Hypertension jnc 8 guideline(1)

Hypertension

1. HYPERTENSION JNC 8 GUIDELINE Speaker- Dr. Chandan Kumar

2. Hypertension definition : Office blood pressure of 140/90 mm Hg or higher. Average awake blood pressure >135/85 and asleep blood pressure >120/75 on 24 hr blood pressure monitoring. C hildren and adolescents Hypertension - systolic and/or diastolic BP consistently >95 percentile for age, sex and height. Night time blood pressure are generally 10-20% lower than daytime blood pressure

3. Hypertension doubles the risk of cardiovascular diseases , including coronary heart disease , CHF, ischemic and hemorrhagic stroke , renal failure , and peripheral arterial disease . Approximately 7.6 million deaths ( 13 - 15% of the total) worldwide were attributable to high blood pressure . Benefit of HTn treatment- 40% reduction in stroke incidence, 25% reduction in myocardial infarction, >50% reduction in heart failure

4. Rule of Halves

5. Measurement technique : Tobacco, caffeine, exercise should be avoided for 30 min. S eated quietly in a chair with feet on the floor and back supported for 5 min in a private , quiet setting with a comfortable room temperature. Width of cuff bladder should equal at least 40% of the arm circumference; the length should encircle at least 80% of the arm circumference . R ate of deflation of the cuff (2 mmHg/s)

6. Hemodynamic Subtypes Three distinctly different hemodynamic subtypes that vary sharply by age Systolic Hypertension in Teenagers and Young Adults : ISH main type in adult (17-25). Increased cardiac output and stiff aorta due to overactivity of sympathetic nervous system. Male>Female. Predispose to diastolic HTn in middle age.

7. + 36 . Diastolic Hypertension in Middle Age 30 to 50 of age, isolated diastolic or combined systolic diastolic HTn . Common in male associated with weight gain. Due to elevated systemic vascular resistance with normal cardiac output . Isolated Systolic Hypertension in Older Adults Stiffening of central aorta and rapid return of reflected pulse wave from periphery

8. Hypertensive crises characterized by severe hypertension and acute target-organ damage to the brain, heart, kidney, retina, or blood vessels. Typically, BP is 220/130 mm Hg or higher but may be much lower in women with preeclampsia who do not have preexisting hypertension Hypertensive urgency denotes severe uncontrolled hypertension without evidence of acute target-organ damage

9. Severe hypertension , defined as a BP of 180/110 mm Hg to 220/130 mm Hg without symptoms of acute target-organ damage- Almost always occurs in patients with chronic hypertension who stopped medication Resistant Hypertension High BP uncontrolled with three or controlled with at least four antihypertensive drugs (including a diuretic)—is associated with a higher prevalence of secondary hypertension and worse CV and renal outcomes

10. Blood pressure : lateral force per unit area of vascular wall BP in arrythmia : few cycles measured, average taken BP in shock : direct intraarterial pressure measurement Isotonic exercise : moderate increase in BP ,systolic BP > mean Isometric exercise : abrupt increase in all systolic diastolic and mean pressure

11. Pseudohypertension : measured pressure far higher than intraarterial pressure Found in elderly White coat hypertension : 3 clinic BPs >140/90 , 2 home BP <140/90 , without target organ damage Masked hypertension : Normal clinic BP in presence of target organ damage. Found in peripheral artery disease.

12. Secondary causes of hypertension

13. JNC 8

14. JNC 8 aims and objectives: The panel members appointed to JNC8 used ri To develop Evidence Statements To develop Recommendations for high blood pressure(BP) treatment based on a systematic review of the literature to meet user needs, especially the needs of the primary clinician.

15. The evidence-based hypertension guidelines focuses on the three questions

16. Inclusion Criteria . E vidence review to Randomised controlled trials only. focused on adults aged 18 years or older with hypertension. . Studies with the following prespecified subgroups: diabetes, CAD, PAD, CHF, previous stroke, CKD, proteinuria, older adults, men and women, racial and ethnic groups, and smokers.

17. Exclusion criteria : Studies with sample sizes <100 Studies with follow up period < 1 year Studies that enrolled prehypertensive or nonhypertensive individuals

18. Grades Strength of Recommendation A Strong Recommendation There is high certainty based on evidence that the net benefit is substantial. B Moderate Recommendation There is moderate certainty based on evidence that the net benefit is moderate to substantial or there is high certainty that the net benefit is moderate. C Weak Recommendation There is at least moderate certainty based on evidence that there is a small net benefit. D Recommendation against There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh benefits. E Expert Opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends.”) Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the committee thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. N No Recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”) Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the committee thought no recommendation should be made. Further research is recommended in this area.

19. Recommendation 1 In the general population aged 60 years or older , initiate pharmacologic treatment to lower BP at systolic blood pressure (SBP) of 150mmHg or higher or diastolic blood pressure (DBP) of 90mmHg or higher and treat to a goal SBP lower than 150mmHg and goal DBP lower than 90mmHg. Strong Recommendation – Grade A Corollary Recommendation In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (for example,<140mmHg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted. Expert Opinion – Grade E

20. Recommendation 2 In the general population younger than 60 years , initiate pharmacologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to a goal DBP of lower than 90mmHg. For ages 30 through 59 years, Strong Recommendation – Grade A For ages 18 through 29 years, Expert Opinion – Grade E Recommendation 3 In the general population younger than 60 years , initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to a goal SBP of lower than 140mmHg. Expert Opinion – Grade E

21. Recommendation 4 In the population aged 18 years or older with CKD , initiate pharmacologic treatment to lower BP at SBP of 140mmHg or higher or DBP of 90mmHg or higher and treat to goal SBP of lower than 140mmHg and goal DBP lower than 90mmHg. Expert Opinion – Grade E Recommendation 5 In the population aged 18 years or older with diabetes , initiate pharmacologic treatment to lower BP at SBP of 140mmHg or higher or DBP of 90 mm Hg or higher and treat to a goal SBP of lower than 140mmHg and goal DBP lower than 90mmHg. Expert Opinion – Grade E

22. 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 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

23. Recommendation 8 In the population aged 18 years or older with CKD and hypertension, initial (or add-on ) antihypertensive treatment should include an ACE I or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. Moderate Recommendation – Grade B

24. Recommendation 9 If goal BP is not reached within a month of treatment I ncrease the dose of the initial drug O r A dd a second drug from one of the classes in recommendation 6 O r Start initially itself with 2 medication classes separately or as fixed dose combinations 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 the drugs in recommendation 6 , 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 . Expert Opinion – Grade E

25. TOPIC JNC 7 JNC 8 Methodology Nonsystematic literature review by expert committee. Included a range of study designs. Recommendations based on concensus . Critical questions & review criteria defined by expert panel Systematic review by methodologists restricted to RCT evidence Recommendations according to a standardized protocol . Definitions Defined Hypertension & Prehypertension Not redefined hypertentension Treatment goals Separate goals for uncomplicated HTN & with various comorbid conditions Similar treatment goals for all hypertensive populations except when evidence review supports different goals for a particular subpopulation Lifestyle Recommendations Recommended based on literature review & expert opinion Recommended by supporting Lifestyle Work Group Drug therapy Recommended 5 classes to be considered as initial therapy. Recommended thiazide type diuretics as initial therapy for most Specified compelling indications with particular antihypertensives to be used Included comprehensive table of oral antihypertensives . Recommended selection among 4 specific medication classes Recommended specific medication only for racial, CKD, & diabetics Panel created a table of drugs & doses used in the outcome trials. Scope of topics Broad Limited Review prior to publication NHBPEPCC Public Voluntary organizations 7 federal agencies Experts affiliated with professional & public organizations Federal agencies

26. JNC 8 Simplified Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else. No staging Non black population- Start with any of the 4 dru g classes (thiazide diuretics, CCBs,ACE I, ARBs) Black population-Start with a thiazide diuretic or CCB . (in black C & D ). CKD>18yrs- Start with an ACEI or ARB

27. ACEI & ARB should not be used together There are 3 strategies of drug therapy , choose any of the three .

28. REFERENCES Harrisons principles of internal medicine 19 th edition Braunwalds 10 th edition Staessen JA, Fagard R, Thijs L, et al; The Systolic Hypertension in Europe ( Syst-Eur ) Trial Investigators. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet . 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(18):1887-1898. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension:final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. Institute of Medicine. Clinical Practice Guidelines We Can Trust.Washington , DC: National Academies Press; 2011. http://www.iom.edu/Reports/2011 /Clinical-Practice-Guidelines-We-Can-Trust.aspx. Accessed November 4, 2013. Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval . 2007;12(10). http://pareonline.net/pdf/v12n10.pdf . Accessed October 28, 2013

29. Historical Comments about Hypertension “ The greatest danger to a man with high blood pressure lies in its discovery……. because then some fool is certain to try his hand and reduce it .” Hay , Brit Med J, 1931

30. THANK YOU