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Hypertension Guidelines-JNC 8

Hypertension Guidelines-JNC 8. Vivek V. Sailam, MD Associated Cardiovascular Consultants Lourdes Cardiology. Disclosures. No disclosures. Hypertension. Hypertension is the most common condition in primary care. 1 in 3 patients have hypertension according to NHLBI

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Hypertension Guidelines-JNC 8

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  1. Hypertension Guidelines-JNC 8 Vivek V. Sailam, MD Associated Cardiovascular Consultants Lourdes Cardiology

  2. Disclosures No disclosures

  3. 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

  4. 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.

  5. Case Question 1 • What goal BP is most appropriate for this patient? • <150/90 mmHg • <130/80 mmHg • <140/90 mmHg • <140/80 mmHg • <140/85 mmHg

  6. Classification of BP – JNC 7

  7. JNC 8 • 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults • JAMA. 2014;311(5):507-520 • December 18, 2013

  8. JNC 8: Hypertension ManagementQuestions Guiding Review • In adults with HTN: • Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? • Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes? • Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

  9. JNC 8: Hypertension ManagementEvidence 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

  10. JNC 8: Hypertension ManagementEvidence Review • RCT’s December 2009 – August 2013 • Major study in hypertension • ACCORD, NEJM 2010 • > 2,000 participants • Multicentered • Met all other inclusion/exclusion criteria

  11. JNC 8: Graded Recommendations A – Strong evidence B – Moderate evidence C – Weak evidence D – Against E – Expert Opinion N – No recommendation

  12. JNC 8: Drug TreatmentThresholds 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

  13. JNC 8: Drug TreatmentThresholds 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

  14. JNC 8: Drug TreatmentThresholds 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

  15. 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)

  16. 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

  17. 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

  18. 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

  19. 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

  20. Blood pressure goals in hypertensive patients SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

  21. Hypertension treatment for people with diabetes SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

  22. Hypertension treatment for people with nephropathy SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

  23. What is the goal BP?

  24. Lifestyle changes for hypertensive patients * Unless contraindicated. BMI, body mass index.

  25. Comparison of RecentGuideline Statements

  26. Goal BP **KDIGO: <140/90 w/o albuminuria <130/80 if >30 mg/24hr *ADA: < 140/80 or lower

  27. Thank you for your attention! vsailam@hotmail.com vs

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