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Blood Pressure JNC 8

posted Jan 29, 2014, 10:03 AM by Ewa Rakowski   [ updated Jan 30, 2014, 8:20 AM ]

A Monte Minute brought to you by RAT resident Christina Cruz:

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: JNC 8

GoalThis report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults

Evidence Review: The evidence review was limited to randomized control trials (RCTs).  Eligible RCTs were those with sample size >100, and follow-up >1 year.  Reported outcomes related to effect on mortality (overall, CVD-related and CKD-related), cardiovascular and renal disease. Initial search dates for the literature review were January 1, 1966, through December 31, 2009.  Two additional independent searches were done between December 2009 and August 2013.  Ultimately, no additional trials met the inclusion criteria (which were different from initial search) for the second search. The panel attempted to achieve 100% consensus whenever possible, but a two-thirds majority was considered acceptable, with the exception of recommendations based on expert opinion, which required a 75% majority agreement for approval.

Questions Guiding Evidence Review:

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

 

The Recommendations:

Recommendation

Reasoning

Recommendation 1

In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.

(Strong Recommendation – Grade A)

 

Corollary Recommendation

In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.

(Expert Opinion – Grade E)

Evidence supports treating BP to a goal <150/90mmHg in this age group, given its subsequent reduction in stroke, heart failure and coronary heart disease.  There was not sufficient evidence to support an SBP goal <140mmHg.

 

Interestingly, the panel made it a point to explicitly state that this decision was not unanimous.  Some members recommended maintaining the previous JNC 7 goal SBP <140 mmHg, stating there was insufficient evidence to raise the goal, especially in high-risk groups.

Recommendation 2

In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg.

(For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E)

High quality evidence demonstrated reduction in cerebrovascular events, heart failure and overall mortality with initiation of antihypertensives for DBP >90 mmHg, with a goal DBP <90 mmHg.  Moreover, the panel found that the evidence did not show additional benefit with DBP goal of 80mmHg or <85mmHg when compared with 90mmHg.

Recommendation 3

In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg.

(Expert Opinion – Grade E)

 

The panel found insufficient evidence supporting specific BP goals for persons younger than 60.

Factors influencing this recommendation include:

1. There was no compelling reason to change current recommendations.

2. In those trials that demonstrated benefit of DBP goal of <90, many participants achieved SBP <140, and so it is not possible to determine if outcome benefits were related to DBP, SBP or both.

3. Given the recommended SBP goal of lower than 140 mm Hg in adults with diabetes or CKD (recommendations 4 and 5), a similar SBP goal for the general population younger than 60 years may facilitate guideline implementation.

Recommendation 4

In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg.

(Expert Opinion – Grade E)

 

This recommendation applies to individuals younger than 70 years with an estimated GFR or measured GFR less than 60 mL/min/1.73 m2 and in people of any age with albuminuria defined as greater than 30 mg of albumin/g of creatinine at any level of GFR.

Of the three trials that met the inclusion criteria, change in GFR and progression to ESRD were primarily addressed with only one trial addressing cardiovascular disease outcomes. None of the trials showed that treatment to a lower BP goal (for example, <130/80 mm Hg) significantly lowered kidney or cardiovascular disease end points compared with a goal of lower than 140/90 mm Hg.

Recommendation 5

In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg.

(Expert Opinion – Grade E)

 

There is moderate quality evidence that treatment goal of SBP <150 improves cardiovascular, cerebrovascular and mortality outcomes, in adults with hypertension and diabetes. No RCTs addressed whether treatment to an SBP goal of lower than 140 mm Hg compared with a higher goal (for example, <150mmHg) improves health

outcomes in adults with diabetes and hypertension.

The panel also recognizes that an SBP goal of lower than 130 mm Hg is commonly recommended for adults with diabetes and hypertension. However, this lower SBP goal is not supported by any RCT that randomized participants into 2 or more groups in which treatment was initiated at a lower SBP threshold than 140 mm Hg or into treatment groups in which the SBP goal was lower than 140 mm Hg and that assessed the effects of a lower SBP threshold or goal on important health outcomes, except for ACCORD-BP which compared SBP <120mmHG with goal <140mmHg and ultimately found no difference in the primary outcome.

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)

 

These four recommended drug classes had comparable effects on overall mortality, cardiovascular, cerebrovascular and renal outcomes.  However, improvements in heart failure outcomes differed, with thiazide diuretics being more effective than ACEi and CCBs, and ACEi more effective than CCB. While the panel recognized that improved heart failure out- comes was an important finding that should be considered when selecting a drug for initial therapy for hypertension, 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.

This recommendation applies to those with diabetes because trials including participants with diabetes showed no differences in major cardiovascular or cerebrovascular outcomes from those in the general population

The panel did not recommend ß-blockers or α-blockers for initial therapy of hypertension because each was shown to worsen cardiovascular or cerebrovascular outcomes.

 

Of note, the panel suggests that any of these four categories are good choices as add-on agents.

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)

 

There are some cases for which the results for black persons were different from the results for the general population.  Most of the evidence supporting this recommendation stems for ALLHAT. In that study, a thiazide-type diuretic was shown to be more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes when compared to an ACEI in the black patient subgroup, which included large numbers of diabetic and nondiabetic participants. CCB was less effective than a diuretic in preventing heart failure in the black subgroup of this trial, but there were no differences in cardiovascular, cerebrovascular, coronary heart disease, renal and overall mortality outcomes.  Therefore both are recommended as first line therapy for hypertension in black patients.

The recommendation for black patients with diabetes is weaker than the recommendation for the general black population.

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 applies to CKD patients with and without proteinuria, as studies using ACEIs or ARBs showed evidence of improved kidney outcomes in both groups.

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 nor ARBs improved cardiovascular outcomes for CKD patients when compared with a β-blocker or CCB.

 

The panel noted the potential conflict between this recommendation to use an ACEI or ARB in those with CKD and hypertension and the recommendation to use a diuretic or CCB (recommendation 7) in black persons: what if the person is black and has CKD? To answer this, the panel relied on expert opinion. 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. In black patients with CKD but without proteinuria, the choice for initial therapy is less clear and includes a thiazide-type diuretic, CCB, ACEI, or ARB. If an ACEI or ARB is not used as the initial drug, then an ACEI or ARB can be added as a second-line drug if necessary to achieve goal BP.

Recommendation 9

The main objective of hypertension 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 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only 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)

This was developed by the panel in response to a perceived need for further guidance to assist in implementation of recommendations 1 through 8.  It differs from the other recommendations be- cause it was not developed in response to the 3 critical questions using a systematic review of the literature. The Figure (see below) is an algorithm summarizing the recommendations. However, this algorithm has not been validated with respect to achieving improved patient outcomes.

 

Of note, for all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. These lifestyle treatments have the potential to improve BP control and even reduce medication needs. Although the authors of this hypertension guideline did not conduct an evidence review of lifestyle treatments in patients taking and not taking antihypertensive medication, we support the recommendations of the 2013 Lifestyle Work Group.


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Ewa Rakowski,
Jan 30, 2014, 8:19 AM
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