2014 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)
dr Nahar Taufiq, Sp.JP (K)

Disclosures
No disclosures

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

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 microalbumin is mildly elevated.

Case Question 1
What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.

<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg

Case Question 2
What is the drug of choice to start?
1.
2.
3.
4.
5.
6.

HCTZ
Amlodipin
Lisinopril
Losartan
Candesartan
Combination therapy

Prevalensi Hipertensi

prevalence of hypertension (%)

SBP > 140 mm Hg

DBP > 90 mm Hg
70

64

60

54

50

44

40
30
20

65

21
4

11

10
0
age (yrs)
18-29

30-39 40-49 50-59 60-69 70-79

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

80+

Hypertension complication
Eyes
retinopathy

Kidneys
renal failure

Brain
stroke

Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure

Peripheral arterial disease

Target Organ damage!!

Damages depend on:

How high of the blood

pressures

How long the uncontrolled and

untreated high blood presure

Blood Pressure Reduction of 2 mmHg

Reduces The Risk of CV Events by 710%
Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
2 mmHg
decrease in
mean SBP

7% reduction in risk
of ischaemic heart
disease mortality
10% reduction in
risk of stroke
mortality

Lewington et al. Lancet 2002;360:190313

E
NIC

NHL
BI

ES
C

JN
C

A
D
A

A
H
A
C
/A
C

HYPERTENSION
GUIDELINES

H
S
J

N
T
H nad
Ca a

ASH/
ISH
IS
B HI

NKF

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

JNC-7 Blood Pressure Classification

Blood Pressure
Classification

Systolic blood
pressure
(mm Hg)

Diastolic blood
pressure
(mm Hg)

< 120

< 80

Pre-hypertension

120-139

80-89

Stage 1 hypertension

140-159

90-99

Stage 2 hypertension

> 160

> 100

Normal

JNC 8: Hypertension Management

Questions Guiding Review
In adults with HTN:
1. Does initiating antihypertensive pharmacologic
therapy at specific BP thresholds improve health
outcomes?
[When to start therapy?]

2. Does treatment with antihypertensive pharmacologic

therapy to a specified goal lead to improvements in
health outcomes?
[How low should I go?]

3. Do various antihypertensive drugs or drug classes

differ in comparative benefits and harms on specific
health outcomes?
[What drug do I use?]

JNC 8: Hypertension Management

Evidence Review
Limited to RCTs
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 RCTs published
after December 2009

JNC 8: Hypertension Management

Evidence Review
RCTs December 2009 August 2013
1. Major study in hypertension

ACCORD, NEJM 2010

2. > 2,000 participants

3. Multicentered
4. Met all other inclusion/exclusion criteria

The Process
Literature review 1/1/1966
12/31/2009

Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4)Kriteria inklusi/eksklusi.

9
Recommenda
tions

A
B
C
D
E
N

JNC 8: Drug Treatment

Thresholds 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

JNC 8: Drug Treatment

Thresholds 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 1839

JNC 8: Drug Treatment

Thresholds 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

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

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

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

2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for most
Patients at lowmoderate CV risk
Patients with diabetes
Consider with previous stroke or TIA
Consider with CHD
Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly

Ages <80 years
Initial SBP 160 mmHg

140-150 mmHg

SBP goal for fit elderly

Aged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP

160 mmHg

140-150 mmHg

DBP goal for most

<90 mmHg

DB goal for patients with diabetes

<85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
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BP goal in the elderly

2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations
Mandatory: initiate drug treatment in patients
with SBP 160 mmHg

Additonal considerations
Strongly recommended: start drug treatment
when SBP 140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes

RAS blockers may be preferred

Especially in presence of preoteinuria or
microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not
recommended

Avoid in patients with diabetes

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
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2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with nephropathy

Recommendations

Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria

Monitor changes in eGFR

RAS blockers more effective to reduce

albuminuria than other agents

Indicated in presence of microalbuminuria or

overt proteinuria

Combination therapy usually required to reach

BP goals

Combine RAS blockers with other agents

Combination of two RAS blockers

Not recommended

Aldosterone antagonist not recommended in

CKD

Especially in combination with a RAS blocker

Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, reninangiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
Powered by
the World

What is the goal BP?

Comparison of Recent
Guideline Statements
JNC 8

ESH/ESC

AHA/ACC

ASH/ISH

>140/90

>140/90 <80 yr
>150/90 >80 yr

>140/90
Threshold
for Drug Rx

>140/90 < 60 yr Eldery SBP >160

>150/90 >60 yr Consider SBP
140-150 if <80 yr

B-blocker
First line Rx

No

Yes

No

No

Initiate Therapy
w/ 2 drugs

>160/100

"Markedly
elevated BP"

>160/100

>160/100

Goal BP
Group

BP Goal (mm Hg)

General
DM*

CKD**

JNC 8:

<60 yr: <140/90

>60 yr: <150/90

< 140/90

< 140/90

ESH/ESC:

< 140/90

< 140/85

< 140/90

Elderly

140-150/90
(<80 yr: SBP<140)

ASH/ISH

< 140/90
>80 yr: <150/90

AHA/ACC

< 140/90

*ADA: < 140/80 or lower

(SBP < 130 if proteinuria)

< 140/90

< 140/90

(Consider < 130/80 if proteinuria)

< 140/90

< 140/90

**KDIGO: <140/90 w/o albuminuria

<130/80 if >30 mg/24hr

2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake

Restrict 5-6 g/day

Moderate alcohol intake

Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal

25 kg/m2

Waist circumference goal

Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals

30 min/day, 5-7 days/week

(moderate, dynamic exercise)
Quit smoking

* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
Powered by
the World

Development of JNC-8
3 critical questions for adults with hypertension
Does initiating antihypertensive pharmacologic
therapy at specific blood pressure thresholds
improve health outcomes? [When to start therapy?]
Does treatment with antihypertensive
pharmacologic therapy to a specified blood pressure
goal lead to improvements in health outcomes?
[How low should I go?]
Do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on specific
health outcomes? [What drug do I use?]
James PA et al. JAMA 2014;311:507-20.

JNC-8 Recommendations
In patients >60 years of age, start medications
at blood pressure of >150/90mm Hg and treat to
goal of <150/90mm Hg
In patients >60 years of age, treatment does not
need to be adjusted if achieved blood pressure
is lower than goal and well-tolerated
James PA et al. JAMA 2014;311:507-20.

Hypertension in the Elderly

Fastest growing segment of the population
Prevalence of hypertension is very high
Several issues make managing HTN unique:
Often present with isolated systolic HTN
More likely to present with comorbidities
Many clinical trials in HTN have excluded these
patients (particularly for those 80 years and older)
Elderly are more susceptible to certain adverse
effects (orthostatic hypotension)

JNC-8 Recommendations
In patients <60 years of age, start medications
at blood pressure of >140/90mm Hg and treat to
goal of <140/90mm Hg
In all adult patients with diabetes or chronic
kidney disease, start medications at blood
pressure of >140/90mm Hg and treat to goal of
<140/90mm Hg
James PA et al. JAMA 2014;311:507-20.

JNC-8 Recommendations
For the non-black population (including
diabetes), initial antihypertensive treatment
may include a thiazide, ACEI, ARB, or CCB
For the black population (including diabetes),
initial antihypertensive treatment should
include a thiazide or CCB
For all patients with CKD, initial (or add-on)
therapy for hypertension should include an
ACEI or ARB
James PA et al. JAMA 2014;311:507-20.

JNC-8 Recommendations
Initiate therapy according to recommendations
If BP is not at goal in one month, increase dose or
add a second agent from recommended classes
If patient is still not at goal, add a third drug from
recommended classes
Do not use an ACEI and ARB together

Drugs from other classes may be used if additional

BP lowering is needed or if contraindications exist
Refer to HTN specialist whenever necessary
James PA et al. JAMA 2014;311:507-20.

Comparisons to Other Guidelines

BP Goal

JNC-7

JNC-8

ASH/ISH ESC/ES
H

CHEP

Age < 60 <140/90

<140/90

<140/90

<140/90

<140/90

Age 6079

<140/90

<150/90

<140/90

<140/90

<140/90

Age 80+

<140/90

<150/90

<150/90

<150/90

<150/90

Diabetes <130/80

<140/90

<140/90

<140/85

<130/80

CKD

<140/90

<140/90

<130/90

<140/90

<130/80

Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

Lifestyle Modification

JNC 8

JNC
7

Guideline Population Goal BP

2014 HT General 60 y
Guideline

ESH/ESC

General <60 y
DM

<140/90
<140/90

CKD

<140/90

CHEP

<150/90

General (non
elderly)
General elderly
<80 y
General 80 y
DM
CKD (no
proteinemia)
CKD +
proteinemia

<140/90

Initial drugs
Non Black: thiazide type diuretic,
ACEI, ARB or ARB
Black: thiazide type-diuretic or CCB
Thiazide type diuretic, ACEI, ARB or
CCB
ACEI or ARB
Bocker, diuretic, CCB, ACEI, ARB

<150/90
<150/90
<140/85
<140/90

ACEI or ARB
ACEI or ARB

<130/90

General <80 y

<140/90

General >80 y
DM

<150/90
<130/80

CKD

<140/90

Thiazide, Blocker (<60y), ACEI (nonblack) or

ARB
Add CVD risk: ACEI or ARB
No CVD risk: ACEI/ARB/Thiazide/DHPCCB
ACEI or ARB

Guideline

Population

Goal BP

Initial drugs

ADA

DM

<140/80

ACEI or ARB

KDIGO

140/90

ACEI or ARB

DM and CKD alb

exc <30 mg/d
DM and CKD
alb exc >30
mg/d

130/80

NICE

General <80 y
General 80 y

<140/90
<150/90

<55 y; ACEI or ARB

55 y or black; CCB

ISHIB

Black, lower risk

TOD or CVD risk

<135/85
<130/80

Diuretic or CCB

JNC 7

General
CKD
DM

<140/90
<130/80
<130/80

ACEI or ARB

* thank you

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)

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