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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 Laf

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

Why Do We Treat Hypertension?


Hypertension can lead to:

Myocardial infarction
Stroke
Renal failure
Death

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)

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
Thiazide-type diuretic

Chronic kidney disease (regardless of race or diabetes status)


ACEI or ARB as initial or add-on antihypertensive therapy

Strength of Recommendation

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

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

Recommendation 2
In the general population <60 years, initiate treatment at
DBP 90 and treat to a goal DBP <90.
For ages 30-59 years, Strong Recommendation Grade A
For ages 18-29 years, Expert Opinion Grade E

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

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.

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

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.

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.

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

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

Figure continued on following

Sources
James PA, Oparil S, Carter BL, et al. 2014 EvidenceBased 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.
doi:10.1001/jama.2013.284427.

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.

In addition to lifestyle modifcations, which of the


following is the most appropriate next step in the
management of this patients 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

In addition to lifestyle modifcations, which of the


following is the most appropriate next step in the
management of this patients 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

Answer
Although JNC 8 did not address pre-hypertension, JNC 7
defned it as SBP 120-139 or DBP 80-89 in the absence of pre
existing disease
Lifestyle modifcations:
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 confrm poor response to antihypertensive medications.

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+ 4.5. A
urine dipstick demonstrates no blood or protein.

In addition to recommending lifestyle modifcations,


which of the following is the most appropriate initial antihypertensive therapy for this patient?

A: Amlodipine
B: Diltiazem
C: HCTZ
D: Lisinopril

In addition to recommending lifestyle modifcations,


which of the following is the most appropriate initial antihypertensive therapy for this patient?

A: Amlodipine
B: Diltiazem
C: HCTZ
D: Lisinopril

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.

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.

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

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

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 beneft of combo therapy with CCB
and ACE inhibitor in reducing cardiovascular events compared to
using a thiazide and ACE inhibitor

Question 19
A 48 yo woman is evaluated during a follow up visit for
newly diagnosed HTN, confrmed by multiple measurements
at home and in the office. PMH of HLD for which she is
taking atorvastatin. Lifestyle modifcations 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,

Which of the following is most likely


to be effective in controlling this
patients HTN?
A: Amlodipine
B: Lisinopril
C: Losartan
D: Lisinopril and amlodipine
E: Losartan and lisinopril

Which of the following is most likely


to be effective in controlling this
patients HTN?
A: Amlodipine
B: Lisinopril
C: Losartan
D: Lisinopril and amlodipine
E: Losartan and lisinopril

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 beneft 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

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 modifcations for his DM, but hasnt 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

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

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

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.