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    JNC-8 New Guidelines Finally: Let The Controversies Begin

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    Jino Bugna
    The document discusses guidelines for treating hypertension from the JNC-8 committee. It summarizes that the JNC-8 guidelines: 1) Raise the threshold for treatment of hypertension in patients over 60 from 140/90 mmHg to 150/90 mmHg. 2) Find insufficient evidence to change treatment thresholds for patients under 60, keeping it at 140/90 mmHg. 3) Would reclassify 13.6 million older Americans with previously uncontrolled high blood pressure as now having controlled blood pressure under the new guidelines.

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    JNC-8 New Guidelines Finally: Let The Controversies Begin

    Uploaded by

    Jino Bugna
    82 views24 pages
    The document discusses guidelines for treating hypertension from the JNC-8 committee. It summarizes that the JNC-8 guidelines: 1) Raise the threshold for treatment of hypertension in patients over 60 from 140/90 mmHg to 150/90 mmHg. 2) Find insufficient evidence to change treatment thresholds for patients under 60, keeping it at 140/90 mmHg. 3) Would reclassify 13.6 million older Americans with previously uncontrolled high blood pressure as now having controlled blood pressure under the new guidelines.

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    The document discusses guidelines for treating hypertension from the JNC-8 committee. It summarizes that the JNC-8 guidelines: 1) Raise the threshold for treatment of hypertension in patients over 60 from 140/90 mmHg to 150/90 mmHg. 2) Find insufficient evidence to change treatment thresholds for patients under 60, keeping it at 140/90 mmHg. 3) Would reclassify 13.6 million older Americans with previously uncontrolled high blood pressure as now having controlled blood pressure under the new guidelines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    82 views24 pages

    JNC-8 New Guidelines Finally: Let The Controversies Begin

    Uploaded by

    Jino Bugna
    The document discusses guidelines for treating hypertension from the JNC-8 committee. It summarizes that the JNC-8 guidelines: 1) Raise the threshold for treatment of hypertension in patients over 60 from 140/90 mmHg to 150/90 mmHg. 2) Find insufficient evidence to change treatment thresholds for patients under 60, keeping it at 140/90 mmHg. 3) Would reclassify 13.6 million older Americans with previously uncontrolled high blood pressure as now having controlled blood pressure under the new guidelines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 24

    JNC-8 New GuidelinesFinally

    Let the controversies begin

    Eric D Peterson, MD, MPH


    Director of DCRI
    http://www.dcri.duke.edu/research/coi.jsp

    Feb, 2014

    Affects 1 billion people worldwide


    US about 1 in 3 adults
    73 million have hypertension (SBP >140/90)
    A 55yo normotensive person has up to a 90% lifetime
    risk of developing hypertension (Vasan 2001)
    Number one reason listed for office visits
    Causes/contributes to 457,000 admissions per year
    A leading cause/contributor to death (MI, stroke,
    vascular disease)

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    How Aggressive to Treat Hypertension


    Some Early Views on the Controversy
    The greatest danger to a man with high blood pressure
    lies in its discovery, because then some fool is certain to
    try and reduce it.- J.H. Hay, 1931.
    Hypertension may be an important compensatory
    mechanism which should not be tampered with, even
    were it certain that we could control it. Paul Dudley
    White, 1937.

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    Stroke and IHD Mortality vs Systolic BP by Age


    Mortality
    (Floating absolute risk and 95% CI)

    Age at risk
    256

    Age at risk:
    80-89 years

    128

    70-79 years

    60-69 years

    64

    60-69 years

    50-59 years

    32

    50-59 years

    256

    80-89 years

    128

    70-79 years

    64
    32

    16

    16

    Stroke

    0
    120

    140

    160

    0
    180

    Usual Systolic BP (mm Hg)

    40-49 years

    Ischemic Heart Disease


    120 140 160 180
    Usual Systolic BP (mm Hg)

    Lancet. 2002;360:1903-1913
    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    BP Reductions as Small as 2 mmHg Reduce


    the Risk of CV Events by Up to 10%
    Meta-analysis of 61 prospective, observational studies
    1 million adults

    12.7 million person-years


    2 mmHg
    increase in
    mean SBP

    7% increase in
    risk of ischemic
    heart disease
    mortality
    10% increase in
    risk of stroke
    mortality

    Prospective Studies Collaboration. Lancet. 2002;360:1903-1913


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    Risk reduction (%)

    Benefits of Treating Hypertension: RCT


    0
    -10
    -20
    -30
    -40
    -50
    -60
    -70
    -80
    -90
    -100

    20%
    50%
    Heart failure

    40%

    Stroke

    Cardiovascular
    death

    Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    Lifestyle Modifications
    Goal blood pressure <140/90 mm Hg
    <130/80 mm Hg with diabetes or chronic kidney disease*
    Initial drug choices
    Without Compelling indications

    With compelling indications

    Stage 1 Hypertension
    (SBP 140-159 DBP 90-99 )

    Stage 2 hypertension
    (SBP 160 or DBP 100)

    Drug(s) for compelling


    indications

    Diuretics for most; may


    consider ACE inhibitor,
    ARB, beta blocker, CCB or
    combination

    2-drug combination for


    most (Diuretic +ACE, ARB,
    beta blocker, or CCB)

    Diuretics, ACE inhibitor,


    ARB, beta blocker, CCB as
    needed

    * Released in 2003
    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    JNC-8 Significantly
    Delayed

    All Rights Reserved, Duke Medicine 2007

    NHLBI Drops Out of


    Guidelines Business

    sb/Strategy & Innovation Group

    James et al JAMA December 13 2014


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    James et al JAMA December 13 2014


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    10

    JNC-8 Hypertension Treatment Choices

    James et al JAMA December 13 2014


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    11

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    12

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    13

    The Evidence for Targets: JATOS Study


    2200 pts per arm
    Baseline BP 170/90
    Target
    <150 mild vs. <140 strict

    Drugs:
    Ca++blocker 50-60%
    Ace 30-40%
    Alpha blocker 15%
    Diuretic 15%
    Follow-up 2 yrs
    Hypertens Res. 2008;31(12):2115-2127
    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    14

    JATOS Results

    Hypertens Res. 2008;31(12):2115-2127


    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    15

    The Evidence for Targets: VALISH Trial


    1630 pts per arm
    Baseline BP 170/80
    Target
    Mild <150, strict <140

    Drugs:
    Valsartan 100%
    Ca++ blacker 30%
    Diuretic 10-15%
    Median Follow-up 3 yrs
    Hypertension. 2010;56(2):196-202
    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    16

    VALISH Trial

    Hypertension. 2010;56(2):196-202
    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    17

    RCTs Evaluating SBP Targets


    in those Aged < 60
    Does the absence of evidence lead to
    the conclusion of evidence of absence?
    JNC-8 authors concluded:
    - Yes for those >60
    - No for those <60

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    18

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    19

    Guidelines, Performance Measures and Policy


    Guideline:
    In past: practical advice on a course of action
    Have become: RCT-based, rigorous
    Performance Measures:
    Distillation of guidelines:
    Use strict criteria to define what should and must
    be done to avoid a quality concern

    Often applied to public reporting or financial


    incentives

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    20

    BP Treatment Targets Have Risks Both Ways


    If one votes to keep all at 140/90
    PMs and incentives may encourage over-treatment
    Worse symptoms, falls, costs in elderly

    If one votes to move to 150/90 in elderly


    Risk of under-treatment
    Despite existing guideline goals/PMs, <50%
    of public reaches goal!

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    21

    JNC-8 Implications for US

    JNC 7: HTN
    Controlled
    JNC 8: HTN
    Controlled

    All Rights Reserved, Duke Medicine 2007

    All US Adults
    66.6
    26.6 (39.9%)
    60.8
    34.3 (56.4%)

    Ages 18-59
    32.8
    13.3 (40.5%)
    30.8
    14.6 (47.4%%)

    Ages 60+
    33.8
    13.3 (39.3%)
    30.0
    19.7 (65.7%)

    sb/Strategy & Innovation Group

    22

    Major Findings
    Currently: 66.7 million in US have hypertension,
    of which 39.9% met guideline targets.
    Using JNC 8: 60.8 million in US have hypertension,
    of which 56.4% have controlled blood pressure.
    In 60+, switching to JNC-8
    improves BP control rates from 34.3% to 60.8%
    reclassifying 13.6 million with previously
    uncontrolled BP now seen as under control

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    23

    Conclusions
    Hypertension: common, costly and modifiable
    Interpretation of existing evidence is challenging
    Determining the optimal threshold will require
    more RCTs.
    In interim: My view:
    Aim for 140/90 but allow for individualization
    Whats your take?

    All Rights Reserved, Duke Medicine 2007

    sb/Strategy & Innovation Group

    24

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