JNC8 Hypertension Guideline Management Algorithm

Adult aged <!18 years with hypertension

Implement lifestyle interventions ( continue throughout management)

Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD).

Age <! 60 years

Blood pressure goal SBP <150 mm Hg DBP<90mm Hg

Nonblack

General population no diabetes or CKD

l Age < 60 years

Blood pressure goal SBP <140 mm Hg I DBP <90 mm Hg

Diabetes or CKD present

All ages Diabetes present

NoCKD

Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg

Black

Initiate thiazide-type diuretic I or ACEJ/ARB or CCB, alone

or in combination (a)

Initiate thiazide-type diuretic or CCB, alone or in combination

Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dosed combination. L._ _____ _____ _

Abbreviations:

SBP - systolic blood pressure

DBP - diastolic blood pressure

ACEI - angiotensin­converting enzyme inhibitor

ARB - angiotensin receptor blocker

CCB - calcium channel blocker

<=.!-t goal blood pressure? Yes

No

Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACE! or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). For strategy C, titrate doses of initial medications to maximum.

Yes

At goal blood pressure?

No

Reinforce medication and lifestyle adherence. Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARG).

Yes

At goal blood pressure? ---~

No Reinforce medication and lifestyle adherence.

~--~ Add additional medication class (eg, f3-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management.

No At goal blood pressure?

Footnotes: (a) ACEls and ARBs should not be used in combination.

All ages CKD present with or

without diabetes

Blood pressure goal SBP <140 mm Hg DBP <90mm Hg

All races

Initiate ACEI or ARB, alone or in combination with other drug

class (a)

Continue current treatment and monitoring(bJ

(b) If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan.

Compelling Indications

Treatment Choice

Heart Failure ACEI/ ARB + BB +diuretic+ sp ironolactone

Post -Ml/Clinical CAD ACEI/ARB AND BB

ACEI, BB, d iuretic, CCB

Diabetes ACEI/ARB, CCB, diuretic

ACEI/ARB

Recurrent stroke prevention ACEI , diuretic

Pregnancy

Drug Class

Diuretics

ACEI/ARB

Beta-Blockers

Calcium channel blockers

Vasodilators

Centrally-acting Agents

labetolol (first line), nifedipine, methyldopa

Agents of Choice

HCTZ 12.5-SOmg, chlorthalidone 12.5-25mg, indapamide 1.25-2.Smg triamterene 100mg K+ sparing- spironolactone 25-SOmg, amiloride 5-lOmg, triamterene 100mg

furosemide 20-80mg twice daily, torsemide 10-40mg

ACE/: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5-lOmg, trandolapril 2-8mg ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-lOOmg, olmesartan 20-40mg, telmisartan 20-80mg

metoprolol succinate 50-lOOmg and tartrate 50-lOOmg twice daily, nebivolol 5-lOmg, propranolol 40-120mg twice daily, carvedilol 6.25-2Smg twice daily, bisoprolol 5-lOmg, labetalol 100-300mg twice daily,

Dihydropyridines: amlodipine 5-lOmg, nifedipine ER 30-9Dmg, Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 times daily or ER 240-48Dmg

hydralazine 25-lOOmg twice daily, minoxidil 5-lOmg

terazosin 1-Smg, doxazosin 1-4mg given at bedtime

clonidine O.l-0.2mg twice daily, methyldopa 250-SOOmg twice daily

guanfacine 1-3mg

Hypertension Treatment

Beta-1 Selective Beta-blockers - possibly safer in patients with COPO, asthma, diabetes, and peripheral vascular disease: • metoprolol • bisoprolol • betaxolol • acebutolol

Comments

Monitor for hypokalemia Most SE are metabolic in nature Most effective when combined w/ ACEI Stronger clinical evidence w/chlorthalidone Spironolactone - gynecomastia and hyperkalemia Loop diuretics may be needed when GFR <40ml/min

SE: Cough (ACEI only), angioedema (more with ACEI}, hyperkalemia Losartan lowers uric acid levels; candesartan may prevent migraine headaches

Not first line agents - reserve for post-MI/CHF Cause fatigue and decreased heart rate Adversely affect glucose; mask hypoglycemic awareness

Cause edema; dihydropyridines may be safely combined w/ B-blocker Non-dihydropyridines reduce heart rate and proteinuria

Hydralazine and minoxidil may cause reflex tachycardia and fluid retention - usually require diuretic+ B-blocker

Alpha-blockers may cause orthostatic hypotension

Clonidine available in weekly patch formulation for resistant hypertension