JNC 8

JNC-8 New Guidelines…Finally
Let the controversies begin
Eric D Peterson, MD, MPH

Director of DCRI
Feb, 2014
http://www.dcri.duke.edu/research/coi.jsp
• Affects 1 billion people worldwide
• US – about 1 in 3 adults
– 73 million have hypertension (SBP >140/90)
• A 55yo normotensive person has up to a 90% lifetime
risk of developing hypertension (Vasan 2001)
• Number one reason listed for office visits
• Causes/contributes to 457,000 admissions per year
• A leading cause/contributor to death (MI, stroke,
vascular disease)
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2
How Aggressive to Treat Hypertension
Some Early Views on the Controversy
• “The greatest danger to a man with high blood pressure

lies in its discovery, because then some fool is certain to
try and reduce it.”- J.H. Hay, 1931.
• “Hypertension may be an important compensatory

mechanism which should not be tampered with, even
were it certain that we could control it.” Paul Dudley
White, 1937.
Stroke and IHD Mortality vs Systolic BP by Age
Age at risk Age at risk:
256 80-89 years 80-89 years
(Floating absolute risk and 95% CI)
256
128 70-79 years 70-79 years
128
64 60-69 years 64 60-69 years
32 32
50-59 years 50-59 years
Mortality
16 16
40-49 years
8 8
4 4
2 2
1 1
Stroke Ischemic Heart Disease
0 0
120 140 160 180 120 140 160 180
Usual Systolic BP (mm Hg) Usual Systolic BP (mm Hg)
Lancet. 2002;360:1903-1913
BP Reductions as Small as 2 mmHg Reduce
the Risk of CV Events by Up to 10%
▶ Meta-analysis of 61 prospective, observational studies

▶ 1 million adults
▶ 12.7 million person-years
7% increase in
risk of ischemic
heart disease
2 mmHg
mortality
increase in
mean SBP
10% increase in
risk of stroke
mortality
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913

Benefits of Treating Hypertension: RCT
0
Risk reduction (%)
-10
-20
-30
-40
-50 ↓ 20%
-60
-70 ↓ 40%
-80 ↓ 50%
-90
-100
Heart failure Stroke Cardiovascular
death
Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996
Lifestyle Modifications
Goal blood pressure <140/90 mm Hg

<130/80 mm Hg with diabetes or chronic kidney disease*
Initial drug choices
Without Compelling indications With compelling indications
Stage 1 Hypertension Stage 2 hypertension Drug(s) for compelling

(SBP 140-159 DBP 90-99 ) (SBP ≥ 160 or DBP ≥ 100) indications
Diuretics for most; may Diuretics, ACE inhibitor,

consider ACE inhibitor, 2-drug combination for
most (Diuretic +ACE, ARB, ARB, beta blocker, CCB as
ARB, beta blocker, CCB or needed
combination beta blocker, or CCB)
* Released in 2003
JNC-8 Significantly NHLBI Drops Out of
Delayed Guidelines Business
James et al JAMA December 13 2014
JNC-8 Hypertension Treatment Choices

The Evidence for Targets: JATOS Study
• 2200 pts per arm
• Baseline BP 170/90
• Target
<150 mild vs. <140 strict
• Drugs:
– Ca++blocker 50-60%
– Ace 30-40%
– Alpha blocker 15%
– Diuretic 15%
• Follow-up 2 yrs
Hypertens Res. 2008;31(12):2115-2127

JATOS Results
Hypertens Res. 2008;31(12):2115-2127

The Evidence for Targets: VALISH Trial
• 1630 pts per arm

• Baseline BP 170/80
• Target
Mild <150, strict <140
• Drugs:
– Valsartan 100%
– Ca++ blacker 30%
– Diuretic 10-15%
• Median Follow-up 3 yrs
Hypertension. 2010;56(2):196-202
VALISH Trial
Hypertension. 2010;56(2):196-202
RCTs Evaluating SBP Targets
in those Aged < 60
“Does the absence of evidence lead to

the conclusion of evidence of absence?”
JNC-8 authors concluded:

- Yes for those >60
- No for those <60
Guidelines, Performance Measures and Policy
• Guideline:
– In past: practical advice on a course of action
– Have become: RCT-based, rigorous
• Performance Measures:
– Distillation of guidelines:
• Use strict criteria to define what should and must
be done to avoid a quality concern
– Often applied to public reporting or financial
incentives
BP Treatment Targets Have Risks Both Ways
• If one votes to keep all at 140/90

– PM’s and incentives may encourage over-treatment
• Worse symptoms, falls, costs in elderly
• If one votes to move to 150/90 in elderly

– Risk of under-treatment
• Despite existing guideline goals/PM’s, <50%
of public reaches goal!
JNC-8 Implications for US
All US Adults Ages 18-59 Ages 60+

JNC 7: HTN 66.6 32.8 33.8
Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%)
JNC 8: HTN 60.8 30.8 30.0
Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)
Major Findings
• Currently: 66.7 million in US have hypertension,

– of which 39.9% met guideline targets.
• Using JNC 8: 60.8 million in US have hypertension,
– of which 56.4% have controlled blood pressure.
• In 60+, switching to JNC-8
– improves BP control rates from 34.3% to 60.8%
– reclassifying 13.6 million with previously
uncontrolled BP now seen as under control
Conclusions
• Hypertension: common, costly and modifiable
• Interpretation of existing evidence is challenging

– Determining the optimal threshold will require
more RCTs.
• In interim: My view:
– Aim for 140/90 but allow for individualization
– What’s your take?

JNC 8

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JNC-8 New Guidelines…Finally

Let the controversies begin

Eric D Peterson, MD, MPH

• “The greatest danger to a man with high blood pressure

• “Hypertension may be an important compensatory

▶ Meta-analysis of 61 prospective, observational studies

Prospective Studies Collaboration. Lancet. 2002;360:1903-1913

Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996

Goal blood pressure <140/90 mm Hg

Initial drug choices

Without Compelling indications With compelling indications

Stage 1 Hypertension Stage 2 hypertension Drug(s) for compelling

Diuretics for most; may Diuretics, ACE inhibitor,

James et al JAMA December 13 2014

Hypertens Res. 2008;31(12):2115-2127

Hypertens Res. 2008;31(12):2115-2127

• 1630 pts per arm

“Does the absence of evidence lead to

JNC-8 authors concluded:

• If one votes to keep all at 140/90

• If one votes to move to 150/90 in elderly

All US Adults Ages 18-59 Ages 60+

• Currently: 66.7 million in US have hypertension,

• Hypertension: common, costly and modifiable

• Interpretation of existing evidence is challenging

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