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    Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice

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    The 2014 JNC 8 guidelines provide 7 recommendations for the management of high blood pressure. The key recommendations are: 1) Initiate pharmacologic treatment for those aged 60+ at SBP of 150 mmHg or DBP of 90 mmHg, treating to goals of <150/<90 mmHg. 2) Initiate treatment for those under 60 at DBP of 90 mmHg, treating to <90 mmHg. 3) For those with diabetes or CKD, initiate treatment at SBP of 140 mmHg or DBP of 90 mmHg, treating to <140/<90 mmHg. 4) For nonblack populations including those with diabetes, initial treatment should include a thiaz

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    Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice

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    harry
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    The 2014 JNC 8 guidelines provide 7 recommendations for the management of high blood pressure. The key recommendations are: 1) Initiate pharmacologic treatment for those aged 60+ at SBP of 150 mmHg or DBP of 90 mmHg, treating to goals of <150/<90 mmHg. 2) Initiate treatment for those under 60 at DBP of 90 mmHg, treating to <90 mmHg. 3) For those with diabetes or CKD, initiate treatment at SBP of 140 mmHg or DBP of 90 mmHg, treating to <140/<90 mmHg. 4) For nonblack populations including those with diabetes, initial treatment should include a thiaz

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    The 2014 JNC 8 guidelines provide 7 recommendations for the management of high blood pressure. The key recommendations are: 1) Initiate pharmacologic treatment for those aged 60+ at SBP of 150 mmHg or DBP of 90 mmHg, treating to goals of <150/<90 mmHg. 2) Initiate treatment for those under 60 at DBP of 90 mmHg, treating to <90 mmHg. 3) For those with diabetes or CKD, initiate treatment at SBP of 140 mmHg or DBP of 90 mmHg, treating to <140/<90 mmHg. 4) For nonblack populations including those with diabetes, initial treatment should include a thiaz

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    36 views23 pages

    Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice

    Uploaded by

    harry
    The 2014 JNC 8 guidelines provide 7 recommendations for the management of high blood pressure. The key recommendations are: 1) Initiate pharmacologic treatment for those aged 60+ at SBP of 150 mmHg or DBP of 90 mmHg, treating to goals of <150/<90 mmHg. 2) Initiate treatment for those under 60 at DBP of 90 mmHg, treating to <90 mmHg. 3) For those with diabetes or CKD, initiate treatment at SBP of 140 mmHg or DBP of 90 mmHg, treating to <140/<90 mmHg. 4) For nonblack populations including those with diabetes, initial treatment should include a thiaz

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    of 23

    Putting the 2014 EvidenceBased Guidelines for the

    Management of High Blood


    Pressure in Adults
    Into Practice
    Moderator
    James A. Underberg, MD
    Clinical Assistant Professor of
    Medicine
    New York University School of
    Medicine
    Director, Bellevue Hospital Lipid Clinic
    New York University Center for

    Panelists

    Louis Kuritzky, MD
    Clinical Assistant Professor
    University of Florida
    Gainesville, Florida

    Raymond R. Townsend, MD
    Professor of Medicine
    Perelman School of Medicine
    Philadelphia, Pennsylvania

    2014 Evidence-Based Guideline for the


    Management of High Blood Pressure in Adults
    Report From the Panel Members Appointed to
    the JNC 8
    Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C.
    Cushman, MD; Cheryl Dennison-Himmelfarb, RN, ANP, PhD; Joel Handler, MD;
    Daniel T. Lackland, DrPH; Michael L. LeFevre, MD, MSPH; Thomas D. MacKenzie,
    MD, MSPH; Olugbenga Ogedegbe, MD, MPH; Sidney C. Smith Jr, MD; Laura P.
    Svetkey, MD, MHS; Sandra J. Taler, MD; Raymond R. Townsend, MD; Jackson T.
    Wright Jr, MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH

    James PA, et al. JAMA. 2014;311:507-520.[1]

    Questions to the JNC 8 Panel


    At what level should you treat BP?
    To what level should it be treated?
    How do you do that?

    Target Audience for JNC 8


    Statements and recommendations for [BP]
    treatment based on a systematic review of the
    literature to meet user needs, especially the
    needs of the primary care clinician.

    James PA, et al. JAMA. 2014;311:507-520.[1]

    Focus of the Recommendations


    Age
    Diabetic
    Black/nonblack
    Chronic kidney disease (CKD)

    Age Recommendations, JNC 2014


    18 years old and younger: Not considered
    30 years old and younger: We have little to no data
    30 to 59 years old: In the general population younger than 60
    years, initiate pharmacologic treatment to lower BP at a DBP of
    90 mm Hg and treat to a goal DBP lower than 90 mm Hg. Strong
    Recommendation: Grade A
    60 years old: In the general population aged 60 years or older,
    initiate pharmacologic treatment to lower BP at an SBP of 150
    mm Hg or higher or a DBP of 90 mm Hg or higher and treat to a
    goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm
    Hg. Strong Recommendation: Grade A
    80 years old: Based on HYVET

    James PA, et al. JAMA. 2014;311:507-520.[1]

    JNC Panel Recommendation for


    Patients With Diabetes and
    Hypertension
    In the population aged 18 years and older with
    diabetes, initiate pharmacologic treatment to
    lower BP at an SBP of 140 mm Hg or a DBP of
    90 mm Hg and treat to a goal of SBP lower
    than 140 mm Hg and goal DBP lower than 90
    mm Hg. Expert Opinion: Grade E

    James PA, et al. JAMA. 2014;311:507-520.[1]

    ACCORD
    Mean Number of Medications Prescribed
    Time, y

    Intensive therapy group

    3.2

    3.4

    3.4

    3.5

    3.5

    3.5

    3.4

    3.4

    Standard therapy group

    1.9

    2.1

    2.1

    2.2

    2.2

    2.3

    2.3

    2.3

    ACCORD Primary Outcome


    Intensive Therapy, %

    Standard Therapy, %

    208 (1.87)

    237 (2.09)

    ACCORD Study Group. N Engl J Med. 2010;362:1575-1585.[6]

    JNC Panel Recommendation for


    Patients With CKD
    In the population aged 18 years with CKD,
    initiate pharmacologic treatment to lower BP
    at an SBP of 140 mm Hg or a DBP of 90 mm
    Hg and treat to goal of an SBP lower than 140
    mm Hg and a goal DBP lower than 90 mm Hg.
    Expert Opinion: Grade E

    James PA, et al. JAMA. 2014;311:507-520.[1]

    JNC Recommendation for Nonblack


    Patients
    In the general nonblack population, including
    those with diabetes, initial antihypertensive
    treatment should include

    Thiazide-type diuretic
    Calcium channel blocker (CCB)
    Angiotensin-concerting enzyme (ACE) inhibitor
    Angiotensin receptor blocker (ARB)
    Moderate Recommendation: Grade B

    James PA, et al. JAMA. 2014;311:507-520.[1]

    ALLHAT
    Outcomes in Hypertensive Black Patients Treated
    With Chlorthalidone, Amlodipine, and Lisinopril
    6-Year Rate per 100 Persons
    Chlorthalidone
    Rate (SE)

    Amlodipine
    No.

    Rate (SE)

    Lisinopril

    Outcome

    No.

    Total randomized

    5369

    CHD
    (nonfatal MI + fatal CHD)

    400

    9.6 (0.5)

    243

    9.5 (0.6)

    260

    10.3 (0.7)

    All-cause mortality

    821

    17.9 (0.6)

    481

    17.0 (0.8)

    520

    18.0 (0.8)

    Cardiovascular mortality

    362

    8.1 (0.5)

    215

    8.4 (0.6)

    224

    8.4 (0.6)

    Combined CHD

    655

    15.2 (0.6)

    407

    15.8 (0.8)

    444

    17.3 (0.8)

    Combined CVD

    1211

    26.8 (0.7)

    767

    28.4 (1.0)

    836

    31.1 (1.0)

    Stroke

    257

    6.0 (0.4)

    145

    5.7 (0.5)

    212

    8.0 (0.6)

    End-stage renal disease

    93

    2.3 (0.3)

    65

    2.7 (0.4)

    71

    3.1 (0.4)

    Cancer

    417

    9.4 (0.5)

    245

    9.8 (0.7)

    254

    9.9 (0.7)

    Hospitalized for
    gastrointestinal bleeding

    282

    8.9 (0.5)

    169

    8.6 (0.7)

    209

    11.1 (0.8)

    3213

    Wright JT, et al. JAMA. 2005;293(13):1595-1608.[17]

    No.

    Rate (SE)

    3210

    JNC Recommendation for Black


    Patients
    In the general black population, including
    those with diabetes, initial antihypertensive
    treatment should include
    Thiazide-type diuretic
    CCB

    For the general black population:


    Moderate Recommendation: Grade B

    For black patients with diabetes:


    Weak Recommendation: Grade C

    James PA, et al. JAMA. 2014;311:507-520.[1]

    Recommendations for Hypertension


    Management
    Recommendation 1: In the general population aged 60 years, initiate pharmacologic
    treatment to lower BP at systolic BP (SBP)150 mm Hg or diastolic BP (DBP) 90 mm Hg and
    treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. (Strong
    Recommendation : Grade A) Corollary Recommendation: In the general population aged 60
    years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm
    Hg) and treatment is well tolerated and without adverse effects on health or quality of life,
    treatment does not need to be adjusted. (Expert Opinion : Grade E)
    Recommendation 2: In the general population younger than 60 years, initiate pharmacologic
    treatment to lower BP at DBP 90 mm Hg and treat to a goal DBP lower than 90 mm Hg. (For
    ages 30 to 59 years, Strong Recommendation : Grade A; for ages 18 to 29 years, Expert
    Opinion: Grade E)
    Recommendation 3: In the general population younger than 60 years, initiate pharmacologic
    treatment to lower BP at SBP to 140 mm Hg and treat to a goal SBP lower than 140 mm Hg.
    (Expert Opinion : Grade E)
    Recommendation 4: In the population aged 18 years with CKD, initiate pharmacologic
    treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP lower than
    140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E)
    Recommendation 5: In the population aged 18 years with diabetes, initiate pharmacologic
    treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to a goal SBP lower
    than 140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E)
    James PA, et al. JAMA. 2014;311:507-520.[1]

    Recommendations for Hypertension


    Management (cont)
    Recommendation 6: In the general nonblack population, including those with diabetes, initial
    antihypertensive treatment should include a thiazide-type diuretic, CCB, angiotensin-converting
    enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation: Grade
    B)
    Recommendation 7: In the general black population, including those with diabetes, initial
    antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black
    population, Moderate Recommendation: Grade B; for black patients with diabetes, Weak
    Recommendation : Grade C)
    Recommendation 8: In the population aged 18 years with CKD, initial (or add-on) antihypertensive
    treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all patients with
    CKD with hypertension regardless of race or diabetes status. (Moderate Recommendation: Grade B)
    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 (thiazide-type diuretic, CCB, ACEI, or
    ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is
    reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list
    provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be
    reached using only the drugs in recommendation 6 because of a contraindication or the need to use
    more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral
    to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using
    the above strategy or for the management of complicated patients for who additional clinical
    consultation is needed. (Expert Opinion : Grade E)

    James PA, et al. JAMA. 2014;311:507-520.[1]

    JNC Management Guideline Algorithm


    Adult aged 18 years and older who have hypertension
    Implement lifestyle interventions (continue throughout management)
    Set BP goal and initiate BP-lowering medication on the basis of age, diabetes status, and CKD
    General population (no diabetes or CKD)
    Age 60 years
    Age < 60 years
    BP goal
    SBP < 150 mm Hg
    DBP < 90 mm Hg

    Nonblack
    Initiate thiazide-type diuretic or
    ACEI or ARB or CCB, alone or
    in combination

    BP goal
    SBP < 140 mm Hg
    DBP < 90 mm Hg

    Black

    Diabetes or CKD present


    All ages/with CKD/ with or
    All ages/with diabetes/no CKD
    without diabetes
    BP goal
    SBP < 140 mm Hg
    DBP < 90 mm Hg

    Initiate thiazide-type diuretic


    or CCB, alone or in
    combination

    All races

    BP goal
    SBP < 140 mm Hg
    DBP < 90 mm Hg

    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-done combination

    At goal BP?
    No
    At goal BP?

    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 ARB).

    At goal BP?

    Reinforce medication and lifestyle adherence


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

    James PA, et al. JAMA. 2014;311:507-520.[1]

    No
    At goal BP?

    Continue current treatment and monitoring

    Yes

    Reinforce medication and lifestyle adherence


    For strategies A and B, 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 ARB).
    No
    For strategy C, titrate doses of initial medications to maximum.

    ASCOT
    Summary of All End Points
    Primary

    Unadjusted hazard ratio (95% CI)


    0.90 (0.79-1.02)

    Nonfatal MI (including silent) + fatal CHD

    Secondary

    0.87 (0.76-1.00)
    0.87 (0.79-0.96)
    0.84 (0.78-0.90)
    0.89 (0.81-0.99)
    0.76 (0.65-0.90)
    0.77 (0.66-0.89)
    0.84 (0.66-1.05)

    Nonfatal MI (excluding silent) + fatal CHD


    Total coronary end point
    Total cardiovascular event and procedures
    All-cause mortality
    Cardiovascular mortality
    Fatal and nonfatal stroke
    Fatal and nonfatal heart failure

    Tertiary
    Silent MI
    Unstable angina
    Chronic stable angina
    Peripheral arterial disease
    Life-threatening arrhythmias
    New-onset diabetes mellitus
    New-onset renal impairment

    1.27 (0.80-2.00)
    0.68 (0.51-0.92)
    0.98 (0.81-1.19)
    0.65 (0.52-0.81)
    1.07 (0.62-1.85)
    070 (0.63-0.78)
    0.85 (0.75-0.97)

    Post hoc
    Primary end point + coronary
    revascularization procedures
    CV death + MI + stroke

    0.86 (0.77-0.96)
    0.84 (0.76-0.92)

    0.50

    0.70

    1.00

    Amlodipine perindopril better


    Dahlf B. Lancet. 2005;366:895-906.[18]

    1.45

    2.00

    Atenolol thiazide better

    Strategies for Reaching BP Goal


    Start 1 drug, titrate to maximum dose, and
    then add a second drug

    Start 1 drug and then add a second drug before


    achieving maximum dose of the initial drug

    Begin with 2 drugs at the same time either as


    2 separate pills or as a single pill combination
    James PA, et al. JAMA. 2014;311:507-520.[1]

    Abbreviations
    ACCORD = Action to Control Cardiovascular Risk in Diabetes
    ACE = angiotensin-converting enzyme
    ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
    Trial
    ARB = angiotensin receptor blockers
    ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial
    BP = blood pressure
    CCB = calcium channel blocker
    CHADS = congestive heart failure, hypertension, age, diabetes mellitus, and
    stroke
    CHD = coronary heart disease
    CI = confidence interval
    CKD = chronic kidney disease
    DBP = diastolic blood pressure
    HYVET = Hypertension in the Very Elderly Trial
    JNC 8 = Eighth Joint National Committee
    MI = myocardial infarction
    SBP = systolic blood pressure

    References
    1. James PA, Oparil S, Carter BL, et al. 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). JAMA. 2014;311:507-520.
    2. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute
    Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
    Blood Pressure; National High Blood Pressure Education Program Coordinating
    Committee. The Seventh Report of the Joint National Committee on Prevention,
    Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA.
    2003;289:2560-2572.
    3. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of
    hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
    4. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the
    management of arterial hypertension: the Task Force for the Management of Arterial
    Hypertension of the European Society of Hypertension (ESH) and of the European
    Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.
    5. Tight blood pressure control and risk of macrovascular and microvascular
    complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.
    BMJ. 1998;317:703-713.

    References (cont)
    6. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, et al. Effects of
    intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med.
    2010;362:1575-1585.
    7. Hebert LA, Kusek JW, Greene T, et al. Effects of blood pressure control on
    progressive renal disease in blacks and whites. Modification of Diet in Renal Disease
    Study Group. Hypertension. 1997;30(3 Pt 1):428-435.
    8. Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and
    Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug
    class on progression of hypertensive kidney disease: results from the AASK trial. JAMA.
    2002;288:2421-2431.
    9. Ruggenenti P, Perna A, Loriga G, et al; REIN-2 Study Group. Blood-pressure control
    for renoprotection in patients with non-diabetic chronic renal disease (REIN-2):
    multicentre, randomised controlled trial. Lancet. 2005;365:939-946.
    10. ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT).
    NCT01206062. http://clinicaltrials.gov/ct2/show/NCT01206062?term=SPRINT&rank=3
    Accessed March 14, 2014.

    References (cont)
    11. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in
    hypertensive patients with and without the metabolic syndrome: Antihypertensive and
    Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med.
    2008;168:207-217.
    12. Wright Jr JT, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR.
    Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in
    Patients Aged 60 Years or Older: The Minority View. Ann Intern Med. 2014. [Epub
    ahead of print]
    13. Dahlf B, Devereux RB, Kjeldsen SE, et al; LIFE Study Group. Cardiovascular
    morbidity and mortality in the Losartan Intervention For Endpoint reduction in
    hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:9951003.
    14. Poulter NR, Wedel H, Dahlf B, et al; ASCOT Investigators. Role of blood pressure
    and other variables in the differential cardiovascular event rates noted in the AngloScandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).
    Lancet. 2005;366:907-913.

    References (cont)
    15. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the
    prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the
    context of expectations from prospective epidemiological studies. BMJ.
    2009;338:b1665.
    16. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
    Collaborative Research Group. Diuretic versus alpha-blocker as first-step
    antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering
    Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42:239-246.
    17. Wright JT Jr, Dunn JK, Cutler JA, et al; ALLHAT Collaborative Research Group.
    Outcomes in hypertensive black and nonblack patients treated with chlorthalidone,
    amlodipine, and lisinopril. JAMA. 2005;293:1595-1608.
    18. Dahlf B, Sever PS, Poulter NR, et al; ASCOT Investigators. Prevention of
    cardiovascular events with an antihypertensive regimen of amlodipine adding
    perindopril as required versus atenolol adding bendroflumethiazide as required, in the
    Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOTBPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-906.

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