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JNC 8

JNC 8. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Dr. Asif Mehmood R.Ph Pharm. D. Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide 1. Number of people with HTN worldwide in 2000 1. 972 million. 60%.

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JNC 8

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  1. JNC 8 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Dr. Asif Mehmood R.Ph Pharm. D

  2. Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide1 Number of people with HTN worldwide in 20001 972 million 60% Increase in the number of adults with HTNglobally by 20251 Percent of all global healthcare spending attributable to high blood pressure2 10% 1.6 Billion HTN patients estimated by 2025 Annual worldwide cost of hypertension2 $370 billion 1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. GazianoTA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.

  3. EU Prevalence of Hypertension~81 Million Adults have elevated Blood Pressure 81M Patients with HTN Diagnosed HTN EU Patients with HTN 81.0M Diagnosed HTN 78% Treated HTN 68% Uncontrolled HTN 38% Resistant HTN 9% - $7.2M Treated HTN Uncontrolled HTN Lloyd-Jones D: Circulation 2010;121:e46 – e215 Persell SD: Hypertension 2011;57:1076-1080 HTN=Hypertension

  4. Hypertension in Pakistan Time to take some serious action FahadSaleem et al; Br J Gen Pract. 2010 June 1; 60(575): 449–450. doi: 10.3399/bjgp10X502182

  5. HTN leads to an increased risk of death from stroke and heart disease 8x Cardiovascular Mortality Risk 4x 2x Systolic BP / Diastolic BP (mmHg) CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2 Chobanianet al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913

  6. Risk Factors for Cardiovascular Disease • Smoking • Hyperlipidaemia • High salt intake • Homocysteinaemia • Lack of exercise • Obesity • Diabetes • Alcohol >4pints of beer/day • Genetic

  7. Accurate Reading of Blood Pressure Cuff bladder encircle >80% pts arm sphygmomanometer Deflate 2-3mm per second Siting comfortably Back supported Legs uncrossed Upper arm bared Arm at heart level SBP INACCURATELY HIGH IF: patient is supine, crossed legs, arm below the heart, arm unsupported, undersized cuff. AHA guidelines

  8. Questions Guiding the Evidence Review

  9. Question-1 • Specific BP thresholds for • Start of antihypertensive pharmacologic therapy • Improvement in health outcomes? • 1) > 160 mm Hg • 2) > 150 mm Hg • 3) > 140 mm Hg • 4) > 130 mm Hg

  10. Question-2 • Does a specified BP goal lead to improvements in health outcomes? • 1) 130/80 mm Hg in a diabetic • 2) < 140/90 in an 84 year old female • 3) < 140/90 in a patient with CKD • 4) < 120/80 in a 38 year old male

  11. Question-3 • Do various antihypertensive drugs or drug classes • differ in comparative benefits and harms on • Specific health outcomes

  12. Level of Recommendation JAMA. 2013;():. doi:10.1001/jama.2013.284427

  13. JNC 8 (2014 Hypertension Guideline Management Algorithm) 1 JAMA. 2013;():. doi:10.1001/jama.2013.284427 2014 Hypertension Guideline Management Algorithm SBP 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 therapeutic plan.

  14. JNC 8 (2014 Hypertension Guideline Management Algorithm) 2 JAMA. 2013;():. doi:10.1001/jama.2013.284427 2014 Hypertension Guideline Management Algorithm SBP 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 therapeutic plan.

  15. JNC 8 (2014 Hypertension Guideline Management Algorithm) 3 JAMA. 2013;():. doi:10.1001/jama.2013.284427 2014 Hypertension Guideline Management Algorithm SBP 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 therapeutic plan.

  16. JNC 8 (2014 Hypertension Guideline Management Algorithm) Full JAMA. 2013;():. doi:10.1001/jama.2013.284427 2014 Hypertension Guideline Management Algorithm SBP 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 therapeutic plan.

  17. Strategies to Dose of Antihypertensive Drugs A B C

  18. Recommendations for Management of Hypertension JNC-8 2014 Guideline for Management of High Blood Pressure

  19. Recommendation 1 • In the general population aged ≥60 years • Initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP)150 mmHg or diastolic blood pressure (DBP)90mmHg • Treatment goal SBP <150 mm Hg and goal DBP <90 mmHg. • (Strong Recommendation – Grade A)

  20. Recommendation 1 Corollary Recommendation • In the general population aged ≥60years • Treatment does not need to be adjusted • if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140mmHg) and treatment is well tolerated and without adverse effects on health or quality of life. • (Expert Opinion – Grade E)

  21. Recommendation 2 • In the general population <60 years • Initiate pharmacologic treatment to lower BP at DBP 90mmHg • Treatment goal DBP<90mmHg. • For ages 30-59 years • Strong Recommendation – Grade A • For ages 18-29 years • Expert Opinion – Grade E

  22. Recommendation 3 • In the general population <60 years • Initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHg • Treatment goal SBP <140mmHg. • (Expert Opinion – Grade E)

  23. Recommendation 4 • In the population aged ≥18 years with chronic kidney disease (CKD) • Initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHg or DBP ≥ 90mmHg • Treatment goal SBP<140mmHg and goal DBP<90mmHg. • (Expert Opinion – Grade E)

  24. Recommendation 5 • In the population aged ≥18years with diabetes • Initiate pharmacologic treatment to lower BP at SBP≥ 140mmHg or DBP ≥ 90mmHg • Treatment goal SBP <140mmHg and DBP <90mmHg. • (Expert Opinion –Grade E)

  25. Recommendation 6 • General nonblack population, including those with diabetes • Initial antihypertensive treatment should include: • A thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). • Moderate Recommendation – Grade B

  26. Recommendation 7 • 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)

  27. 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. • Applies to all CKD patients with hypertension regardless of race or diabetes status. • Moderate Recommendation – Grade B

  28. 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 recommendation6 (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 whom additional clinical consultation • is needed. (Expert Opinion – Grade E)

  29. Comparison of Current Recommendations With JNC 7 Guidelines

  30. JNC 7 vs JNC 8 Methodology JNC 7 JNC 8 (2014 Hypertension Guideline) Critical questions and review criteria defined by expert panel with input from methodology team Initial systematic review by methodologists restricted to RCT evidence Subsequent review of RCT evidence and recommendations by the panel according to a standardized protocol • Nonsystematic literature review by expert committee including a range of study designs • Recommendations based on consensus

  31. JNC 7 vs JNC 8 Definitions JNC 7 JNC 8 (2014 Hypertension Guideline) Definitions of hypertension and prehypertension not addressed But thresholds for pharmacologic treatment were defined • Defined hypertension and prehypertension

  32. JNC 7 vs JNC 8 Treatment Goals JNC 7 JNC 8 (2014 Hypertension Guideline) Similar treatment goals defined for all hypertensive populations Except when evidence review supports different goals for a particular subpopulation • Separate treatment goals defined for • “uncomplicated”hypertension • Subsets with various comorbid conditions • (diabetes and CKD)

  33. JNC 7 vs JNC 8 Lifestyle recommendations JNC 7 JNC 8 (2014 Hypertension Guideline) Lifestyle modifications recommended by endorsing the evidence basedRecommendations of the Lifestyle Work Group • Recommended lifestyle modifications • Based on literature review and expert opinion

  34. JNC 7 vs JNC 8 Drug therapy JNC 7 JNC 8 (2014 Hypertension Guideline) Recommended selection among 4 specific medication classes ACEIor ARB, CCB or diuretics Doses based on RCT evidence Recommended specific medication classes based on evidence review for racial, CKD, and diabetic subgroups Panel created a table of drugs and doses used in the outcome trials • Recommended 5 classes to be considered as initial therapy • Recommended thiazide-type diuretics as initial therapy for most patients without compelling indication for another class • Specified particular antihypertensive medication classes for patients with compelling indications, ie, diabetes, CKD, heart failure, myocardial infarction, stroke, and high CVD risk • Included a comprehensive table of oral antihypertensive drugs including names and usual dose ranges

  35. JNC 7 vs JNC 8 Scope of topics JNC 7 JNC 8 (2014 Hypertension Guideline) Addressed a limited number of questions Those judged by the panel to be of highest priority. Evidence review of RCTs • Addressed multiple issues • blood pressure measurement methods • Patient evaluation components • Secondary hypertension • Adherence to regimens • Resistant hypertension • Hypertension in special populations • Based on literature review and expert opinion

  36. JNC 7 vs JNC 8 Review process prior to publication JNC 7 JNC 8 (2014 Hypertension Guideline) Reviewed by experts including those affiliated with Professional Public organizations Federal agencies No official sponsorship by any organization should be inferred • Reviewed by the National High Blood Pressure Education Program • Coordinating Committee • a coalition of 39 major professional • Public and voluntary organizations and 7 federal agencies

  37. Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension JAMA. 2013;():. doi:10.1001/jama.2013.284427

  38. THANK YOU!! For Your Valuable Time

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