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

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

2 Table of Contents Why Do We Treat Hypertension? Blood Pressure Treatment Goals Initial Therapy Strength of Recommendation Recommendation 1 Corollary Recommendation Recommendation 2 Recommendation 3 Recommendation 4 Recommendation 5 Recommendation 6 Recommendation 7 Recommendation 8 Recommendation 9 Evidence Based Dosing for Antihypertensive Drugs Hypertension Guideline Management Algorithm Sources

3 Why Do We Treat Hypertension? Hypertension can lead to: Myocardial infarction Stroke Renal failure Death

4 Blood Pressure Treatment Goals Persons 60 years or older without diabetes or CKD BP < 150/90 (based on strong evidence) Persons less than 60 years of age, with diabetes, and/or with CKD BP <140/90 (based on expert opinion)

5 Initial Therapy Non-black persons Angiotensin-converting enzyme inhibitor (ACEI) Angiotensin receptor blocker (ARB) Calcium channel blocker (CCB) Thiazide-type diuretic Black persons (including those with diabetes) CCB Thiazide-type diuretic Chronic kidney disease (regardless of race or diabetes status) ACEI or ARB as initial or add-on antihypertensive therapy

6 Strength of Recommendation

7 Recommendation 1 In the general population aged 60 years, initiate treatment at systolic blood pressure (SBP) 150 or diastolic blood pressure (DBP) 90 and treat to a goal SBP <150 and DBP <90. Strong Recommendation Grade A

8 Corollary Recommendation In the general population aged 60 years, if treatment results in lower achieved SBP (e.g. SBP <140) and treatment is well tolerated without adverse effects on health or quality of life, treatment does not need to be adjusted. Expert Opinion Grade E

9 Recommendation 2 In the general population <60 years, initiate treatment at DBP 90 and treat to a goal DBP <90. For ages years, Strong Recommendation Grade A For ages years, Expert Opinion Grade E

10 Recommendation 3 In the general population <60 years, initiate treatment at SBP 140 and treat to a goal SBP<140. Expert Opinion Grade E

11 Recommendation 4 In the population aged 18 with chronic kidney disease (CKD), initiate treatment at SBP 140 or DBP 90 and treat to goal SBP <140 and DBP <90. Expert Opinion Grade E Based on the inclusion criteria used in the randomized controlled trials (RCTs) reviewed by the panel, this recommendation applies to individuals <70 years with an estimated GFR or measured GFR <60 and in people of any age with albuminuria defined as >30 mg of albumin/g of creatinine at any level of GFR.

12 Recommendation 5 In the population aged 18 years with diabetes, initiate treatment at SBP 140 or DBP 90 and treat to a goal SBP <140 and DBP <90. Expert Opinion Grade E

13 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 RCTs that were limited to specific nonhypertensive populations, such as those with coronary artery disease (CAD) or heart failure (HF) were not reviewed for this recommendation. Therefore, recommendation 6 should be applied with caution to these populations. For more details regarding why other drug classes were not recommended for initial therapy please see the notes for this slide.

14 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 For more information regarding why the other drug classes were not recommended as initial therapy for black persons please see the notes for this slide.

15 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 CKD patients with hypertension regardless of race or diabetes status. Moderate Recommendation Grade B

16 Recommendation 9 The main objective of 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. The clinician should continue to assess BP and adjust the treatment regimen until the goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided in recommendation 6. If goal BP cannot be reached using on 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 whom additional clinical consultation is needed. Expert Opinion Grade E

17

18 Figure continued on following slide.

19

20 Sources James PA, Oparil S, Carter BL, et al 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(5): doi: /jama

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