Pharmacotherapy, Management of Hypertension, JNC 8 guidelines
JNC 8 Handouts
-
Upload
lovelots1234 -
Category
Documents
-
view
244 -
download
0
Transcript of JNC 8 Handouts
-
7/26/2019 JNC 8 Handouts
1/51
JNC-8 Handouts
-
7/26/2019 JNC 8 Handouts
2/51
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
-
7/26/2019 JNC 8 Handouts
3/51
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
-
7/26/2019 JNC 8 Handouts
4/51
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
-
7/26/2019 JNC 8 Handouts
5/51
Hypertension:
What Do We Know?
-
7/26/2019 JNC 8 Handouts
6/51
Lower Systolic Blood Pressure Reduces Risk of Ischemic Heart Disease and
Stroke Mortality
-
7/26/2019 JNC 8 Handouts
7/51
Oklahoma eart
Small Reductions in BP May Result in
Large Risk Reductions for CV Events
-
7/26/2019 JNC 8 Handouts
8/51
Oklahoma eart
High Blood Pressure Remains One of the Most Important Multipliers for CV
Risk
-
7/26/2019 JNC 8 Handouts
9/51
Oklahoma eart
-
7/26/2019 JNC 8 Handouts
10/51
JNC 6 Guidelines
The Sixth Report of the Joint National
Committee on Prevention, Detection,
Evaluation and Treatment of HighBlood Pressure.
-
7/26/2019 JNC 8 Handouts
11/51
Oklahoma eart
Classification of Blood Pressure in
Individuals 18 Years of Age*
Optimal
-
7/26/2019 JNC 8 Handouts
12/51
Oklahoma eart
Impact of High Normal
Blood Pressure Over 12 Years
NEJM 11/01/01Vasan et al
-
7/26/2019 JNC 8 Handouts
13/51
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
-
7/26/2019 JNC 8 Handouts
14/51
Oklahoma eart
Hypertension JNC - 7
BP Classification Systolic BP Diastolic BP
Normal < 120 < 80
Pre-hypertension 120139 8089
Stage 1 140159 9099
Stage 2 > 160 > 100
-
7/26/2019 JNC 8 Handouts
15/51
Oklahoma eart
JNC 7: Algorithm for Treatment of Hypertension
-
7/26/2019 JNC 8 Handouts
16/51
Oklahoma eart
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:
-
7/26/2019 JNC 8 Handouts
17/51
How Low Should Blood Pressure
Be Lowered?
-
7/26/2019 JNC 8 Handouts
18/51
Oklahoma eart
BP Control Usually Requires
Combination Therapy
-
7/26/2019 JNC 8 Handouts
19/51
JNC 8 HypertensiveGuidelines
JAMA December 13, 2014
-
7/26/2019 JNC 8 Handouts
20/51
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
-
7/26/2019 JNC 8 Handouts
21/51
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:
-
7/26/2019 JNC 8 Handouts
22/51
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
-
7/26/2019 JNC 8 Handouts
23/51
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
-
7/26/2019 JNC 8 Handouts
24/51
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
-
7/26/2019 JNC 8 Handouts
25/51
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
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
-
7/26/2019 JNC 8 Handouts
26/51
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)
Recommendation 1 Corollary
In general population aged > 60 y/o, if drug
treatment for high BP results in lower
achieved SBP (i.e.,
-
7/26/2019 JNC 8 Handouts
27/51
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
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
-
7/26/2019 JNC 8 Handouts
28/51
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
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
-
7/26/2019 JNC 8 Handouts
29/51
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
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
-
7/26/2019 JNC 8 Handouts
30/51
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
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
-
7/26/2019 JNC 8 Handouts
31/51
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
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
-
7/26/2019 JNC 8 Handouts
32/51
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
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
-
7/26/2019 JNC 8 Handouts
33/51
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
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
-
7/26/2019 JNC 8 Handouts
34/51
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
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
-
7/26/2019 JNC 8 Handouts
35/51
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
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
-
7/26/2019 JNC 8 Handouts
36/51
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 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
-
7/26/2019 JNC 8 Handouts
37/51
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 Summary 2
For All Ages with Diabetes:
BP Goal < 140/90 mmHg
For All Ages with Chronic Kidney Disease:
BP Goal < 140/90 mmHg
JAMA. 2014:311(5): 507-520
-
7/26/2019 JNC 8 Handouts
38/51
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 Summary 3
For All Ages with Chronic Kidney Disease:
BP Goal < 140/90 mmHg
Initiate ACE-I or ARB,Alone or in combination with other drug classes
JAMA. 2014:311(5): 507-520
All races
-
7/26/2019 JNC 8 Handouts
39/51
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 Summary 3
For Black Population
Initiate thiazide-type diuretic or CCBalone or in combination
JAMA. 2014:311(5): 507-520
All ages
-
7/26/2019 JNC 8 Handouts
40/51
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)
The Controversy Begins
JAMA. 2014:311(5): 507-520
-
7/26/2019 JNC 8 Handouts
41/51
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)
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
-
7/26/2019 JNC 8 Handouts
42/51
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)
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
-
7/26/2019 JNC 8 Handouts
43/51
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.
-
7/26/2019 JNC 8 Handouts
44/51
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
-
7/26/2019 JNC 8 Handouts
45/51
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
On-Treatment Blood Pressure Categories and Risk of Primary Outcome
Cumulative event rate was lowest in the group with achieved systolic blood pressure (SBP)
-
7/26/2019 JNC 8 Handouts
46/51
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
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)
-
7/26/2019 JNC 8 Handouts
47/51
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 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)
-
7/26/2019 JNC 8 Handouts
48/51
JNC 8 HypertensiveGuidelines
JAMA December 13, 2014
-
7/26/2019 JNC 8 Handouts
49/51
Copyright 2014 American MedicalAssociation. All rights reserved.JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
-
7/26/2019 JNC 8 Handouts
50/51
Oklahoma eart
-
7/26/2019 JNC 8 Handouts
51/51
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