JAMA - Medscape

Report
Putting the 2014 EvidenceBased Guidelines for the
Management of High Blood
Pressure in Adults Into Practice
Moderator
James A. Underberg, MD
Clinical Assistant Professor of Medicine
New York University School of Medicine
Director, Bellevue Hospital Lipid Clinic
New York University Center for Prevention
of Cardiovascular Disease
New York City
Panelists
Louis Kuritzky, MD
Raymond R. Townsend, MD
Clinical Assistant Professor
University of Florida
Gainesville, Florida
Professor of Medicine
Perelman School of Medicine
Philadelphia, Pennsylvania
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
James PA, et al. JAMA. 2014;311:507-520.[1]
Questions 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 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 Recommendations
• Age
• Diabetic
• Black/nonblack
• Chronic kidney disease (CKD)
Age 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
• 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 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 Primary Outcome
Intensive Therapy, %
Standard Therapy, %
208 (1.87)
237 (2.09)
ACCORD Study Group. N Engl J Med. 2010;362:1575-1585.[6]
JNC 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
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]
ALLHAT
Outcomes in Hypertensive Black Patients Treated
With Chlorthalidone, Amlodipine, and Lisinopril
6-Year Rate per 100 Persons
Chlorthalidone
Rate (SE)
Amlodipine
No.
Rate (SE)
Lisinopril
Outcome
No.
Total randomized
5369
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)
3213
Wright JT, et al. JAMA. 2005;293(13):1595-1608.[17]
No.
Rate (SE)
3210
JNC 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]
Recommendations 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]
Recommendations for Hypertension
Management (cont)
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)
James PA, et al. JAMA. 2014;311:507-520.[1]
JNC Management Guideline Algorithm
Adult aged 18 years and older who have hypertension
Implement lifestyle interventions (continue throughout management)
Set BP goal and initiate BP-lowering medication on the basis of age, diabetes status, and CKD
General population (no diabetes or CKD)
Age ≥ 60 years
Age < 60 years
BP goal
SBP < 150 mm Hg
DBP < 90 mm Hg
BP goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Diabetes or CKD present
All ages/with CKD/ with or
All ages/with diabetes/no CKD
without diabetes
BP goal
SBP < 140 mm Hg
DBP < 90 mm Hg
BP goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Nonblack
Black
All races
Initiate 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 strategy
A. Maximize first medication before adding second or
B. Add second medication before reaching maximum dose of first medication or
C. Start with 2 medication classes separately or as fixed-done combination
At goal BP?
No
At goal BP?
Reinforce medication and lifestyle adherence
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).
At goal BP?
Reinforce medication and lifestyle adherence
Add additional medication class (eg, beta-blocker, aldosterone antagonist, or
others) and/or refer to physician with expertise in hypertension management.
James PA, et al. JAMA. 2014;311:507-520.[1]
No
At goal BP?
Continue current treatment and monitoring
Yes
Reinforce medication and lifestyle adherence
For 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).
No
For strategy C, titrate doses of initial medications to maximum.
ASCOT
Summary of All End Points
Primary
Unadjusted hazard ratio (95% CI)
0.90 (0.79-1.02)
Nonfatal MI (including silent) + fatal CHD
Secondary
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)
Nonfatal MI (excluding silent) + fatal CHD
Total coronary end point
Total cardiovascular event and procedures
All-cause mortality
Cardiovascular mortality
Fatal and nonfatal stroke
Fatal and nonfatal heart failure
Tertiary
Silent MI
Unstable angina
Chronic stable angina
Peripheral arterial disease
Life-threatening arrhythmias
New-onset diabetes mellitus
New-onset renal impairment
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)
Post hoc
Primary end point + coronary
revascularization procedures
CV death + MI + stroke
0.86 (0.77-0.96)
0.84 (0.76-0.92)
0.50
0.70
1.00
Amlodipine  perindopril better
Dahlöf B. Lancet. 2005;366:895-906.[18]
1.45
2.00
Atenolol  thiazide better
Strategies for Reaching BP Goal
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
James PA, et al. JAMA. 2014;311:507-520.[1]
Abbreviations
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
References
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.
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Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
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BMJ. 1998;317:703-713.
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.
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9. Ruggenenti P, Perna A, Loriga G, et al; REIN-2 Study Group. Blood-pressure control
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NCT01206062. http://clinicaltrials.gov/ct2/show/NCT01206062?term=SPRINT&rank=3
Accessed March 14, 2014.
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;359:9951003.
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 AngloScandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).
Lancet. 2005;366:907-913.
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 (ASCOTBPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-906.

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