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)

dr Nahar Taufiq, Sp.JP (K)

Disclosures

No disclosures
Hypertension

• Hypertension is the most common

condition in primary care.

• 1 in 3 patients have hypertension

according to NHLBI

• Risk factor for MI, CVA, ARF, death

Case

• A 58 year old African-American woman

with diabetes and dyslipidemia has a
BP of 158/94 confirmed on several
office visits. Other than obesity, the
exam is normal. Labs show normal
renal function, well-controlled lipids on
atorvastatin and well-controlled
diabetes on metformin. Urine micro-
albumin is mildly elevated.
Case Question 1

• What goal BP is most appropriate for

this patient?
1. <150/90 mmHg
2. <130/80 mmHg
3. <140/90 mmHg
4. <140/80 mmHg
5. <140/85 mmHg
Case Question 2

• What is the drug of choice to start?

1. HCTZ
2. Amlodipin
3. Lisinopril
4. Losartan
5. Candesartan
6. Combination therapy
Prevalensi Hipertensi
SBP > 140 mm Hg
DBP > 90 mm Hg
70
prevalence of hypertension (%)

64 65
60

50 54
44
40

30
21
20
4 11
10

0
age (yrs)
18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension complication

Eyes Brain
retinopathy stroke Target Organ damage!!

Heart Damages depend on:

ischaemic heart disease
Kidneys left ventricular hypertrophy • How high of the blood
renal failure heart failure pressures
• How long the uncontrolled and
untreated high blood presure
Peripheral arterial disease
Blood Pressure Reduction of 2 mmHg
Reduces The Risk of CV Events by 7–10%

• Meta-analysis of 61 prospective, observational studies

• 1 million adults
• 12.7 million person-years
7% reduction in risk
2 mmHg of ischaemic heart
decrease in disease mortality
mean SBP 10% reduction in
risk of stroke
mortality

Lewington et al. Lancet 2002;360:1903–13

 ASH/
ISH

HYPERTENSION
GUIDELINES
JNC 8

• 2014 Evidence-Based Guidelines for

the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
– December 18, 2013
 JNC-7 Blood Pressure Classification

Blood Pressure Systolic blood Diastolic blood

Classification pressure pressure
(mm Hg) (mm Hg)
Normal < 120 < 80

Pre-hypertension 120-139 80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension > 160 > 100

JNC 8: Hypertension Management
Questions Guiding Review
• In adults with HTN:
1. Does initiating antihypertensive pharmacologic
therapy at specific BP thresholds improve health
outcomes?
[When to start therapy?]
2. Does treatment with antihypertensive
pharmacologic therapy to a specified goal lead to
improvements in health outcomes?
[How low should I go?]
3. Do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on
specific health outcomes?
[What drug do I use?]
JNC 8: Hypertension Management
Evidence Review
• Limited to RCT’s
– Hypertensive adults > 18 years old
– Sample size > 100
– Follow-up > 1 year
– Reported effect of treatment on important
health outcomes (mortality, MI, HF, CVA,
ESRD)
• January 1966 to December 2009
– Separate criteria used of RCT’s published
after December 2009
JNC 8: Hypertension Management
Evidence Review
• RCT’s December 2009 – August 2013
1. Major study in hypertension
• ACCORD, NEJM 2010
2. > 2,000 participants
3. Multicentered
4. Met all other inclusion/exclusion criteria
The Process
Literature review 1/1/1966 –
12/31/2009

Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4) Kriteria inklusi/eksklusi.

9
Recommenda
tions
A

N
 JNC 8: Drug Treatment
Thresholds and Goals
• Age > 60 yo
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A
 JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yo
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for ages 40-59; Grade E for ages 18-
39
 JNC 8: Drug Treatment
Thresholds and Goals
• Age > 18 yo with CKD or DM
– JNC 7: < 130/80 (MDRD NEJM 1994)
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade E
JNC 8: Initial Drug Choice

• Age > 18 yo with CKD and HTN

(regardless of race or diabetes)
– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria
• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo
• Diuretic is an option for initial therapy
JNC 8: Subsequent Management

• Reassess treatment monthly

• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
– Consider referral to HTN specialist
– LOE: Grade E
Recent HTN Guideline Statements

• 2013 ESH/ESC Guidelines for the management of

arterial hypertension.
• J Hypertnsion 2013;31:1281-1357.
• An Effective Approach to High Blood Pressure
Control: A Science Advisory From the AHA, ACC, and
CDC.
• Hypertension online November 15, 2013.
• Clinical Practice Guidelines for the Management of
HTN in the Community A Statements by the ASH/ISH.
• J Hypertension 2014;32:3-15
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for “most” <140 mmHg
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD

SBP goal for elderly 140-150 mmHg

•Ages <80 years
•Initial SBP ≥160 mmHg

SBP goal for fit elderly <140 mmHg

Aged <80 years

SBP goal for elderly >80 years with SBP 140-150 mmHg
•≥160 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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BP goal in the elderly
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations Additonal considerations
Mandatory: initiate drug treatment in patients • Strongly recommended: start drug treatment
with SBP ≥160 mmHg when SBP ≥140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg

All hypertension treatment agents are • RAS blockers may be preferred

recommended and may be used in patients with • Especially in presence of preoteinuria or
diabetes microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not • Avoid in patients with diabetes

recommended

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with nephropathy

Recommendations Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria • Monitor changes in eGFR

RAS blockers more effective to reduce • Indicated in presence of microalbuminuria or

albuminuria than other agents overt proteinuria

Combination therapy usually required to reach BP • Combine RAS blockers with other agents
goals

Combination of two RAS blockers • Not recommended

Aldosterone antagonist not recommended in CKD • Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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What is the goal BP?
 Comparison of Recent
Guideline Statements

JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90
Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr
for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr
140-150 if <80 yr

B-blocker No Yes No No
First line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100

w/ 2 drugs elevated BP"
 Goal BP
Group BP Goal (mm Hg)
General DM* CKD**
JNC 8: <60 yr: <140/90 < 140/90 < 140/90
>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)
ASH/ISH < 140/90 < 140/90 < 140/90
>80 yr: <150/90 (Consider < 130/80 if proteinuria)
AHA/ACC < 140/90 < 140/90 < 140/90

**KDIGO: <140/90 w/o albuminuria

*ADA: < 140/80 or lower
<130/80 if >30 mg/24hr
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)

Quit smoking

* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
 Development of JNC-8
• 3 critical questions for adults with hypertension
– Does initiating antihypertensive pharmacologic
therapy at specific blood pressure thresholds
improve health outcomes? [When to start therapy?]
– Does treatment with antihypertensive
pharmacologic therapy to a specified blood pressure
goal lead to improvements in health outcomes?
[How low should I go?]
– Do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on specific
health outcomes? [What drug do I use?]
James PA et al. JAMA 2014;311:507-20.
 JNC-8 Recommendations

• In patients >60 years of age, start medications

at blood pressure of >150/90mm Hg and treat to
goal of <150/90mm Hg

• In patients >60 years of age, treatment does not

need to be adjusted if achieved blood pressure
is lower than goal and well-tolerated

James PA et al. JAMA 2014;311:507-20.

 Hypertension in the Elderly
• Fastest growing segment of the population
• Prevalence of hypertension is very high
• Several issues make managing HTN unique:
– Often present with isolated systolic HTN
– More likely to present with comorbidities
– Many clinical trials in HTN have excluded these
patients (particularly for those 80 years and older)
– Elderly are more susceptible to certain adverse
effects (orthostatic hypotension)
 JNC-8 Recommendations
• In patients <60 years of age, start medications
at blood pressure of >140/90mm Hg and treat to
goal of <140/90mm Hg

• In all adult patients with diabetes or chronic

kidney disease, start medications at blood
pressure of >140/90mm Hg and treat to goal of
<140/90mm Hg
James PA et al. JAMA 2014;311:507-20.
 JNC-8 Recommendations
• For the non-black population (including
diabetes), initial antihypertensive treatment
may include a thiazide, ACEI, ARB, or CCB
• For the black population (including diabetes),
initial antihypertensive treatment should
include a thiazide or CCB
• For all patients with CKD, initial (or add-on)
therapy for hypertension should include an
ACEI or ARB
James PA et al. JAMA 2014;311:507-20.
 JNC-8 Recommendations
• Initiate therapy according to recommendations
• If BP is not at goal in one month, increase dose or
add a second agent from recommended classes
• If patient is still not at goal, add a third drug from
recommended classes
– Do not use an ACEI and ARB together
• Drugs from other classes may be used if additional
BP lowering is needed or if contraindications exist
• Refer to HTN specialist whenever necessary

James PA et al. JAMA 2014;311:507-20.

 Comparisons to Other Guidelines
BP Goal JNC-7 JNC-8 ASH/ISH ESC/ES CHEP
H
Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90

Age 60- <140/90 <150/90 <140/90 <140/90 <140/90

79
Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90

Diabetes <130/80 <140/90 <140/90 <140/85 <130/80

CKD <130/80 <140/90 <140/90 <130/90 <140/90

Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

Lifestyle Modification
JNC 8
JNC 7
Guideline Population Goal BP Initial drugs
2014 HT General ≥60 y <150/90 Non Black: thiazide type diuretic,
Guideline ACEI, ARB or ARB
General <60 y <140/90 Black: thiazide type-diuretic or CCB
DM <140/90 Thiazide type diuretic, ACEI, ARB or
CCB
CKD <140/90 ACEI or ARB

ESH/ESC • General (non <140/90 βBocker, diuretic, CCB, ACEI, ARB

elderly)
• General elderly <150/90
<80 y
• General ≥ 80 y <150/90
• DM <140/85 ACEI or ARB
• CKD (no <140/90 ACEI or ARB
proteinemia)
• CKD + <130/90
proteinemia

CHEP General <80 y <140/90 Thiazide, βBlocker (<60y), ACEI (nonblack) or

ARB
General >80 y <150/90
DM <130/80 Add CVD risk: ACEI or ARB
No CVD risk: ACEI/ARB/Thiazide/DHPCCB
ACEI or ARB
CKD <140/90
Guideline Population Goal BP Initial drugs

ADA DM <140/80 ACEI or ARB

KDIGO • DM and CKD alb ≤140/90 ACEI or ARB

exc <30 mg/d
• DM and CKD
alb exc >30 mg/d ≤130/80

NICE General <80 y <140/90 <55 y; ACEI or ARB

General ≥80 y <150/90 ≥55 y or black; CCB

ISHIB Black, lower risk <135/85 Diuretic or CCB

TOD or CVD risk <130/80

JNC 7 General <140/90

CKD <130/80 ACEI or ARB
DM <130/80
* thank you
JNC 8: Initial Drug Choice

• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B

• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
Dissenting Editorial

• Ann Intern Med. January 14, 2014

• 5/17 authors (29%)

• “Insufficient evidence” to increase

target SBP to 150 mmHg.

• Expertise vs. Scientific Evidence