RECENT HYPERTENSION GUIDELINES

WHAT’S NEW FROM JNC-8 AND OTHER CONCENSUS

Rochmad Romdoni
M. Rafdi Amadis
 HYPERTENSION

• The most prevalent condition seen in primary care

• Global: 1.39 B (31.2%)
• Indonesia: 26,5% (Riskesdas 2013)
• Leading preventable cause of premature death and disability worldwide
• Treatment and control of hypertension are critically important for the prevention
of consequent cardiovascular and kidney diseases
HYPERTENSION GUIDELINES
CLARITY vs CONFUSION
 Joint National Comittee 8
• Limited its evidence review to RCT
• Focused on 3 questions
1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds
improve outcomes? (When to start therapy?)
2. In adults with hypertension, does treatment with antihypertensive therapy to a specified BP goal lead to
improvements in health outcomes? (How low should I go?)
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and
harms on specific health outcomes? (What drug should I use?)
 JNC-7 versus JNC-8
Topic JNC-7 JNC-8
Methodology Non systematic review, range Critical questions, restricted to
of study designs RCT
Definition Defined Not addressed
Treatment goals Uncomplicated < 140/90 Elderly <150/90
DM & CKD <130/80 DM & CKD <140/90
Initial Drug Therapy Thiazide, ACEI, ARB, CCB, BB Thiazide, ACEI, ARB, CCB
Scope of topics Multiple issues Limited number of questions
 1. JNC-8 Controversies: Increased Treatment Threshold
• Most controversial
• Five members (of 14) of JNC-8 voted against this recommendation
• Cochrane Review (2009): insufficient evidence to support initiation of therapy <150/90 in
elderly
• SHEP (1991) and HYVET (2008) trial: reducing SBP to <140 in elderly provided substantial
benefit without unnecessary risks
• SPRINT (2015): intensive vs standard therapy, 25% decrease of CV outcomes, 27% decrease
in all-cause mortality
 2. JNC-8 Controversies: Removal of β-blocker as the First-line

• Metaanalysis (Messerli et al, 1998; Lindholm et al, 2005) : increased the risk of
stroke and decreased efficacy in elderly?
• Other metaanalysis (Ettehad et al, 2016) : <60 y.o, β-blocker decreased stroke
and mortality risk
• Many analyses used atenolol  β-blocker is not a class effect
What do other guidelines say?
 Controversies about Diagnosis of Hypertension
• Office blood pressure measurement
• Standardized method, calibrated device, both arms, >1x
• The worst method for diagnosing and monitoring in clinic
• Important role of ABPM and HBPM (home blood pressure monitoring)
• NICE & NHF: suspected hypertension should be confirmed by 24h ABPM
• Identification of WCH (white coat hypertension) and masked hypertension
 Controversies about Target Therapy
• Different target between guidelines
• JNC-8 controversial : increase in BP target for elderly
• More controversy after SPRINT publication : intensive (SBP <120
mmHg) vs standard (SBP <140 mmHg) therapy
 SPRINT Primary Outcome Cumulative Hazard

MI,
ACS,
stroke, 319 events
HF, CV
death
243 events Decreased
25%
Median follow up 3.26 years Year
 All Cause Mortality: Cumulative Hazard

All cause
mortality
210 events 155 events

Decreased 27%
Median follow up 3.26 years

Year
 SPRINT Primary Outcome and its Components
Event Rates and Hazard Ratios
Intensive Standard
No. of Rate, No. of Rate, HR (95% CI) P value
Events %/year Events %/year
Primary Outcome 243 1.65 319 2.19 0.75 (0.64, 0.89) <0.001
All MI 97 0.65 116 0.78 0.83 (0.64, 1.09) 0.19
Non-MI ACS 40 0.27 40 0.27 1.00 (0.64, 1.55) 0.99
All Stroke 62 0.41 70 0.47 0.89 (0.63, 1.25) 0.50
All HF 62 0.41 100 0.67 0.62 (0.45, 0.84) 0.002
CVD Death 37 0.25 65 0.43 0.57 (0.38, 0.85) 0.005
 SPRINT Impact

• SPRINT was published in 2015

• Guidelines published ≤ 2015 has not include SPRINT result yet
• NHF of Australia (2016) and Hypertension Canada (2017) has already made
specific recommendation regarding the SPRINT result
• Remember of the side effects: Hypotension, syncope, electrolyte abnormality, AKI
 Blood Pressure Target: Summary
Populasi NICE (2011) ESH/ESC (2013) JNC-8 (2014) ASH/ISH (2015) NHF of Australia Hypertension Canada (2017)
(2016)
< 140/90 < 140/90 <140/90 <140/90 <140/90 <140/90
General SBP <120 high TDS <120 high cardiovascular risk
cardiovascular risk population >50 y.o
population >50 y.o
< 150/90 (age ≥ 80 Age > 80 yo: SBP 140 – 150 Age ≥ 60 y.o: 150/90 < 150/90 (age ≥ 80 <140/90 <140/90
Eldery y.o) Age < 80 yo, fit condition: SBP < y.o) SBP <120 high TDS <120 high cardiovascular risk
140 cardiovascular risk population >50 y.o
Frail: clinician discretion population >50 y.o

Not addressed < 140/85 <140/90 <140/90 <140/90 <130/80

Diabetes
Not addressed SBP < 140 <140/90 <140/90 <140/90 <140/90
CKD SBP < 130 if proteinuria <130/80 if SBP <120 if tolerated
proteinuria
 Choice of Drug: Summary
Populasi NICE (2011) ESH/ESC (2013) JNC-8 (2014) ASH/ISH (2015) NHF of Australia Hypertension Canada
(2016) (2017)
General <55 y.o: ACEI, ARB Thiazide, CCB, ACEI, ARB, BB Thiazide, CCB, ACEI, ACEI, ARB Thiazide, CCB, ACEI, ARB Thiazide, CCB, ACEI, ARB, BB
ARB
Elderly >55 y.o: CCB, Thiazide-like Diuretics, CCB ~ general population >60 y.o: CCB, Thiazide, CCB, ACEI, ARB Isolated systolic
diuretics (Chlortalidone, Thiazide hypertension:
indapamide) CCB, Thiazide, ARB

Black CCB, Thiazide-like diuretics Not addressed Thiazide, CCB Thiazide, CCB Not addressed First line agent other than
(Chlortalidone, indapamide) ACEI

Diabetes Not addressed All class ~ general population ARB, ACEI, in black Thiazide, CCB, ACEI, ARB Thiazide, CCB, ACEI, ARB
If proteinuria: ACEI/ARB patients, it is If proteinuria or there is
acceptable to start other cardiovascular risk
with a CCB or factor: ACEI/ARB
thiazide
CKD Not addressed If proteinuria: ACEI/ARB ACEI, ARB ACEI, ARB Thiazide, CCB, ACEI, ARB ACEI, ARB
If proteinuria: ACEI/ARB
 Conclusion
• Hypertension is most prevalent condition managed in primary care
• JNC-8 published in early 2014 results in numerous controversy
• Results from SPRINT study for the first time suggest that a lower-than-140/90
mmHg target is associated with further reduction in mortality (in selected
patient)
• It is important to remember that guidelines should not be a substitute for good
clinical judgment
THANK YOU
Major Inclusion Criteria Exclusion Criteria
• ≥50 years old • Stroke
• Systolic blood pressure : 130 – 180 mm Hg • Diabetes mellitus
(treated or untreated) • Polycystic kidney disease
• Additional cardiovascular disease (CVD) risk (at • Congestive heart failure (symptoms or
EF < 35%)
least one) • Proteinuria >1g/d
• Clinical or subclinical CVD (excluding stroke)
• Chronic kidney disease (CKD), defined as eGFR 20 – <60
• CKD with eGFR < 20 mL/min/1.73m 2

ml/min/1.73m 2 (MDRD)
• Framingham Risk Score for 10-year CVD risk ≥ 15% • Adherence concerns
• Age ≥ 75 years
 Clinical Indications Defining High-Risk Patients as
Candidates for Intensive Management
(Hypertension Canada 2017)

• Clinical or subclinical cardiovascular disease

• CKD (non diabetic nephropathy, proteinuria <1 g/d, eGFR 20 –
59 mL/min/1.73 m ) 2

• Estimated 10-year global cardiovascular risk ≥ 15%

• Age 75 years or older
 Generalizability of Intensive Blood Pressure-Lowering:
Caution and Contraindication
• Limited or no evidence • Inconclusive evidence • Contraindication
• HF (EF <35%) or recent MI (within past • DM • Patient unwilling or unable to
3 months) • Previous stroke adhere to multiple medication
• Indication for, but not currently receiving • eGFR <20 mL/min/1.73 m2 • Standing SBP <110 mmHg
beta blocker • Inability to measure SBP
• Institutionalized elderly patient accurately
• Known secondary cause(s) of
hypertension