JNC 8 guideline to Management of Hypertension

JNC - 8 guidelines to management of Hypertension.
Rencent developments in CKD (Chronic Kidney Disease) and DM (Daibetes Mellitus) management.
Drugs discussed along with doses and side effects.
Compelling indiactions.
2017 AHA/ACC criteria for Hypertension management in brief.
>> Contains animation. Download and view.

1. Hypertension: Overview of Management Presenter: Dr Pranav Sopory Moderator: Dr Sudhir C. Sarangi 1

2. Contents 2 Clinical disorders of Hypertension Classification of BP Drugs used in Hypertension JNC 8 methodology JNC 8: Guideline Algorithm

3. Clinical disorders of HTN Essential (90 %): Unknown specific cause – multifactorial. Environmental factors Genetic factors Secondary: C onsequence of a specific disease Kidney disease Adrenal gland tumors Thyroid disease 3

4. JNC – 8 Classification of BP 4

5. Drugs used in Hypertension 5

6. I. Diuretics 6 Loop Diuretics Ascending LOH: #NaK2Cl Reabsorbs: 1 Na, 1 K, 2 Cl Agents: Furosemide, Ethacrynic acid Use: When GFR< 30 ml/min K + sparing Diuretics CD: 1. Aldosterone receptor # : Agents: Spironolactone S/E: Hyperkalemia, gynaecomastia 2. ENaC channel # : Agents: Amiloride Thiazide Diuretics DCT: #NaCl symport Reabsorbs: 1 Na, 1 Cl Agents: Chlorthiazide , Chlorthalidone , Indapamide Use: Strongest evidence with Chlorthalidone S/E: hypokalemia

7. II. Sympathoplegics 7 Prazosin : Selective ⍺1 antagonist Location of alpha 1 receptors: Blood vessels Prostate (BPH use) Adverse Effects: Postural hypotension (should be given at bedtime) Similar drugs: Terazosin Doxazosin Alfuzosin Non- Selectives : Phenoxybenzamine , Phentolamine

8. II. Sympathoplegics Clonidine : ⍺2 agonist Presynaptic ⍺2 agonism : Indirect # of SNS Adverse effects: Drying of secretions Sedation Rebound HTN on sudden discontinuation (Downregulated alpha 1: increase in number of receptors) Similar drugs: Methyldopa Guanfacine 8 Epinephrine Nor-Epinephrine Use: Resistant HTN

9. II. Sympathoplegics First generation: Non- Selective (β1, β2) Propanolol Timolol Nodalol Contraindication: Asthma: Beta 2 blockade DM: hypoglycemic unawareness PVD: worsens intermittent claudication Uses: Tremors, thyroid storm, migraine Second Generation: Cardioselective (β1) 9 Third Generation: β1 + addl. CV advantage ⍺1#: Labetalol, Carvedilol Release N.O.: Nevibolol , Nipradilol #Ca channel: Carvedilol K+ channel opener: Tilisolol β2 agonism : Celiprolol (Asthma) Metoprolol Bisoprolol Betaxolol Acebutalol

10. III. Vasodilators Hydralazine Action: Arteriodilator Adverse Effects Reflex tachycardia Fluid retention Similar drugs: Minoxidil 10 Amlodipine Action: CCB Adverse Effects: Cause edema Reduce heart rate Similar drugs: Nifedipine Nimodipine (SAH) Nicardipine

11. IV. Angiotensin inhibitors Captopril Action: ACE inhibitor Adverse Effects: Cough and angioedema C/I in Pregnancy C/I in B/L Renal artery stenosis Similar drugs: Lisinopril Fosinopril Ramipril 11 Losartan Action: Selective AT1 # Adverse Effects: Same as ACEI except cough and angioedema Similar drugs: Valsartan Telmisartan Candesartan Aliskiren Action: Renin # Adverse Effects: Hypotension Similar drugs: Ramiskiren Enalkiren

12. JNC 8: Methodology Critical questions defined by expert panel Threshold of initiating pharmacologic therapy Goal in different subpopulations Impact of drugs Systematic review restricted to RCT evidence 12

13. JNC 8: Outcomes considered: Mortality: overall, CVD related, CKD related , MI, HF (hospitalization due to HF), stroke Revascularization: Coronary (CABG, Angioplasty, Stent placement), others (carotid, renal, lower extremity) Renal status: ESRD (resulting in dialysis or transplant), doubling Creatinine level, halving GFR 13 JNC 8: Recommendations Recommendations 1-5: Threshold and goals for HTN treatment Recommendations 6-8: Selection of anti-HTN drugs Recommendation 9: Summary of strategies (expert opinion)

14. JNC 8 (2014 Hypertension Guideline Management Algorithm) 14

15. 15

16. 16

17. Recommendation 1-3: General population R-1: Gen. pop >60 yo Initiate Rx at > 150/90 Goal: <150/90 Recommendation: Grade A (strong) Reduces R/O stroke, HF and CAD Goal of <140/90: No benefit 17 R-2: Gen. pop < 60 yo Initiate Rx at DBP > 90 Goal: DBP < 90 Recommendation: Grade A: > 30 yo Grade E:18-29 yo 5 RCTs show ↓ mortality assos . HF & CV events R-3: Gen. pop < 60 yo I nitiate Rx at SBP > 140 Goal: SBP < 140 Recommendation: Grade E (Expert opinion) Insufficient evidence for benefits of an SBP goal lower than 140

18. Recommendation 4-5 : With CKD or DM R-4: ≥ 18 yo with CKD Initiate Rx at > 140/90 Goal: <140/90 Grade E: Expert opinion Weak evidence showing benefit at SBP <150 18 R-5: ≥ 18 yo with DM Initiate Rx at > 140/90 Goal: <140/90 Grade E: Expert opinion No improvement in health outcomes when compared against 150/90

19. Recommendation 6: General non-black pop. including those with DM 19 β blocker not included: MI, Stroke: worse outcome than ARBs Insufficient evidence showing superiority compared to TD, CCB, ACEI ⍺ blocker not included: Worse outcomes (CVA, HF, CA) when compared with TD No good quality RCTs showing benefit for: Dual ⍺+β blocker: Carvedilol Vd β blocker: Nebivolol Central ⍺2 agonist: Clonidine Direct Vd : Hydralazine Loop diuretics: Furosemide Initiate Rx with: 1. TD 2. ACEI 3. ARB 4. CCB Recommendation: Gr B: Moderate Only RCTs comparing one class to another reviewed (placebos excluded) All 4 classes: comparable results ∴ no first-line Rx Similar for DM pts.: No difference in major CVD, CVA outcomes than general population

20. Recommendation 7 : General black pop. including those with DM 20 TD superior than ACEI: Preventing CVA, HF, CAD, kidney function and overall mortality. CCB vs ACEI: 50% ↑ R/o stroke with ACEI ACEI and ARB: less effective in reducing BP parameters. (Low renin physiology) Initiate Rx with: 1. TD 2. CCB Recommendation: For general black pop. : Grade B (Moderate)

21. Recommendation 8 : ≥ 18 yo with CKD 21 Both ACEI and ARBs: similar outcomes No benefits with β blocker or CCBs in CAD, HF outcomes All CKD pts., regardless of DM status or race: Initial Rx should include: ACEI ARB Recommendation: Grade B (Moderate)

22. Recommendation 9 : Objective – Attain & Maintian Goal BP 22

23. Compelling indications 23

24. AHA/ACC 2017 guidelines Precisely ASCVD risk taken into account JNC takes into account: mortality assos . with stroke and CAD, kidney outcomes. CKD and DM goals at <130/80 mm Hg 24

25. Thank You 25

26. 26