetes:
Initial antihypertensive treatment should include :
Thiazide-type diuretic
CCB.
Recommendation 8
Population aged 18 years or older with CKD and hypertension
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.
Recommendation 9
The main objective of hypertension 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 (thiazide-type diuretic, CCB, ACEI, or ARB).
The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.
Opinion for starting & adding drugs
.
Recommendation 9
Recommendation 9 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 the need to use more than 3 drugs to reach goal BP: antihypertensive drugs from other classes can be used.
Date of download: 12/21/2013Copyright © 2012 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. 2013;():. doi:10.1001/jama.2013.284427
Strategies to Dose Antihypertensive Drugs
Figure Legend:
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
JNC-8 ASH/ISH AHA/ACC Published on 18th Dec 2013 19th Dec 2013 21st Nov 2013
Target goal
For general patients including DM/CKD
<140/90 <140/90 <140/90
Lower targets may be appropriate for
LVD, LVH, DM, CKD
For Elderly people
150/90(≥60 yrs) 150/90(≥80 yrs) Lower targets for
the Elderly
Treatment preference
General <60 yrs
Initiate Thiazide-type Diuretic or ACEI or ARB or
CCB
For uptitration, any possible
combination from above (avoid ACEI+ARB)
Stage 1 HT:
ACEI or ARB
(If needed, add CCB or Thiazide-
type Diuretic)
Stage 1 HT:
Thiazide for most patients or
ACEI, ARB, CCB, (or combination, if
uncontrolled)
Stage 2 HT:
ACEI or ARB
+
CCB or Thiazide-type Diuretic
Stage 2 HT:
Thiazide with
ACEI / ARB/ CCB,
or
ACEI with CCB
General ≥60 yrs Same as above
Stage 1: CCB or Thiazide (If
needed, add ACEI or ARB)
Same as Above
Hypertension with Diabetes
Same as above
ACEI or ARB
If needed add CCB or thiazide-type
diuretic
ACEI or ARB, thiazide, BB,
calcium channel blocker
Hypertension with CKD
ACEI or ARB alone
Or in combination with other
ACEI or ARB
If needed add CCB or thiazide-type
diuretic
ACEI or ARB
Comparison..(cont.)
Hypertension with CAD
---
β-Blocker plus ARB or ACE inhibitor
If needed add CCB or thiazide-type
diuretic
β-Blocker, ACEI
Hypertension with stroke
---
ACE inhibitor or ARB
If needed add CCB or thiazide-type
diuretic
Thiazide, ACEI.
Hypertension with HF
---
ARB or ACE inhibitor+ β -
blocker+ diuretic+
spironolactone regardless of blood
pressure
ACEI or angiotensin-
receptor blocker (ARB), BB,
aldosterone antagonist,
thiazide;
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 carefully consider and incorporate the clinical characteristics of each individual.
Thank you for your patience