jnc 8 handouts

7/26/2019 JNC 8 Handouts

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JNC-8 Handouts


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JNC 8 Hypertensive Guidelines:

The Controversy Begins

Wayne N. Leimbach, Jr. MD, FACC.

Clinical Associate Professor of Medicine

University of Oklahoma College of Medicine - Tulsa

Director of the Cardiac Catheterization Laboratories

Oklahoma Heart Institute at Hillcrest Medical Center

Director of Cardiology

Oklahoma Heart Institute


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Hypertension Facts

Affects 1 billion people worldwide

USabout 1 in 3 adults ( 73 million with

hypertension ( SBP > 140/90) A 55 y/o normotensive person has a 90%

lifetime risk of developing HTN (Vasan 2001)

Number one reason listed for office visits A leading contributor to CV death/ MI/ Stroke/

renal failure/ vascular disease


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Hypertension Facts

Meta-analyses have demonstrated a

linear relationship between level of BP

control and risk of CV events* Suboptimal BP control is estimated to

be responsible for 62% of

cerebrovascular disease and 49% ofischemic heart disease.

Lancet 2002:360;1903-13


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Hypertension:

What Do We Know?


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Lower Systolic Blood Pressure Reduces Risk of Ischemic Heart Disease and

Stroke Mortality


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Small Reductions in BP May Result in

Large Risk Reductions for CV Events


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High Blood Pressure Remains One of the Most Important Multipliers for CV

Risk


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JNC 6 Guidelines

The Sixth Report of the Joint National

Committee on Prevention, Detection,

Evaluation and Treatment of HighBlood Pressure.


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Classification of Blood Pressure in

Individuals 18 Years of Age*

Optimal


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Impact of High Normal

Blood Pressure Over 12 Years

NEJM 11/01/01Vasan et al


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THE JNC 7 ReportThe Seventh Report of the Joint

National Committee on Prevention,Detection, Evaluation, and

Treatment of High Blood Pressure

2003JAMA: May 21, 2003


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Hypertension JNC - 7

BP Classification Systolic BP Diastolic BP

Normal < 120 < 80

Pre-hypertension 120139 8089

Stage 1 140159 9099

Stage 2 > 160 > 100


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JNC 7: Algorithm for Treatment of Hypertension


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High Blood Pressure

Goal is BP < 140/90; with BP < 120/80 as ideal

For diabetics, Goal is BP < 130/80

Diet is a low Sodium Diet:


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How Low Should Blood Pressure

Be Lowered?


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BP Control Usually Requires

Combination Therapy


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JNC 8 HypertensiveGuidelines

JAMA December 13, 2014


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JNC - 8

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)

Paul A. James, MD1; Suzanne Oparil, MD2; Barry L. Carter, PharmD1; William C. Cushman, MD3;

Cheryl Dennison-Himmelfarb, RN, ANP, PhD4; Joel Handler, MD5; Daniel T. Lackland, DrPH6; Michael

L. LeFevre, MD, MSPH7; Thomas D. MacKenzie, MD, MSPH8; Olugbenga Ogedegbe, MD, MPH, MS9; Sidney

C. Smith Jr, MD10; Laura P. Svetkey, MD, MHS11; Sandra J. Taler, MD12; Raymond R. Townsend, MD13;

Jackson T. Wright Jr, MD, PhD14; Andrew S. Narva, MD15; Eduardo Ortiz, MD, MPH16,17

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

From: 2014 Evidence Based Guideline for the Management of High Blood Pressure in Adults: Report From the


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Date of download: 9/1/2014 Copyright 2014 American MedicalAssociation. All rights reserved.

From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From thePanel Members Appointed to the Eighth Joint National Committee (JNC 8)

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

2014 Hypertension Guideline Management AlgorithmSBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeuticplan.

Figure Legend:


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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)

Recommendations in response to high

priority questions

Based on systematic review restricted to

randomized controlled clinical trial evidence

Evidence grades range from A (strong) to E

(expert opinion)

JAMA. 2014:311(5): 507-520


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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)

Three Highest Ranked Questions to Answer

In adults with hypertension, does initiating

antihypertensive therapy at specific BP thresholds

improve health outcomes?

In adults with HTN, does treatment withantihypertensive drugs to a specific BP goal lead to

improvements in health outcomes?

In adults with HTN, do various antihypertensive

drugs or drug classes differ in comparative benefitsand harms on specific health outcomes?

JAMA. 2014:311(5): 507-520


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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)

Nine Recommendations

Made

JAMA. 2014:311(5): 507-520


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Recommendation 1:

In the general population aged >60 y/o,

Initiate pharmacologic treatment to lower BP atsystolic BP of 150 mmHg or higher

Or diastolic BP of 90 mmHg or higher,

And treat to a goal SBP lower than 150 mmHgand goal diastolic BP lower than 90 mmHg

JAMA. 2014:311(5): 507-520


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Recommendation 1 Corollary

In general population aged > 60 y/o, if drug

treatment for high BP results in lower

achieved SBP (i.e.,


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Recommendation 2:

In the general population < 60 y/o,

initiate drug treatment to lower BP atdiastolic BP > 90 mmHg

JAMA. 2014:311(5): 507-520


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Recommendation 3:

In the general population < 60 y/o,

initiate drug treatment to lower BP atSystolic BP > 140 mmHg

and treat to a goal systolic BP < 140 mm Hg

(Expert OpinionGrade E)

JAMA. 2014:311(5): 507-520


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Recommendation 4:

Population > 18 y/o with CKD,

Initiate drug treatment to lower SBP > 140 mm Hgor DBP > 90 mm Hg

And treat to goal SBP < 140 mmHg

and goal DBP


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Recommendation 5:

In population > 18 y/o with diabetes,

Start drug therapy to lower BP atSBP > 140 mmHg

Or DBP < 90 mmHg

And treat to a goal of SBP < 140 mmHgAnd DBP < 90 mmHg.

JAMA. 2014:311(5): 507-520


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Recommendation 6:

In the general nonblack population, including

those with diabetes,Initial BP Med should include a thiazide-type

diuretic, CCB, ACE-I, or ARB.

JAMA. 2014:311(5): 507-520


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Recommendation 6:

In the general nonblack population, including

those with diabetes,Initial BP Med should include a thiazide-type

diuretic, CCB, ACE-I, or ARB

Note: NO BETA-BLOCKER

JAMA. 2014:311(5): 507-520


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Recommendation 7:

In the general black population, including those

with diabetes mellitus,Initial BP Med should include

a thiazide-type diuretic or CCB

JAMA. 2014:311(5): 507-520


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Recommendation 8:

In the population > 18 y/o with CKD,

Initial (or add-on ) antihypertensive treatmentShould include an ACE-I or ARB to improve

kidney outcomes.

This applies to all CKD patients with HTN,Regardless of race or diabetes status.

JAMA. 2014:311(5): 507-520


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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.If more than 3 drugs are needed, consider consult

to a hypertension specialist.

JAMA. 2014:311(5): 507-520


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Nine Recommendations Summary 1

For the General Population without DM or CKD:

Age > 60 y/o:

BP Goal = < 150/90 mmHg

Age < 60 y/o:

BP Goal = < 140/90 mmHg

JAMA. 2014:311(5): 507-520


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For All Ages with Diabetes:

BP Goal < 140/90 mmHg

For All Ages with Chronic Kidney Disease:


JAMA. 2014:311(5): 507-520


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For All Ages with Chronic Kidney Disease:


Initiate ACE-I or ARB,Alone or in combination with other drug classes

JAMA. 2014:311(5): 507-520

All races


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For Black Population

Initiate thiazide-type diuretic or CCBalone or in combination

JAMA. 2014:311(5): 507-520

All ages


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JAMA. 2014:311(5): 507-520


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The American Heart Association and the ACC are

staying with JNC7 for now,

And will update their guidelines next year.

JAMA. 2014:311(5): 507-520


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Major Findings:Currently: 66.7 million in the US have hypertension,

of which 39.9% met JNC-7 guideline targets.

Using JNC8: 60.8 million in US have hypertension,

of which 56.4% have controlled blood pressure.

In 60 y/o + population, switching to JNC-8:

-improves BP control rates from 34.3% to 60.8%

- reclassifying 13.6 million from uncontrolled to controlled

JAMA. 2014:311(5): 507-520


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JNC8 Controversy

For Age > 60 y/o, target BP < 150/90;

Analysis of 8,354 patients from INVEST

Trial showed less benefit for patients

not at BP < 140/90.


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Date of download:9/1/2014

Copyright The American College of Cardiology.All rights reserved.

From: 2014 Eighth Joint National Committee Panel Recommendation for Blood Pressure Targets Revisited:

Results From the INVEST Study

J Am Coll Cardiol. 2014;64(8):784-793. doi:10.1016/j.jacc.2014.05.044

Study Design and Main Outcomes

Patients who achieved a systolic blood pressure


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Date of download:9/1/2014

Copyright The American College of Cardiology.All rights reserved.




On-Treatment Blood Pressure Categories and Risk of Primary Outcome

Cumulative event rate was lowest in the group with achieved systolic blood pressure (SBP)


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Date of download:9/1/2014 Copyright The American College of Cardiology.All rights reserved.




On-Treatment Blood Pressure Categories and Risk of All-Cause and Cardiovascular Mortality

Cumulative event rate was lowest in the group with achieved systolic blood pressure (SBP)


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Date of download:9/1/2014 Copyright The American College of Cardiology.All rights reserved.


Results From the INVEST StudyJ Am Coll Cardiol. 2014;64(8):784-793. doi:10.1016/j.jacc.2014.05.044

On-Treatment Blood Pressure Categories and Risk of Nonfatal Myocardial Infarction, Total Stroke (Fatal and Nonfatal),

Nonfatal Stroke, Heart Failure, and Revascularization

Cumulative event rate for nonfatal myocardial infarction (A) was lower in the group with achieved systolic blood pressure (SBP)


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JNC 8 HypertensiveGuidelines

JAMA December 13, 2014


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JNC 8 Hypertensive Guidelines:


Wayne N. Leimbach, Jr. MD, FACC.

Clinical Associate Professor of Medicine

University of Oklahoma College of Medicine - Tulsa

Director of the Cardiac Catheterization Laboratories

Oklahoma Heart Institute at Hillcrest Medical Center

Director of Cardiology

Oklahoma Heart Institute

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