ModeratorJames A. Underberg, MDClinical Assistant Professor of MedicineNew York University School of MedicineDirector, Bellevue Hospital Lipid ClinicNew York University Center for Prevention of Cardiovascular DiseaseNew York City

Putting the 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults Into Practice

Putting the 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults Into Practice

Panelists Louis Kuritzky, MDClinical Assistant ProfessorUniversity of FloridaGainesville, Florida

Raymond R. Townsend, MDProfessor of MedicinePerelman School of Medicine Philadelphia, Pennsylvania

James PA, et al. JAMA. 2014;311:507-520.[1]

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

Report From the Panel Members Appointed to the JNC 8

Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; Cheryl Dennison-Himmelfarb, RN, ANP, PhD; Joel Handler, MD; Daniel T. Lackland, DrPH; Michael L. LeFevre, MD, MSPH; Thomas D. MacKenzie, MD, MSPH; Olugbenga Ogedegbe, MD, MPH; Sidney C. Smith Jr, MD; Laura P. Svetkey, MD, MHS; Sandra J. Taler, MD; Raymond R. Townsend, MD; Jackson T. Wright Jr, MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH

Questions to the JNC 8 PanelQuestions to the JNC 8 Panel

• At what level should you treat BP?

• To what level should it be treated?

• How do you do that?

Target Audience for JNC 8Target Audience for JNC 8

“Statements and recommendations for [BP]

treatment based on a systematic review of the

literature to meet user needs, especially the

needs of the primary care clinician.”

James PA, et al. JAMA. 2014;311:507-520.[1]

Focus of the RecommendationsFocus of the Recommendations

• Age

• Diabetic

• Black/nonblack

• Chronic kidney disease (CKD)

Age Recommendations, JNC 2014Age Recommendations, JNC 2014

• 18 years old and younger: Not considered

• 30 years old and younger: We have little to no data

• 30 to 59 years old: In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at a DBP of 90 mm Hg and treat to a goal DBP lower than 90 mm Hg. Strong Recommendation: Grade A

• 60 years old: In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at an SBP of 150 mm Hg or higher or a DBP of 90 mm Hg or higher and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. Strong Recommendation: Grade A

• 80 years old: Based on HYVET

James PA, et al. JAMA. 2014;311:507-520.[1]

JNC Panel Recommendation for Patients With Diabetes and Hypertension

JNC Panel Recommendation for Patients With Diabetes and Hypertension

• In the population aged 18 years and older with diabetes, initiate pharmacologic treatment to lower BP at an SBP of 140 mm Hg or a DBP of 90 mm Hg and treat to a goal of SBP lower than 140 mm Hg and goal DBP lower than 90 mm Hg. Expert Opinion: Grade E

James PA, et al. JAMA. 2014;311:507-520.[1]

ACCORD Mean Number of Medications PrescribedACCORD Mean Number of Medications Prescribed

Time, y 1 2 3 4 5 6 7 8

Intensive therapy group 3.2 3.4 3.4 3.5 3.5 3.5 3.4 3.4

Standard therapy group 1.9 2.1 2.1 2.2 2.2 2.3 2.3 2.3

ACCORD Study Group. N Engl J Med. 2010;362:1575-1585.[6]

ACCORD Primary Outcome

Intensive Therapy, % Standard Therapy, %

208 (1.87) 237 (2.09)

JNC Panel Recommendation for Patients With CKDJNC Panel Recommendation for Patients With CKD

• In the population aged 18 years with CKD, initiate pharmacologic treatment to lower BP at an SBP of 140 mm Hg or a DBP of 90 mm Hg and treat to goal of an SBP lower than 140 mm Hg and a goal DBP lower than 90 mm Hg. Expert Opinion: Grade E

James PA, et al. JAMA. 2014;311:507-520.[1]

JNC Recommendation for Nonblack PatientsJNC Recommendation for Nonblack Patients

• In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include – Thiazide-type diuretic

– Calcium channel blocker (CCB)

– Angiotensin-concerting enzyme (ACE) inhibitor

– Angiotensin receptor blocker (ARB)

– Moderate Recommendation: Grade B

James PA, et al. JAMA. 2014;311:507-520.[1]

ALLHATOutcomes in Hypertensive Black Patients Treated With Chlorthalidone, Amlodipine, and Lisinopril

Wright JT, et al. JAMA. 2005;293(13):1595-1608.[17]

6-Year Rate per 100 Persons

Chlorthalidone Amlodipine Lisinopril

Outcome No. Rate (SE) No. Rate (SE) No. Rate (SE)

Total randomized 5369 3213 3210

CHD (nonfatal MI + fatal CHD) 400 9.6 (0.5) 243 9.5 (0.6) 260 10.3 (0.7)

All-cause mortality 821 17.9 (0.6) 481 17.0 (0.8) 520 18.0 (0.8)

Cardiovascular mortality 362 8.1 (0.5) 215 8.4 (0.6) 224 8.4 (0.6)

Combined CHD 655 15.2 (0.6) 407 15.8 (0.8) 444 17.3 (0.8)

Combined CVD 1211 26.8 (0.7) 767 28.4 (1.0) 836 31.1 (1.0)

Stroke 257 6.0 (0.4) 145 5.7 (0.5) 212 8.0 (0.6)

End-stage renal disease 93 2.3 (0.3) 65 2.7 (0.4) 71 3.1 (0.4)

Cancer 417 9.4 (0.5) 245 9.8 (0.7) 254 9.9 (0.7)

Hospitalized for gastrointestinal bleeding 282 8.9 (0.5) 169 8.6 (0.7) 209 11.1 (0.8)

JNC Recommendation for Black PatientsJNC Recommendation for Black Patients

• In the general black population, including those with diabetes, initial antihypertensive treatment should include– Thiazide-type diuretic

– CCB

• For the general black population: – Moderate Recommendation: Grade B

• For black patients with diabetes: – Weak Recommendation: Grade C

James PA, et al. JAMA. 2014;311:507-520.[1]

James PA, et al. JAMA. 2014;311:507-520.[1]

Recommendations for Hypertension ManagementRecommendations for Hypertension Management

Recommendation 1: In the general population aged 60 years, initiate pharmacologic treatment to lower BP at systolic BP (SBP)150 mm Hg or diastolic BP (DBP) 90 mm Hg and treat to a goal SBP lower than 150 mm Hg and goal DBP lower than 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)

Recommendation 2: In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at DBP 90 mm Hg and treat to a goal DBP lower than 90 mm Hg. (For ages 30 to 59 years, Strong Recommendation : Grade A; for ages 18 to 29 years, Expert Opinion: Grade E)

Recommendation 3: In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at SBP to 140 mm Hg and treat to a goal SBP lower than 140 mm Hg. (Expert Opinion : Grade E)

Recommendation 4: In the population aged 18 years with CKD, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E)

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 lower than 140 mm Hg and goal DBP lower than 90 mm Hg. (Expert Opinion: Grade E)

James PA, et al. JAMA. 2014;311:507-520.[1]

Recommendation 6: In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, CCB, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation: Grade B)

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)

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 patients with CKD with hypertension regardless of race or diabetes status. (Moderate Recommendation: Grade B)

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 who additional clinical consultation is needed. (Expert Opinion : Grade E)

Recommendations for Hypertension Management (cont)Recommendations for Hypertension Management (cont)

JNC Management Guideline AlgorithmJNC Management Guideline Algorithm

James PA, et al. JAMA. 2014;311:507-520.[1]

Adult aged 18 years and older who have hypertensionImplement lifestyle interventions (continue throughout management)

Set BP goal and initiate BP-lowering medication on the basis of age, diabetes status, and CKDGeneral population (no diabetes or CKD) Diabetes or CKD present

Age ≥ 60 years Age < 60 years All ages/with CKD/ with or without diabetes

All ages/with diabetes/no CKDBP goal

SBP < 150 mm Hg DBP < 90 mm Hg

BP goalSBP < 140 mm Hg DBP < 90 mm Hg

BP goalSBP < 140 mm Hg DBP < 90 mm Hg

BP goalSBP < 140 mm Hg DBP < 90 mm Hg

Nonblack Black All racesInitiate thiazide-type diuretic or ACEI or ARB or CCB, alone or

in combination

Initiate thiazide-type diuretic or CCB, alone or in

combination

Initiate thiazide-type diuretic or CCB, alone or in combination

Select a drug treatment titration strategyA. Maximize first medication before adding second orB. Add second medication before reaching maximum dose of first medication orC. Start with 2 medication classes separately or as fixed-done combination

At goal BP?

No

Reinforce medication and lifestyle adherenceFor strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).For strategy C, titrate doses of initial medications to maximum.

Reinforce medication and lifestyle adherenceAdd and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).

Reinforce medication and lifestyle adherenceAdd additional medication class (eg, beta-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management.

Continue current treatment and monitoring

At goal BP?

At goal BP?

At goal BP?

No

No

Ye

s

Primary Nonfatal MI (including silent) + fatal CHD

SecondaryNonfatal MI (excluding silent) + fatal CHDTotal coronary end pointTotal cardiovascular event and proceduresAll-cause mortalityCardiovascular mortalityFatal and nonfatal strokeFatal and nonfatal heart failure

Tertiary Silent MIUnstable anginaChronic stable anginaPeripheral arterial diseaseLife-threatening arrhythmiasNew-onset diabetes mellitusNew-onset renal impairment

Post hoc Primary end point + coronary revascularization proceduresCV death + MI + stroke

Unadjusted hazard ratio (95% CI)0.90 (0.79-1.02)

0.87 (0.76-1.00)0.87 (0.79-0.96)0.84 (0.78-0.90)0.89 (0.81-0.99)0.76 (0.65-0.90)0.77 (0.66-0.89)0.84 (0.66-1.05)

1.27 (0.80-2.00)0.68 (0.51-0.92)0.98 (0.81-1.19)0.65 (0.52-0.81)1.07 (0.62-1.85)070 (0.63-0.78)0.85 (0.75-0.97)

0.86 (0.77-0.96)0.84 (0.76-0.92)

ASCOT Summary of All End PointsASCOT Summary of All End Points

Dahlöf B. Lancet. 2005;366:895-906.[18]

Amlodipine perindopril better Atenolol thiazide better0.50 0.70 1.00 1.45 2.00

Strategies for Reaching BP GoalStrategies for Reaching BP Goal

James PA, et al. JAMA. 2014;311:507-520.[1]

Start 1 drug, titrate to maximum dose, and then add a second drug

Start 1 drug and then add a second drug before achieving maximum dose of the initial drug

Begin with 2 drugs at the same time either as 2 separate pills or as a single pill combination

AbbreviationsAbbreviations

ACCORD = Action to Control Cardiovascular Risk in Diabetes

ACE = angiotensin-converting enzyme

ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

ARB = angiotensin receptor blockers

ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial

BP = blood pressure

CCB = calcium channel blocker

CHADS = congestive heart failure, hypertension, age, diabetes mellitus, and stroke

CHD = coronary heart disease

CI = confidence interval

CKD = chronic kidney disease

DBP = diastolic blood pressure

HYVET = Hypertension in the Very Elderly Trial

JNC 8 = Eighth Joint National Committee

MI = myocardial infarction

SBP = systolic blood pressure

ReferencesReferences

1. James PA, Oparil S, Carter BL, et al. 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). JAMA. 2014;311:507-520.

2. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.

3. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.

4. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.

5. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.

References (cont)References (cont)

6. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.

7. Hebert LA, Kusek JW, Greene T, et al. Effects of blood pressure control on progressive renal disease in blacks and whites. Modification of Diet in Renal Disease Study Group. Hypertension. 1997;30(3 Pt 1):428-435.

8. Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421-2431.

9. Ruggenenti P, Perna A, Loriga G, et al; REIN-2 Study Group. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365:939-946.

10. ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT). NCT01206062. http://clinicaltrials.gov/ct2/show/NCT01206062?term=SPRINT&rank=3 Accessed March 14, 2014.

References (cont)References (cont)

11. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168:207-217.

12. Wright Jr JT, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View. Ann Intern Med. 2014. [Epub ahead of print]

13. Dahlöf B, Devereux RB, Kjeldsen SE, et al; LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:995-1003.

14. Poulter NR, Wedel H, Dahlöf B, et al; ASCOT Investigators. Role of blood pressure and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). Lancet. 2005;366:907-913.

References (cont)References (cont)

15. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.

16. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Diuretic versus alpha-blocker as first-step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42:239-246.

17. Wright JT Jr, Dunn JK, Cutler JA, et al; ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293:1595-1608.

18. Dahlöf B, Sever PS, Poulter NR, et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-906.