1. JNC 8 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults
April 22, 2016
Connie Tien
Daniel Kim
Jeffrey Hughes
Michelle Di Fiore
Ola Lafi

2. Table of Contents Why Do We Treat Hypertension? Recommendation 5
Blood Pressure Treatment Goals
Recommendation 6
Initial Therapy
Recommendation 7
Strength of Recommendation
Recommendation 8
Recommendation 1
Recommendation 9
Corollary Recommendation
Evidence Based Dosing for Antihypertensive Drugs
Recommendation 2
Hypertension Guideline Management Algorithm
Recommendation 3
Recommendation 4
Sources

3. Why Do We Treat Hypertension?
Hypertension can lead to:
Myocardial infarction
Stroke
Renal failure
Death

4. Blood Pressure Treatment Goals
Persons 60 years or older without diabetes or CKD
BP < 150/90 (based on strong evidence)
Persons less than 60 years of age, with diabetes, and/or with CKD
BP <140/90 (based on expert opinion)

5. Initial Therapy Non-black persons
Angiotensin-converting enzyme inhibitor (ACEI)
Angiotensin receptor blocker (ARB)
Calcium channel blocker (CCB)
Thiazide-type diuretic
Black persons (including those with diabetes)
CCB
Chronic kidney disease (regardless of race or diabetes status)
ACEI or ARB as initial or add-on antihypertensive therapy

6. Strength of Recommendation

7. Recommendation 1
In the general population aged ≥60 years, initiate treatment at systolic blood pressure (SBP) ≥150 or diastolic blood pressure (DBP) ≥90 and treat to a goal SBP <150 and DBP <90.
Strong Recommendation – Grade A

8. Corollary Recommendation
In the general population aged ≥60 years, if treatment results in lower achieved SBP (e.g. SBP <140) and treatment is well tolerated without adverse effects on health or quality of life, treatment does not need to be adjusted. Expert Opinion – Grade E

9. Recommendation 2
In the general population <60 years, initiate treatment at DBP ≥90 and treat to a goal DBP <90. For ages years, Strong Recommendation – Grade A For ages years, Expert Opinion – Grade E

10. Recommendation 3
In the general population <60 years, initiate treatment at SBP ≥140 and treat to a goal SBP<140. Expert Opinion – Grade E

11. Recommendation 4
In the population aged ≥18 with chronic kidney disease (CKD), initiate treatment at SBP ≥140 or DBP ≥90 and treat to goal SBP <140 and DBP <90.
Expert Opinion – Grade E
Based on the inclusion criteria used in the randomized controlled trials (RCTs) reviewed by the panel, this recommendation applies to individuals <70 years with an estimated GFR or measured GFR <60 and in people of any age with albuminuria defined as >30 mg of albumin/g of creatinine at any level of GFR.

12. Recommendation 5
In the population aged ≥18 years with diabetes, initiate treatment at SBP ≥140 or DBP ≥90 and treat to a goal SBP <140 and DBP <90. Expert Opinion – Grade E

13. Recommendation 6
In the 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
RCTs that were limited to specific nonhypertensive populations, such as those with coronary artery disease (CAD) or heart failure (HF) were not reviewed for this recommendation. Therefore, recommendation 6 should be applied with caution to these populations.
For more details regarding why other drug classes were not recommended for initial therapy please see the notes for this slide.
For this recommendation, only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed; placebo-controlled RCTs were not included.
Each of the 4 drug classes recommended yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes, with one exception: heart failure.
Initial treatment with a thiazide-type diuretic was more effective than a CCB or ACEI and an ACEI was more effective than a CCB in improving heart failure outcomes.
However, the panel did not conclude that it was compelling enough within the context of the overall body of evidence to preclude the use of the other drug classes for initial therapy since the evidence supported BP control rather than a specific agent used to achieve that control as the most relevant consideration for this recommendation.
The panel did not recommend β-blockers for the initial treatment of hypertension because in one study use of β-blockers resulted in a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to the use of an ARB, a finding that was driven largely by an increase in stroke. In the other studies that compared β-blockers to the 4 recommended drug classes, the β-blocker performed similarly to the other drugs or the evidence was insufficient to make a determination.
α-blockers were not recommended as first-line therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic.
There were no RCTs of good or fair quality comparing the following drug classes to the 4 recommended classes: dual α1- + β-blocking agents, vasodilating β-blockers, central α2-adrenergic agonists, direct vasodilators, aldosterone receptor antagonists, adrenergic neuronal depleting agents, and loop diuretics.

14. 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
For more information regarding why the other drug classes were not recommended as initial therapy for black persons please see the notes for this slide.
This recommendation stems from a prespecified subgroup analysis of data from a single large trial (ALLHAT) that was rated good. Although a CCB was less effective than a diuretic in preventing heart failure in the black subgroup of this trial, there were no differences in other outcomes (cerebrovascular, coronary heart disease, combined cardiovascular, and kidney outcomes, or overall mortality) between a CCB and a diuretic.
There was a 51% higher rate of stroke in black persons in ALLHAT with the use of an ACEI as initial therapy compared with use of a CCB. ACEI was also less effective in reducing BP in black individuals compared with the CCB.
There were no outcome studies meeting the eligibility criteria that compared diuretics or CCBs vs β-blockers, ARBs, or other renin-angiotensin system inhibitors in black persons.
Outcomes for the comparison between initial use of a CCB compared to initial use of an ACEI in black persons with diabetes were not reported in any of the studies eligible for review. Therefore, the evidence was extrapolated from findings in the black participants in ALLHAT, 46% of whom had diabetes.

15. 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 CKD patients with hypertension regardless of race or diabetes status. Moderate Recommendation – Grade B
This recommendation is based primarily on kidney outcomes because there is less evidence favoring ACEI or ARB for cardiovascular outcomes in patients with CKD.
Neither ACEIs or ARBs improved cardiovascular outcomes for CKD patients compared with a β-blocker or CCB.
In black patients with CKD and proteinuria, an ACEI or ARB is recommended as initial therapy because of the higher likelihood of progression to ESRD.

16. Recommendation 9
The main objective of 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.
The clinician should continue to assess BP and adjust the treatment regimen until the goal BP is reached.
If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided in recommendation 6.
If goal BP cannot be reached using on 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

18. Figure continued on following slide.

20. Sources
James PA, Oparil S, Carter BL, et al 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): doi: /jama

21. Question #1
A 43 yo M is evaluated during a routine physical examination. He has no current symptoms and no PMH. FH is notable for DM and HTN in 2 1st degree relatives. He takes no meds.
On physical exam, initial BP is 144/86; repeat measurement after 5 minutes of rest are 136/86 and 134/88. BMI is 32. The remainder of the exam is normal.
Labs show normal Cr and plasma glucose levels.

22. In addition to lifestyle modifications, which of the following is the most appropriate next step in the management of this patient’s blood pressure?
A: Initiate a low dose ACE inhibitor B: Initiate low dose chlorthalidone C: Order ambulatory BP monitoring D: Recheck blood pressure in 1 year

23. In addition to lifestyle modifications, which of the following is the most appropriate next step in the management of this patient’s blood pressure?
A: Initiate a low dose ACE inhibitor B: Initiate low dose chlorthalidone C: Order ambulatory BP monitoring D: Recheck blood pressure in 1 year

24. Answer
Although JNC 8 did not address pre-hypertension, JNC 7 defined it as SBP or DBP in the absence of pre existing disease
Lifestyle modifications:
Low salt diet, DASH diet, exercise regimen
Follow-up: annual visits.
Answer A &B: although there is increased risk of stroke, CV dx, and development of HTN, ACE inhibitor has not been shown to reduce the risk.
Answer C: Ambulatory BP monitoring records BP periodically during normal activities. Indicated for “white-coat” HTN, masked HTN, or confirm poor response to antihypertensive medications.

25. Question 89
A 57 yo African American M is evaluated for treatment of newly diagnosed HTN. History is notable for HLD, which is treated with moderate-dose simvastatin. On exam, BP 151/94, HR 72, BMI 28. Remainder of exam is unremarkable. Labs show Cr 1.0, fasting glucose 104, and K A urine dipstick demonstrates no blood or protein.

26. In addition to recommending lifestyle modifications, which of the following is the most appropriate initial anti-hypertensive therapy for this patient?
A: Amlodipine B: Diltiazem C: HCTZ D: Lisinopril

27. In addition to recommending lifestyle modifications, which of the following is the most appropriate initial anti-hypertensive therapy for this patient?
A: Amlodipine B: Diltiazem C: HCTZ D: Lisinopril

28. Answer:
Patient is African American with stage 1 HTN. Thiazide diuretics and CCB alone or in combo are recommended by JNC 8.
Patient is on moderate dose statin that uses CYP3A4 pathway which can be inhibited by CCB and can cause increased statin myopathy, so thiazide diuretic would be more appropriate.
REMEMBER: African Americans have less BP response to renin- angiotensin system agents despite similar plasma renin activity.
ACE inhibitor is not indicated

29. Question 98
A 60 yo woman is evaluated during a follow-up visit for HTN. History is also notable for HLD. She tolerates her medications well except for minor pedal edema since starting her anti-hypertensive medication. She is active and plays tennis 3x/wk. Current medications are amlodipine 5mg/d and rosuvastatin. On exam, the average of 2 BP readings is 152/86 which is consistent with measurements she has obtained at home for 3 months. HR 64, BMI 22. Trace pedal edema is noted. Labs show normal chemistry panel and urine dipstick shows no protein.

30. Which of the following is the most appropriate next step in management?
A: Add Lisinopril B: Add metoprolol C: Increase amlodipine to 10mg/d D: Continue current regimen

31. Which of the following is the most appropriate next step in management?
A: Add Lisinopril B: Add metoprolol C: Increase amlodipine to 10mg/d D: Continue current regimen

32. Answer
Patient has stage 1 hypertension and JNC 8 recommends BP goal <150/90 for patients >60 yo.
She has no evidence of CV or kidney dx and is not frail and has a longer expected lifetime than the general population of this age, cautious stepped care for lower blood pressure goals is reasonable.
Increasing dose of 1 agent is less effective in reducing BP then addition of 2nd agent at low dose, also avoids the risk of SIDE EFFECTS
Beta blocker is not indicated for the initial Rx of HTN
ACCOMPLISH trial demonstrated benefit of combo therapy with CCB and ACE inhibitor in reducing cardiovascular events compared to using a thiazide and ACE inhibitor

33. Question 19
A 48 yo woman is evaluated during a follow up visit for newly diagnosed HTN, confirmed by multiple measurements at home and in the office. PMH of HLD for which she is taking atorvastatin. Lifestyle modifications have been recommended. On exam, BP 160/92, HR 64, BMI 32. Remainder of exam unremarkable. Labs show Cr 1.1mg/dL, fasting glucose 114 and K+ 4.0, urine dipstick demonstrates no blood or protein.

34. Which of the following is most likely to be effective in controlling this patient’s HTN?
A: Amlodipine B: Lisinopril C: Losartan D: Lisinopril and amlodipine E: Losartan and lisinopril

35. Which of the following is most likely to be effective in controlling this patient’s HTN?
A: Amlodipine B: Lisinopril C: Losartan D: Lisinopril and amlodipine E: Losartan and lisinopril

36. Answer
Combination therapy with ACE inhibitor and amlodipine is appropriate with stage 2 HTN
Stage 2: SBP > 160 or DBP >100
Single agent is unlikely to control BP who are >20/10mmg Hg above target BP.
Combo of 2 agents at moderate doses is more successful at achieving goal than 1 at maximal dose
Combos supported by JNC 8
Thiazide w/ ACE inhibitor or ARB
CCB w/ ACE inhibitor or ARB
ACCOMPLISH trial demonstrated benefit of combo therapy with CCB and ACE inhibitor in reducing cardiovascular events compared to using a thiazide and ACE inhibitor
ACE and ARB should not be used in combination

37. Question 10
A 51 yo M is evaluated during a follow up visit for management of newly diagnosed hypertension and diabetes. He started a program of lifestyle modifications for his DM, but hasn’t started anti-hypertensive medication. He currently takes no meds. On exam, BP 148/92, HR 76, BMI 33. The remainder of the exam was normal. Labs show Cr 1.5, K+4.2, urine dipstick with no hematuria or proteinuria and spot urine protein-creatinine ratio 50mg/g

38. Which of the following is the most appropriate anti-hypertensive treatment for this patient?
A: HCTZ B: Lisinopril C: Lisinopril and amlodipine D: Lisinopril and HCTZ E: Lisinopril and losartan

39. Which of the following is the most appropriate anti-hypertensive treatment for this patient?
A: HCTZ B: Lisinopril C: Lisinopril and amlodipine D: Lisinopril and HCTZ E: Lisinopril and losartan

40. Answer: Patient has Stage 1 HTN, DM, and CKD.
Regardless of DM status, ACEi/ARB have protective effect on kidney and is recommended by JNC8 with goal <140/90
Recommendations for more aggressive BP goals <130/80 in this population have ben tempered by the lack of efficacy in reducing mortality and increase adverse events.