Jnc 8

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  • Eighth Joint National Committee JNC 8
  • This evidence-based hypertension guideline focuses on the panel’s3highest- ranked questions related to high BP management.
  • Nine recommendations are made reflecting these questions. Recommendations 1 -5 address questions 1 & 2 concerning thresholds and goals for BP treatment. Recommendations 6, 7, 8 address question concerning selection of antihypertensive drugs.Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs
  • In patients aged ≥60 years, initiate pharmacologic treatment if systolic BP ≥150mmHg or diastolic BP ≥90mmHg and treat to a goal systolic BP <90mmHg.  (Strong Recommendation–Grade A)
  • 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.
  • 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.
  • 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 140mm Hg and goal DBP lower than 90mmHg.
  • 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.
  • Nine recommendations are made reflecting these questions. Recommendations 1 -5 address questions 1 & 2 concerning thresholds and goals for BP treatment. Recommendations 6, 7, 8 address question concerning selection of antihypertensive drugs.Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs

Jnc 8 Jnc 8 Presentation Transcript

  • Evidence-Based Guideline for Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) Dr Arun kochar MD;DM;DNB Senior interventional cardiologist Fortis Hospital, Mohali
  • JNC 8 is not just JNC 7 “Renovated”…. but 911ed and Reconstructed
  • 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
  • Let us take a early dinner…      Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else. Any of 4 classes of drugs could be chosen. Destination is important and not the journey. No stages please. In blacks C and D. THANK YOU
  • Introduction  Hypertension remains one of the most important preventable contributors to disease and death.  Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes.  This report highlights the Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
  • Introduction  The panel members appointed to the JNC 8 used evidence-based methods, developing Evidence Statements and recommendations for blood pressure treatment.  Recommendations are based on a systematic review of the literature to meet needs of the primary care clinician.  This is an Executive summary of the evidence and is provides clear recommendations for all clinicians.
  • From: 2014 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. 2013;():. doi:10.1001/jama.2013.284427 Figure Legend: Comparison of Current Recommendations With JNC 7 Guidelines Date of download: 12/21/2013 Copyright © 2012 American Medical Association. All rights reserved.
  • Questions Guiding the Evidence Review  Guideline focuses on the panel’s most debated questions related to high BP management.  These questions address:  Thresholds and goals for treatment of hypertension.  Whether particular antihypertensive drugs have a bearing health outcomes.
  • Questions Guiding the Evidence Review 1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Goals 2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvement in health outcomes? Targets 3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? Impact of drugs
  • Recommendations
  • Concerning thresholds and goals. Recommendations 1 -5
  • Recommendation 1  General population aged 60 years or older Initiate Treatment at : SBP ≥150 mmHg Or DBP ≥ 90mmHg Goal of Treatment : SBP <150 mmHg OR DBP of < 90mmHg.
  • Recommendation 2  General population < 60 years Initiate Treatment at : DBP ≥ 90mmHg Goal of Treatment : DBP of < 90mmHg.
  • Recommendation 3  General population < 60 years Initiate Treatment at : SBP ≥ 140 mmHg Goal of Treatment : SBP of < 140 mmHg.
  • Recommendation 4  Population aged 18 years or older with CKD Initiate Treatment at: SBP ≥ 140 mmHg Or DBP ≥ 90 mmHg Goal of Treatment : SBP < 140 mmHg Or DBP < 90 mmHg
  • Recommendation 5  Population aged 18 years or older with diabetes Initiate Treatment at: SBP ≥ 140 mmHg Or DBP ≥ 90 mmHg Goal of Treatment : SBP < 140 mmHg Or DBP < 90 mmHg
  • Concerning selection of antihypertensive drugs. Recommendations6,7,8
  • Recommendation 6  In General nonblack population, including those with diabetes  Initial antihypertensive treatment should include any of the following:     A thiazide-type diuretic Calcium channel blocker (CCB) Angiotensin-converting enzyme inhibitor (ACEI) or Angiotensin receptor blocker (ARB).
  • Recommendation 7  In general black population, including those with diabetes:  Initial antihypertensive treatment should include :  Thiazide-type  CCB. diuretic
  • Recommendation 8  Population aged 18 years or older with CKD and hypertension  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.
  • Recommendation 9  The main objective of hypertension 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 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.
  • Opinion for starting & adding drugs . Recommendation 9
  • Recommendation 9  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 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.
  • From: 2014 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. 2013;():. doi:10.1001/jama.2013.284427 Strategies to Dose Antihypertensive Drugs Figure Legend: Date of download: 12/21/2013 Copyright © 2012 American Medical Association. All rights reserved.
  • Recommendation 9  For patients in whom goal BP cannot be attained using the above strategy OR  The management of complicated patients for whom additional clinical consultation is needed.  Referral to a hypertension specialist may be indicated
  • JNC-8 Published on Target goal 18th Dec 2013 <140/90 ASH/ISH 19th Dec 2013 <140/90 For general patients including DM/CKD For Elderly people 150/90(≥60 yrs) 150/90(≥80 yrs) AHA/ACC 21st Nov 2013 <140/90 Lower targets may be appropriate for LVD, LVH, DM, CKD Lower targets for the Elderly Treatment preference Stage 1 HT: Initiate Thiazidetype Diuretic or ACEI or ARB or CCB General <60 yrs For uptitration, any possible combination from above (avoid ACEI+ARB) ACEI or ARB (If needed, add CCB or Thiazidetype Diuretic) Stage 2 HT: ACEI or ARB + CCB or Thiazidetype Diuretic General ≥60 yrs Hypertension with Diabetes Same as above Same as above ACEI or ARB alone Hypertension with CKD Or in combination with other Stage 1: CCB or Thiazide (If needed, add ACEI or ARB) ACEI or ARB If needed add CCB or thiazide-type diuretic ACEI or ARB If needed add CCB or thiazide-type diuretic Stage 1 HT: Thiazide for most patients or ACEI, ARB, CCB, (or combination, if uncontrolled) Stage 2 HT: Thiazide with ACEI / ARB/ CCB, or ACEI with CCB Same as Above ACEI or ARB, thiazide, BB, calcium channel blocker ACEI or ARB
  • Comparison..(cont.) β-Blocker plus ARB or ACE inhibitor Hypertension with CAD --- Hypertension with stroke --- Hypertension with HF --- If needed add CCB or thiazide-type diuretic ACE inhibitor or ARB If needed add CCB or thiazide-type diuretic ARB or ACE inhibitor+ β blocker+ diuretic+ spironolactone regardless of blood pressure β-Blocker, ACEI Thiazide, ACEI. ACEI or angiotensinreceptor blocker (ARB), BB, aldosterone antagonist, thiazide;
  • Conclusion  Guidelines Offer clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies  Provides evidence-based management of high BP  Should meet the clinical needs of most patients.  However, these recommendations are not a substitute for clinical judgment, and decisions must carefully consider and incorporate the clinical characteristics of each individual. recommendations for the
  • Thank you for your patience