Hypertension Update: 2014 JNC VIII Guidelines

Hypertension Update:
2014 JNC VIII
Guidelines
Ruben Salinas, Jr., MD, FAAFP
LTC, MC, USA
Geriatric Fellow
16 March 2014
Objectives
• Review 3 major questions addressed by JNC VIII
• Engage the new HTN Algorithm with 9 recs
• Examine the list of JNC VIII initial HTN meds
• Compare JNC VIII to other HTN Guidelines
JNC VIII Key Questions
• 1. Does initiating antihypertensive pharmacologic therapy
at specific BP thresholds improve health outcomes?
• 2. Does treatment with antihypertensive pharmacologic
therapy to a specified BP goal lead to improvements in
health outcomes?
• 3. Do various antihypertensive drugs or drug classes differ
in comparative benefits and harms on specific health
outcomes?
2014 JNC VIII Algorithm
>18 years old
with HTN
Lifestyle
interventions
at all levels
Set goal BP;
Initiate BP med
based on Age,
DM, CKD
General Population ( No CKD or DM )
Age > 60
years
Rec # 1
Grade A
Rec #1
< 140 / 90 ok,
Grade E
BP Goal
SBP < l50 mm Hg
DBP < 90 mm Hg
Age < 60
years
Rec # 2
Grade A, E
Rec # 3
Grade E
BP Goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Non – Black
Initiate TTD, CCB,
ACEI, or ARB
Black
Initiate TTD or
CCB
Rec # 6 Grade B
Rec # 7 Grade B
Diabetes or CKD Present
All Ages
Diabetes
No CKD
Rec # 5
Grade E
All Ages
CKD
+ / - Diabetes
BP Goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Non - Black
Initiate TTD, CCB,
ACEI, or ARB
Rec # 6 Grade B
Black
Initiate TTD or CCB
Rec # 7 Grade C
Rec # 4
Grade E
BP Goal
SBP < 140 mm Hg
DBP < 90 mm Hg
All Races
ACEI or ARB
( Alone / Combo with
other drug class )
Rec # 8 Grade B
Selection of Titration Drug Therapy
Select from TTD, CCB, ACEI, or ARB
A. Maximize first med before adding second
B. Add second med before reaching max
dose of first medication
C. Start with two medication classes
separately or as fixed – dose combo
Rec # 9 Grade E
Not at Goal Blood Pressure
Reinforce med and lifestyle adherence
Strategies A and B
Add and titrate TTD, CCB, ACEI, or ARB
Use med class not previously used
Avoid combined use of ACEI and ARB
Strategy C, titrate doses of initial meds to
max
Rec # 9 Grade E
Not at Goal BP ( Continued )
After Maximize 2 Meds
Reinforce medication and lifestyle adherence
Add 3rd med & titrate TTD, CCB, ACEI, or ARB
Use med class not previously used
Avoid combined use of ACEI and ARB
Rec # 9 Grade E
Not at Goal BP ( Continued )
Reinforce medication and lifestyle adherence
Add additional medication class
Beta – Blocker
Aldosterone Antagonist
or others
Rec # 9 Grade E
+ / - Refer to physician with expertise in HTN
Management
At Goal Blood Pressure
Continue Current Tx and Monitoring
Anti – Hypertensive Medications
Anti – HTN
Medications
Initial Daily
Dose, mg
Target dose in RCTs
reviewed, mg
No. of doses per
day
Captopril
50
150 - 200
2
Enalapril
5
20
1-2
Lisinopril
10
40
1
Eprosartan
400
600 - 800
1-2
Candesartan
4
12 - 32
1
Losartan
50
100
1-2
Valsartan
40 - 80
160 – 320
1
Irbesartan
75
300
1
Ace - Inhibitors
ARBs
James A. Paul 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 ( 5 ): 507 – 520.
Anti – Hypertensive Medications
Initial Daily
Dose, mg
Target dose in
RCTs reviewed, mg
No. of doses per
day
Atenolol
25 - 50
100
1
Metoprolol
50
100 - 200
1-2
Amlodipine
2.5
10
1
Diltiazem ER
120 – 180
360
1
Nitrendipine
10
20
1-2
Bendroflumethiazide
5
10
1
Chlorthalidone
12.5
12.5 - 25
1
Hydrochlorthiazide
12.5 - 25
25 - 100
1-2
Indapamide
1.25
1.25 – 2.5
1
Anti – HTN Meds
Beta Blockers
CCBs
Thiazide – Type Diuretics
James A. Paul 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 ( 5 ): 507 – 520.
Guideline Comparisons ( Goal BP and Initial Tx )
Guideline
Population
Goal BP mm Hg
Initial Treatment
JNC VIII
2014
General > 60 y
< 150 / 90
Non - Black: TTD, ARB, ACEI, or
CCB
General < 60 y
< 140 / 90
Black: TTD or CCB
Diabetes
< 140 / 90
TTD, ACEI, ARB, or CCB
CKD
< 140 / 90
ACEI or ARB
Gen Non - Elderly
< 140 / 90
BB, TTD, CCB, ACEI, or ARB
Gen Elderly < 80 y
< 150 / 90
General > 80 y
< 150 / 90
Diabetes
< 140 / 85
ACEI or ARB
CKD no proteinuria
< 140 / 90
ACEI or ARB
CKD + proteinuria
< 130 / 90
Diabetes
< 140 / 80
ESH / ESC
2013
ADA 2013
ACEI or ARB
James A. Paul 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 ( 5 ): 507 – 520.
Guideline Comparisons ( Continued )
Guideline
Population
Goal BP mm Hg
Initial Treatment
CHEP 2013
General < 80 y
< 140 / 90
TTD, BB ( < 60 y ), ARB, or
ACEI ( nonblack )
General > 80 y
< 150 / 90
Black: TTD or CCB
Diabetes
< 130 / 80
ACEI or ARB (+ CVD risk)
ACEI, ARB, TTD, DHPCCB
( - CVD risk )
CKD
< 140 / 90
ACEI or ARB
CKD no proteinuria
< 140 / 90
ACEI or ARB
CKD + proteinuria
< 130 / 80
General < 80 y
< 140 / 90
< 55 y: ACEI or ARB
General > 80 y
< 150 / 90
> 55 y or Black: CCB
Black, lower risk
< 135 / 85
Diuretic or CCB
Target Organ Damage
or CVD Risk
< 130 / 80
KDIGO 2012
NICE 2011
ISHIB 2010
James A. Paul 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 ( 5 ): 507 – 520.
Additional Guideline Comparison
NICE 2011
ESH / ESC
2013
ASH / ISH
2014
Go A. et al.
AHA / ACC
/ CDC 2013
JNC VIII
2014
Definition
of HTN
> 140 / 90 or
ABPM > 135 / 85
> 140 / 90
> 140 / 90
> 140 / 90
Not Addressed
Rx in Low
Risk Pts
> 160 / 100 or
ABPM > 150 / 95
> 140 / 90
> 140 / 90
> 140 / 90
< 60 y > 140 / 90
> 60 y > 150 / 90
BBs as 1st
Line Rx
No
Yes
No
No
No
Diuretic
Chlorthalidone,
Indapamide
Thiazides,
Chlor, Inda
Thiazides, Chlor,
Inda
Thiazides
Thiazides, Chlor,
Inda
Initiate
with 2 Rx
Not Mentioned
Marked Inc BP
> 160 / 100
> 160 / 100
> 160 / 100
BP
Targets
< 140 / 90
> 80 y < 150 / 90
< 140 / 90
< 80 y 140 – 150
SBP < 140 in fit
> 80 y 140 - 150
< 140 / 90
> 80 y < 150 / 90
< 140 / 90
Lower BPs
in fit pts
< 60 y < 140 / 90
> 60 y < 150 / 90
BP Target
in DM
Not Addressed
< 140 / 85
< 140 / 90
< 140 / 90
< 140 / 90
BP
( mm Hg )
Weber et al. ASH / ISH Guidelines. The Journal of Clinical Hypertension. Volume 16, Issue 1, pages 14–26, January 2014.
Summary JNC VIII
Patient Subgroup
Target SBP
( mm Hg )
Target DBP
( mm Hg )
> 60 years
< 150
< 90
< 60 years
< 140
< 90
> 18 years with CKD
< 140
< 90
> 18 years with DM
< 140
< 90
Summary JNC VIII
• General Non - Black Population
– Thiazides, CCB, ACEI, or ARB initially
• General Black Population
– Thiazides or CCB initially
• Chronic Kidney Disease
– ACEI or ARB
• Up – titrate or add therapy after 1 month if BP goal
not achieved
– Don’t use ARB and ACEI together
– If > 3 BP meds, refer to HTN specialist
Questions?
New JNC VIII HTN Guideline Algorithm
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. 2013;doi:10.1001/jama.2013.284427
Algorithm ( Continued )
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. 2013;doi:10.1001/jama.2013.284427.
American Society of Hypertension and the International Society of Hypertension
Recommendation # 1
• Age > 60 years old
• Initiate pharmacologic tx if SBP > 150 mm Hg or DBP >
90 mm Hg
• Treat to a goal of < 150 / 90 mm Hg
• Grade A Recommendation ( Strong )
• If BP < 140 / 90 mm Hg with treatment and without
adverse effects, no need to adj meds
– Grade E Recommendation ( Expert Opinion )
Recommendation # 2
• Age < 60 years old
• Initiate drug tx if DBP > 90 mm Hg
• Treat to a goal DBP < 90 mm Hg
• Grade A Recommendation for 30 – 59 yrs old
• Grade E Recommendation for 18 – 29 yrs old
Recommendation # 3
• Age < 60 years old
• Initiate drug tx if SBP > 140 mm Hg
• Treat to a goal SBP < 140 mm Hg
• Grade E Recommendation
Recommendation # 4
• Age > 18 years old with Chronic Kidney Dz
• Initiate meds if SBP > 140 mm Hg or DBP > 90 mm Hg
• Treat to a goal < 140 / 90 mm Hg
• Grade E Recommendation
Recommendation # 5
• Age > 18 years old with Diabetes
• Initiate pharmacologic tx if SBP > 140 mm Hg or DBP > 90
mm Hg
• Treat to a goal of < 140 / 90 mm Hg
• Grade E Recommendation
Recommendation # 6
• General Non – Black Population + / - Diabetes
• Initial Anti – HTN Meds:
– Thiazide – Type Diuretic
– Calcium Channel Blocker ( CCB )
– Angiotensin – Converting Enzyme Inhibitor ( ACEI )
– Angiotensin Receptor Blocker ( ARB )
• Grade B Recommendation ( Moderate )
DM
Recommendation # 7
• General Black Population + / - Diabetes
• Initiate therapy with the following:
– Thiazide – Type Diuretic
– CCB
• Grade B Recommendation for general black
population
• Grade C ( Weak ) Recommendation for black
patients with diabetes
Recommendation # 8
• Age > 18 years with Chronic Kidney Dz
• Regardless of race or diabetes status
• Initiate therapy with the following:
– ACEI
– ARB
• Grade B Recommendation
Recommendation # 9
• BP not at goal within 1 month - Options
– Increase dose of initial med or
– Add a 2nd drug from those in Recommendation # 6
1st
2nd
• If BP not at goal with 2 meds, add and titrate 3rd agent from
Recommendation # 6 list
– Do not combine ACEI and ARB
3rd
• If BP not at goal with 3 meds from list, use other BP meds from
other classes
• May refer to HTN specialist if not at BP goal
• Grade E Recommendation
4th

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