comparison of jnc 7 and jnc 8

Comparison of JNC 7 and JNC 8

S. Sickler & F. MumbuloState University of New York Institute of Technology

(duanelbarber.hubpages.com, 2014)

Definition of the Problem

• Domino (2011) divides hypertension into two categories – primary (essential) – secondary

(Domino, 2013; Foex & Sear, 2004; medicalbox.com, 2014)


• Diagnosis of essential hypertension – A person has two or more elevated blood

pressures during two or more office visits with no known cause for the increase • Systolic >140mmHg, Diastolic >90mmHg

(Domino, 2013; Foex & Sear, 2004)


• Secondary hypertension uses the same parameters for both systolic and diastolic measurements but has identifiable underlying mechanisms for the increase in blood pressure – Medications, toxins, underlying disease

• Over time this chronic elevation in blood pressure results in end organ damage, which in turn increases a persons morbidity and mortality

(Domino, 2013; Foex & Sear, 2004)

Pathophysiology

• Regulation and control of blood pressure by the body is complex and involves:– The autonomic nervous system,– The cardiovascular system – The renin – angiotensin - aldosterone system (RAAS).

(Dreisbach, 2013; es123rf.com, 2013)

Pathophysiology

• Arterial pressure in the body is determined both by: – Cardiac output (CO) – Peripheral vascular resistance (PVR).


Pathophysiology

• However there are several other factors that effect CO:– Sodium intake– Renal function – Mineral-corticoids – Extracellular fluid volume and the – Contractility of the heart


Pathophysiology

• Peripheral vascular resistance relies upon – Sympathetic branch of the autonomic nervous system– Humoral factors – Local auto regulation


Pathophysiology

• Alpha & beta Effects on the bodies vessels is a direct result of the alpha and beta effects from the sympathetic nervous system– Vasoconstriction – Vasodilation


Pathophysiology

• Patients with hypertension may have several pathways that are causing their disease

• One pathway is an increased CO and/or systemic vascular resistance (SVR). – Younger age groups tend to have an elevated CO– Older populations tend to have an increased SVR and

vascular stiffness.

(Foex & Sear, 2004; es123rf.com, 2013)

Pathophysiology

• A second pathway would be an over stimulation of the alpha affect or peptides such as angiotensin, causing an increased vascular tone

• Lastly an increase in the calcium concentration of the intracellular fluid can cause vasoconstriction within the vascular smooth muscle

(es123rf.com, 2013)

Etiology

• Estimated 50 million Americans and 1 billion people world wide suffer from some form of hypertention

– Essential hypertension accounts for 90-95% of all adult cases • No known causes

– Secondary hypertension only accounts for 2-10% of the total patient population • Numerous known causes

(Madhur, 2014; U.S. Department of Health and Human Services, 2003)

Etiologies of Secondary

• Renal causes account for 2-6% of the population and include:– Renal parenchymal and renal vascular diseases

• Examples include– polycystic kidney disease, – chronic kidney disease – urinary tract obstruction– renin-producing tumor and – liddle syndrome (autosomal dominant disorder)

(Madhur, 2014)


• Vascular causes – Coarctation of the aorta (genetic narrowing near ductus

arteriosus/ligamentum ateriosum)

(dermis.net, 2014; Madhur, 2014; texasheart.org, 2013; ufhealth.org, 2011)

Vasculitis Collagen vascular disease (autoimmune)

Etiologies of Secondary• Endocrine causes account for

1-2% of the patient population and include:– Both exogenous and

endogenous hormone imbalances

• Most common cause of exogenous imbalances– Steroid use for therapeutic

purposes • Increases blood pressure by

expanding intravascular volume

(Madhur, 2014)


• Other exogenous imbalances include– Use of non-steroidal anti-inflammatory drugs (NSAID’s)

(cause increased sodium retention through COX-1 & COX-2)

– Oral contraceptives (activates the RAAS).

(Madhur, 2014)


• Endogenous hormonal causes include – Primary hyperaldosteronism – Cushing syndrome – Pheochromocytoma– Congenital adrenal hyperplasia

(Madhur, 2014; traditionalbotanicalmedicine.com, 2011)


• Other factors include– Neurogenic, such as brain tumor, bulbar poliomyelitis and

intracranial hypertension – Drugs and other toxins such as alcohol, cocaine, NSAID’s,

erythropoietin, decongestants and nicotine – Co-morbidities such as hyperthyroidism/hypothyroidism,

hypercalcemia, hyperparathyroidism, acromegaly, pregnancy induced hypertension and obstructed sleep apnea (OSA) • Half the patients that are diagnosed with OSA have hypertension

and half the patients diagnosed with hypertension have OSA

(Madhur, 2014)

87% of patients ages 3 – 20 in a study were not recognized

by medical staff of having elevated blood pressures

Brady et. al, (2010)

Microalbuminuria screening done at 1, 2, 5, or 10-year intervals starting at age 50 in patients with risk factors

(diabetes and hypertension) is suggested in order to detect chronic kidney disease in early stages

Other factors to consider in patients with HTN include risk factors for cardiovascular co-morbidities consider screening for the following:• Fasting HDL & LDL every 5 yrs for

normal risk patients starting at age 20 (higher risk patients with abnormal levels will need closer monitoring)

• Blood glucose every 3 yrs (starting at age 45)

• BMI every annual exam (starting at age 20)

• Waist Circumference needed to evaluate cardiovascular risk (starting at age 20)

• Every visit discuss smoking cessation, physical activity & dietary issues (starting at age 20)

Screening Facts

(Brady,, Solomon, Neu, Siberry, & Perekh, 2010; Hoerger et. al, 2010)

• JNC-7 recommendations suggest when screening for hypertension – Patient must be seated for five minutes – Arm resting at heart level with patient relaxed

Screening & Risk Factors

(Chaix et. al, 2010; Garrison & Oberhelman, 2013; walgreens.com, 2014)

Garrison and Oberhelman’s (2013) study pointed out that accurate blood pressures obtained in an office visit may not be within the parameters of the JNC-7 specifications.

Contributing Risk Factors • Risk factors associated with elevated blood pressure include

– physical inactivity– alcohol consumption – smoking– body mass index – waist circumference– resting heart rate – ethnicity – environmental – socioeconomic– race

(Chaix et. al, 2010; Sos03.com, 2011)

• Age• Sex• Marital status• Individual/parental education• Occupation

Contributing Risk Factors

• Employment status• Household income• Financial strain• Mortgage owners• Human development

(self-willed-land.org.uk, n.d.)

Clinical Findings

• The clinical findings for hypertension remain the same between the JNC7 and JNC 8 recommendations.

• Normal BP SBP <120 DBP <80• Pre-HTN SPB 120-139 DBP 80-89• Stage I SBP 140-159 DBP 90-99• Stage II SBP >160

DBP >100

Differential Dx

• Differential diagnosis for hypertension can be – secondary hypertension – resistant hypertension

Adults & secondary hypertension

Atherosclerotic renal stenosis

Fibromuscular dysplasia Aldosteronism Thyroid

dysfunctionObstructive sleep apnea

Cushing syndrome Phyeochromocytoma

Adolescents & secondary hypertension Thyroid dysfunction Fibromuscular dysplasia Renal parenchymal disease

Children & secondary hypertension

Renal parenchymal disease Coarctation of the aorta

(Viera & Neutze, 2010)

Drugs & Secondary HTN

estrogen

herbs (Ephedra, ginseng, ma huang)

amphetamines

cocaine

NSAID

’s

Buspar

Tegretol

Clozaril

Prozac

lithium

tricyclic

antidepressants

decongestants

diet pill

steroids (D

epo-Medrol &

prednisone)

(footage.shuttershock.com, 2014; Viera & Neutze, 2010)

Differential Dx

• Resistant hypertension is defined as an office blood pressure that remains high even after the use of three antihypertensive agents with one of them being a diuretic

(Domino, 2013; Sierra et. al, 2011; well.blogs.nytimes.com, 2013)

WHITE COAT syndrome: You may want the patient to re-check BP in a

relaxing environment

Laboratory Tests/Diagnostics• Use of a manual sphygmomanometer to take an accurate BP

which consists of patient sitting for 5 minutes, arm resting at heart level & a relaxed patient– HTN diagnosis only after 2 or more elevated readings at 2 different visits over a period of

1 – several wks

• Blood pressure at least once every 2 yrs if BP < 120/80 (starting at age 20)– If SBP is 120-139 mmHg or DBP 80-90 mmHg then yearly screening is necessary

• If consecutive blood pressure readings are needed then be sure to use the same arm, same position, and wait at least ten minutes between readings or within 24 hours

• The use of the correct size cuff must be maintained to obtain an accurate reading

(AHRQ, 2010; Chaix et. al, 2010; Domino, 2013; Garrison & Oberhelman 2013; Raina et. al, 2012).

Laboratory Tests/Diagnostics• Other laboratory tests that are useful are

– CBC, hemoglobin/hematocrit– urinalysis– potassium– Calcium– creatinine– lipid profile – fasting glucose– A1c– uric acid– GFR

(advancedhealthcareofthepalmbeaches.com, 2013; Domino, 2013)

Laboratory Tests/Diagnostics• Good history taking is essential to learn the background of a

patient’s family

• Diagnostic procedures are determined by risk factors and outcome of laboratory tests

• Other recommendations include – Blood pressure measurements of both arms– Complete cardiac and peripheral pulse exam with comparison– Abdominal exam to assess for bruits– Neurologic exam

(Domino, 2013)

Management and Treatment • Goals of Therapy JNC-7

– Reduction of cardiovascular and renal morbidity and mortality – Primary emphasis on SBP reduction

• Reduce SBP and DBP will also reduce

• Decreasing SBP and DBP to <140/90 mmHg– Decreases CVD complications

• Patients with HTN and DM or renal disease – Goal should be to decrease BP below 130/80mmHg

(imakenews.com, 2014; James et. al, 2013)

Management and Treatment

• Start with Non-Pharm Management JNC-7 JNC-8– Weight reduction

• Maintain BMI 18.5-24.9– Will reduce SBP by 5-20mmHg/10 kg

• DASH eating plan– Diet rich in fruits, vegi’s, lowfat dairy– Reduce content of saturated and total fat

» Will reduce SBP 8-14mmHg

• Dietary Sodium reduction – Reduce intake to <100mmol/day (2.4g of Na or 6g of NaCl)– Will reduce SBP 2-8mmHg

(James et. al, 2013; systems.cs.columbia.edu, n.d.)


• Non-Pharm Management JNC-7 JNC-8– Aerobic physical activity

• At least 30 minutes a day most days of the week– Will reduce SBP 4-9mmHg

– Moderation of alcohol consumption • Men <2 drinks/day• Women with lighter weight <1 drink per day

– Will decrease SBP 2-4 mmHg

(James et. al, 2013; personal.psu.edu, 2010)

Management and Treatment • Thiazide diuretic should be used as the initial therapy for for

the treatment of HTN– Either alone or in combination with one of the other classes of

medications – Thiazides are usually the basis for most outcome based trials– Help prevent cardiovascular complications of HTN – Enhance the efficiency of other anti-hypertensive medications– Are affordable– Yet underutilized in the treatment of HTN

(clinicalcorrilations.org, 2007; Flack et. al, 2010; James et. al, 2013)

Management and Treatment • Several classes of anti-

hypertensive's – Thiazide diuretics– Loop diuretics – Potassium sparing diuertics– Aldosterone receptor blockers– Beta Blockers (BB’s)– Combined alpha and BB’s– ACE Inhibitors (ACEI’s)– Angiotensin II antagonists

(ARB’s)– Calcium Channel Blockers (CCBs)

non-Dihydropyridines– CCBs Dihydropyridines

– Alpha-1 blockers– Central alpha-2 agonists

and other centrally acting drugs

– Direct vasodilators – Combinations

• ACEI & CCB• ACEI & diuretic• ARB & diuretic• BB & diuretic• Centrally acting drug &

diuretic • Diuretic & Diuretic

(Flack et. al, 2010; James et. al, 2013; telegraph.co.uk, 2010)


• Without co-morbidities – Stage 1 HTN• Thiazide diuretic for most patients• Consider

– ACEI, ARB, BB, CCB or combination

– Stage 2 HTN• 2 Drug combination for most patients

(Flack et. al, 2010; James et. al, 2013)

Patients with co-morbidities may benefit from specific anti-hypertensive regimens

HFDiuretic, BB, ACEI &

Aldosterone antagonist

High coronary disease risk

Diuretic, BB, ACEI, & CCB

Post MIBB, ACEI, & Aldosterone

antagonist

DMDiuretic, BB, ACEI, ARB, &

CCB

Chronic kidney diseaseACEI & ARB

Recurrent Stroke prevention

Diuretic & ACEI

(Flack et. al, 2010; James et. al, 2013)

Complications • Ischemic heart disease

– Most common target organ damage associated with HTN• Heart Failure

– Results from Systolic hypertension and ischemic heart disease • Cerebrovascular Disease

– CVA’s, TIA’s• Renal disease• Peripheral vascular disease• Atherosclerosis

Complications

• Resistant hypertension– Explore reasons behind

why the patient is not reaching their target BP

– Attention needs to ne paid to the the diuretic type and dose in relation to the patients renal function

– Consultation with a HTN specialist maybe required

(renalfellow.blogspot.com, 2011)

Follow up

• Establish antihypertensive medication– F/U monthly to adjust medication until BP goal is reached– Once stable F/U visits every 3-6 months– Frequent F/U visits if patient has co-morbidities

• Serum potassium and creatinine should be monitored 1-2 times a year

• Tobacco avoidance should be aggressively promoted • Low dose ASA therapy should be initiated once BP is

under control– If patient is not controlled they run the risk of hemorrhagic stroke and

ASA therapy should not be started

Counseling, Education, Referral

• Stress the importance of non-pharmacological treatments– Nutritionist– Fitness trainer (lose weight & exercise)

• Stress the importance of smoking cessation– NY Quits help line

• Signs and symptoms of CVA or TIA & what to do if an event happens

• When to seek emergency room or office care for HTN

(doctormsu.blogsport.com, 2011)

Review

JNC7 vs JNC 8

• The JNC 8 guidelines were just released in January 2014 by the Journal of the American Medical Association

• JNC 8 guidelines for the treatment of HTN remain the same as the JNC 7 recommendation

• Additional recommendations were made in JNC 8 on specific populations and when to treat


JNC 8 • Recommendation 1

– >60yrs old begin treatment to lower BP when systolic is >150mmHg or diastolic >90mmHg.

– Treat to a goal of systolic <150 or diastolic <90• Recommendation 2

– 30-59yrs old begin treatment if DBP is >90mmHg– Treat to a goal of a diastolic <90

• Recommendation 3 – Less than 60 yrs of age begin treatment to lower BP when SBP >140mmHg to a

goal of a SBP less than 140• Recommendation 4

– >18yrs old with chromic kidney disease start treatment when SBP >140 or DBP >90mmHg and treat to a goal of less then SBP 140 and DBP 90.


JNC 8• Recommendation 5

– >18yrs old with DM start treatments when SBP is >140 or DBP >90mmHg and treat to a goal of less than 140 and 90

• Recommendation 6– In general non-african american’s including those with DM, initial therapy

should include thiazide diuretic, CCB, ACEI or ARB• Recommendation 7

– In general african americans including those with DM, initial treatment should include thiazide diuretic or CCB

• Recommendation 8– >18yrs old with chronic kidney disease initial or add on therapy should include

an ACEI or ARB to improve kidney outcomes– This also applies to all chronic kidney disease patients regardless of race or DM

history


JNC 8• Recommendation 9

– The main goal of treatment is to attain and maintain target BP– If initial goal is not reached within 1 month either increase the dose of the

initial drug or add a second medication from one of the other classes– Continued assessment and adjustment is needed until target BP is reached– If target BP can not be reached with 2 medications a third should be added

from a different class– Do not use a ACEI or ARB together – If a target BP cannot be reached with a 3 drug regimen due to contradictions

or the need use 3 drugs to reach target BP, antihyopertensive medicaitons from other classes can be used

– A referral to a hypertensive specialist maybe required is unable to obtain target BP


(blog.thesanjosegroup.com, n.d.: nurse-practioners-and-physician-assistants.advanceweb.com, 2011)

Multiple Choice• What are the parameters for pre-hypertension?

– 120/80– 120-139/80-90– >160 or >100– 140-159/90-99

• What are the parameters for stage II hypertension?– 220/110– 120/80– 140-159/90-99– >160/>100

• What is the first line medication for stage I hypertension?– CCB– BB – ACEI– Thiazide diuretic

• What is the minimum number of medications needed to treat stage II hypertension? – 1– 3– 2– 6

(es123rf.com, 2013)

Multiple Choice• What is a side effect that some patients complain about when taking an

ACEI?– Hypotension– Cough – Hicups– Sneezing

• If the patient complains about the specific side effect of an ACEI what would be your next choice medication that would offer a similar benefit?– CCB– ARB– BB– Loop Diuretic

(es123rf.com, 2013)

Multiple Choice• Of the following non-pharmacological measures which is the most

important for the patient to adopt?– Smoking cessation– Low sodium diet– Exercise – Stress reduction

• Mr Smith presents to your office with a BP of 220/110. He complains of a bounding headache. He has never been treated for HTN in your office. What should you do?– See the patient and send him for out-patient blood work and a Rx for a diuretic– Call 911 and have a the paramedics transport him to a local ER or stroke care center– Give him a clonidine 0.2mg tab PO and monitor him in the office till his blood pressure

decreases– Give him PO lasix 40mg and send him home with a Dx of a migraine

(es123rf.com, 2013)

Multiple Choice• How is HTN initially diagnosed?

– Have the patient do ten squat thrusts at two or more office visits then take blood pressure

– Have the patient go for stress echo– Send the patient for a CBC, H/H CMP– Monitor the patients blood pressure at 2 or more office visits in the seated position after

5 minutes using the same arm and properly sized BP cuff

• What class of people have an increased risk for HTN?– African American Males– Asian decent – Caucasian– Polynesian

(es123rf.com, 2013)

ReferencesAHRQ. (2012). The guide to clinical preventive services 2012: Recommendations of the U.S.

preventive services task force. Retrieved from http://www.ahrq.gov

Brady, T. M., Solomon, B. S., Neu, A. M., Siberry, G. K., & Parekh, R. S. (2010). Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics, 125(6), e1286-e1293. doi: 10.1542/peds.2009-0555

Chaix, B., Bean, K., Leal, C., Thomas, F., Havard, S., Evans, D., Jego, B., & Pannier, B. (2010). Individual/neighborhood social factors and blood pressure in the record cohort study: Which risk factors explain the associations? Hypertension, 55, 760-775. doi: 10.1161/HYPERTENSIONAHA.109.143206

de la Sierra, A., Segura, J., Banegas, J. R., Gorostidi, M., de la Cruz, J. J., Armario, P., Oliveras, A., & Ruilpe, L. M. (2011). Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension, 57, 898-902. doi: 10.1161/HYPERTENSIONAHA.110.168948

Domino, J. F. (2013). The 5-minute clinical consult, 21 ed., Philadelphia, PA: Lippincott Williams & Wilkins, Wolters Kluwer.

ReferencesDreisbach, A. W. (2013). Pathophysiology of hypertension. Retrieved from

http://emedicine.medscape.com/article/241381-overview#aw2aab6b2b4

Flack, J. M., Sica, D. A., Bakris, G., Brown, A. L., Ferdinand, K. C., Grimm, R. H., Hall, W. D., Jones, W. E., Kountz, D. S., Lea, J. P., Nasser, S., Nesbitt, S. D., Saunders, E., Scisney-Matlock, M., & Jamerson, K. A. (2010). Management of high blood pressure in blacks: An update of the international society on hypertension in blacks consensus statement. Hypertension, 56, 780-800. doi: 10.1161/HYPERTENSIONAHA.110.152892

Foex, P & Sear J.W. (2004). Hypertension: pathophysiology and treatment. Continuing Education in Anaesthesia, Critical Care & Pain, 4(3), 71-75.

Garrison, G. M. & Oberhelman, S. (2013). Screening for hypertension annually compared with current practice. Annuals of Family Medicine, 11(2), 116-121. doi: 10.1370/afm.1467

Hoerger, T. J., Wittenborn, J. S., Segel, J. E., Burrows, N. R., Imai, K., Eggers, P., Pavkov, M. E., Jordan, R., Hailpern, S. M., Schoolwerth, A. C., & Williams, D. E. (2010). A health policy model of CKD: 2. the cost-effectiveness of microalbuminuria screening. American Journal of Kidney Diseases, 55(3), 463-473. doi: 10.1053/j.ajkd.2009.11.017

References

James, P. A., Oparil, S., Carter, B. L., Cushman, W.C., Dennison-Himmelfarb, C., Handler, J., Lackland, D.T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2013). 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. Journal of the American Medical Association, E1-E14. doi:10.1001/jama.2013.284427

Madhur, M. S. (2014). Hypertension clinical presentation. Retrieved from http://emedicine.medscape.com/article/241381-clinical

Raina, P., Ciliska, D., Hammill, A., Gauld, M., Rice, M., Haq, M., Lindsay, P., Birtwhistle, R., Joffres, M., McKay, D., Cloutier, L., Gorber. S. C., & Jaramillo, A. (2012). Screening for Hypertension. Retrieved from http://www.canadiantaskforce.ca

U.S. Department of Health and Human Services. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (NIH Publication No. 03-5233). Washington, DC: U.S. Government Printing Office.

ReferencesViera, A. J. & Neutze, D. M. (2010). Diagnosis of secondary hypertension: An age-based approach.

American Academy of Family Physicians, 82(12), 1471-1478.

comparison of jnc 7 and jnc 8

Documents

foex sear

heart dreisbach

divides hypertension

problemsecondary hypertension

vascular stiffness

increased vascular tone

blood pressure results

blood pressure medications