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

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Mary Johnson

on 28 January 2014

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

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

Objectives
Explain the process behind appointing panel members who updated the guidelines
Outline the questions guiding evidence review
Reveal the process of evidence review
Explain how the quality of evidence and strength of recommendation was made
Outline the recommendations
Compare the guidelines develop by JNC 7 and JNC8
Discuss limitations to the updated guidelines
Compare JNC 8 to other hypertension guidelines

The Evidence Review
Limited to RCTs (Jan. 1, 1966 to Dec. 31, 2009)
Searched for studies published between Dec. 2009 and Aug. 2013 but did not meet strict inclusion criteria
Focused on adults >18 yo with HTN
Included studies in patients with DM, CAD, AD, HF, previous stroke, CKD, proteinuria, older adults, men and women, different racial and ethnic groups and smokers
Studies were included only if they reported having effects on the following: reported effects on overall mortality, MI, HF, stroke, coronary revascularization, ESRD, doubling the creatinine level, halving of the GFR
Exclusion criteria
Sample size <100
Follow up < 1 yr

Recommendations
Recommendation 1

Recommendation 2

Recommendation 3

Recommendation 4

Recommendation 5

Discussing the Updated
Guidelines

Questions Guiding the 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?

Recommendation 6

Recommendation 7

Recommendation 8

Recommendation 9
Selected from 400 nominees based on their expertise in hypertension
17 members
Senior scientist from the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK)
Senior medical officer from National Heart, Lung, and Blood Institute (NHLBI)
Senior scientist from NHLBI who withdrew from authorship prior to publication
Two members left because of new job commitments
Conflicts of interest were disclosed
Studies evaluated in this report and relationships with industry
Four panel members (24%) did not vote on evidence statements due to conflicts of interest.

Panel Member Appointments
Submitted for external peer review by NHLBI in January 2013
20 individuals who had expertise in hypertension
16 federal agencies
16 individual reviewers and 5 federal agencies responded.
Comments were collected, collated, anonymized, reviewed and discussed by the panel from March through June 2013 and incorporated into a revised document.

Guideline Peer Review
The Process of Updating the Guidelines
Comparison of JNC8 with other Guidelines
Patients often have multiple comorbidities - JNC8 only focuses on 1 at a time
Cost was not incorporated
Adherence was not incorporated
Effect sizes may have been overestimated due to higher risks of cardiovascular morbidity and mortality in previous studies
Studies with prehypertensive and nonhypertensive individuals were excluded
Only RCT were studied, no observational studies, systematic reviews, or meta-analyses were included in the review
Limitations
In the general population ≥ 60 yrs old,
initiate pharmacologic
treatment to lower blood pressure at
systolic blood pressure ≥ 150 mm Hg or
diastolic blood pressure ≥ 90 mm Hg and
treat to a goal SBP < 150 mm Hg and
goal DBP < 90 mm Hg.
Based on trials: HYVET, Syst-EUR, SHEP,
JATOS, VALISH, and CARDIO-SIS
(strong recommendation - Grade A)

Recommendation 1
Corollary Recommendation
In the general population aged ≥ 60 yrs old,
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 < 60 years,
initiate pharmacologic treatment to lower
BP at DBP ≥ 90 mm Hg and treat to a goal
DBP < 90 mm Hg.
Based on high-quality evidence from 5 DBP trials (HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative)

(For ages 30-59 years, Strong Recommendation
- Grade A; for ages 18-30 years, Expert Opinion
-Grade E)
Recommendation 3
In the general population < 60 years,
initiate pharmacologic treatment to
lower BP at SBP ≥ 140 mm Hg and treat
to a goal < 140 mm Hg.

(Expert opinion - Grade E)
Recommendation 4
In the population ≥ 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)
Recommendation 5
In the population aged ≥ 18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP
≥ 140 mm Hg or DBP ≥ 90 and treat to a goal SBP < 140 mm Hg and goal DBP < 90 mm Hg.
Based on 4 trials: SHEP, Syst-Eur, UKPDS, and ACCORD-BP

(Expert Opinion - Grade E)
Recommendation 6
In the general nonblack population, including those with diabetes, intial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).
Recommendation supported by 3 federally funded trials: VA Cooperative Trial, HDFP, and SHEP

(Moderate Recommendation - Grade B)
Recommendation 7
In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide diuretic or CCB.
Recommendation supported by the ALLHAT trial

(For general black population: Moderated 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 and ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.
Recommendation supported by AASK study.

(Moderate Recommendation - Grade C)
Recommendation 9
The main objective of hypertension treatment is to attain and maintain goal BP
If goal BP is not reached within 1 month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (tzd, ACEI, ARB, CCB).
continue to assess BP and adjust treatment until goal BP is reached
If goal BP cannot be reached with 2 drugs, add and titrate a 3rd drug
If goal 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.
Do not use an ACEI and an ARB together in the same patient.
(Expert opinion - Grade E)
Treatment Algorithm
New recommendations are highly evidence-based and graded with regards to the level of evidence.
Changes based upon 5 key RCT: HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative.
Emphasis on safe use of ACEIs and ARBs.
Emphasis on the use of drug therapies that decrease CV events and not just decrease BP.
More lenient SBP goals based on limited evidence of strict SBP lowering in reducing CV events and in an effort to reduce low SBP related adverse effects.
Simplified follow-up recommendations.
Similar emphasis on lifestyle modifications.
Lacking in classification/definition of hypertension.
Recommend the use of JNC 7 to guide therapy in certain cases not addressed in JNC 8.

Summary of Changes to JNC 7
Full transcript