Hypertension Guidelines JNC Recommendations Robert E. Bulow DO FACOI, FACC
None Disclosures
Question At what blood pressure should pharmacologic therapy be initiated in the non diabetic pt with age greater than 60 years of age? 20% 1. 120/80 20% 20% 20% 20% 2. 130/85 3. 140/90 4. 150/90 5. 160/100 10 Countdown
Objectives 1. When should hypertension be treated with antihypertensive medications? 2. Is there an age factor that influences antihypertensive therapy? 3. How are diabetic and chronic kidney disease patients treated differently for hypertension compared to the general population?
Case 66 y/o Black male presents to PCP with BP 144/86, HR 72 bpm, BMI 32, waist circumference 52 inches. Non diabetic egfr 95 Non smoker Sedentary lifestyle 2-3 alcoholic beverages daily. Recommendations?
Treatment of HTN Background / History History of NHLBI & Guidelines JNC-7 JNC-(8) Future Guidelines Renal denervation
Background HTN remains one of the most important and preventable contributions to disease and death. 65+ million Americans have HTN World wide 1 billion+ have HTN Greater than 9 million globally die of HTN related diseases annually In the US < 50% of people with BP>140/90 are aware of it and of those receiving therapy <33% reach target blood pressures Lowering SBP by 10mmHg reduces coronary heart disease risk by 25%, and risk of stroke by 33%.
History NHLBI and JNC 1940 FDR dedicates NIH Bethesda Campus 1972 Elliot Richardson Secretary of the US Dept of Health, Education, and Welfare established National Hypertensive Program. 1976 JNC1 1980 JNC2 1984 JNC3 1988 JNC4 1992 JNC5 1997 JNC6 2003 JNC7 2013 JNC (8)
JNC 7 The purpose of JNC reports is to synthesize the available scientific evidence and offer guidance to busy primary care physicians. Dr. Aram V. Chobanian M.D. chair Executive Committee began work on the Express version Dec 2002 and was published May 2003. Evidence based approach including observational, RCT, and meta analysis s. Consensus based guideline, not a rigorous guideline based on IOM Extensive review and guideline.
JNC 8 Panel created for JNC8 in 2008 Dr. Paul James Chair Panel members 45 External Methodology team performed the literature review Panel members created evidence statements from the literature review Review process included the time period Jan1,1966 to Dec 31, 2009. Dec 2009 August 2013. Jan 2013 guideline submitted to external peer review by NHLBI to 20 reviewers Statement by NHLBI in June 2013, out of guideline buisiness JNC panel releases guideline in Dec 2013, no endorsement
Literature Review Rigorous criteria RCT adults aged 18 or greater Studies with sample sizes smaller than 100 or follow up less than 1 year excluded HTN patients Hard endpoints IOM Institute of medicine Standards for systematic reviews Development of trustworthy guidelines
Definition of HTN
JNC 8
Comparison to JNC7
Evidence
Recommendation
Recommendations
Antihypertensive drugs
Strategies
Guidelines
Lifestyle Changes
Case
Future Guidelines NHLBI to refocus its health education agenda on their core mission of knowledge generation and synthesis by supporting and producing rigorous systematic reviews that can then be used by other collaborating organizations ti generate guidelines. Oct 2013 AHA/ACC announce that jointly they will assume the governance and management of these preventive guidelines
Question At what age should pharmacologic therapy be initiated in the non diabetic greater than 60 years of age? 1. 120/80 2.130/85 3.140/90 4. 150/90 5.160/100
Question At what age should pharmacologic therapy be initiated in the non diabetic greater than 60 years of age? 20% 1. 120/80 20% 20% 20% 20% 2. 130/85 3. 140/90 4. 150/90 5. 160/100 10 Countdown
At what age should pharmacologic therapy be initiated in the non diabetic greater than 60 years o... 1 20% 20% 1 20% 20% 1 20% 20% 1 20% 20% 1 20% 20% First Slide Second Slide
Renal Denervation
Afferent Renal Nerve Signaling
Catheter Based Approach
Change in Office DBP and SBP in the Simplicity HTN-2 Trial
Two year follow up in the Simplicity HTN-1 Trial
Conclusions
Confidence what you start out with before you understand the situation Anonymous