JNC 8

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A very very concise presentation of the JNC8 recommendations. A quick reference for busy clinicians, if they find it useful, i.e!

Published in: Health & Medicine, Education

JNC 8

  1. 1. JNC 8 Evidence to the fore?
  2. 2. PROCESS  >400 nominees  Members selected  Guidelines first draft - January 2013  Reviewed by 20 reviewers + 16 federal agencies February 2013  Revised document - June 2013
  3. 3. QUESTIONS In adults with HTN:•Starting Pharmac Rx @ specific BP threshold = benefit? •Treating •Diff to specific BP goal = benefit? anti-HTN drugs/classes = Diff benefit or harm in specific health outcomes?
  4. 4. EVIDENCE SELECTION
  5. 5. POPULATION CRITERIA • • Adults ≥ 18 years with HTN Subgroups • • • • • • • • • • DM CAD PAD HF Prev Stroke CKD Proteinuria Older adults Men/Women Racial/ethnic groups,
  6. 6. OUTCOMES CONSIDERED • Mortality: overall, CVD related, CKD related • MI, HF, Hospitalization for HF, stroke • Revasc: Coronary (Plasty/Bypass), others (carotid, renal, limb) • ESRD, Creat x 2, GFR/2
  7. 7. TRIALS  Only RCTs  Period Jan 1, 1966 to Dec 31, 2009  Secondary search  PubMed & CINAHL  Dec 2009 – Aug 2013  Major study in HTN, ≥ 2000 subjects, multicentric, met incl/excl criteria
  8. 8. COLLATION • • • • Data tabulated Evidence summarized Evidence statements crafted Voting Agree/disagree with evidence statement • Quality of evidence • • • Clinical recommendations crafted Voting Agree/disagree with recomm • Strength of recomm •
  9. 9. RESULTANT  9 recommendations  Strength of recommendation for each  Recomm 1 – 5  Threshold  Recomm 6 – 8  Selection  and goals of antiHTN drugs Recomm 9  Summary of strategies (expert opinion)
  10. 10. RECOMMENDATIONS
  11. 11. RECOMMENDATION 1  Gen pop ≥ 60 years  Start at SBP>150 OR DBP>90  Goal SBP<150 AND DBP<90  Strong – Grade A  PS: If already having lower values + no adverse effects = continue present Rx  Exp Op – Grade E
  12. 12. RECOMMENDATION 2  Gen pop < 60 years  Start at DBP ≥ 90  Goal DBP < 90  Strong – Grade A (30-59 years)  Exp Op – Grade E (18-29 years)
  13. 13. RECOMMENDATION 3  Gen pop < 60 years  Start at SBP ≥ 140  Goal SBP < 140  Exp Op – Grade E
  14. 14. RECOMMENDATION 4  CKD ≥ 18 years  Start at SBP ≥ 140 OR DBP ≥ 90  Goal SBP < 140 and DBP < 90  Exp Op – Grade E  PS: No evid for BP goal – CKD > 70 years  Induvidualize Rx
  15. 15. RECOMMENDATION 5  DM ≥ 18 years  Start at SBP ≥ 140 OR DBP ≥ 90  Goal SBP < 140 AND DBP < 90  Exp Op – Grade E
  16. 16. RECOMMENDATION 6  Gen pop non-black (+/- DM)  Initial drug: Thiazide diuretic  CCB  ACEi  ARB  Mod Recomm – Grade B
  17. 17. CAVEATS  Only for initial drug choice. Add-on any will do  Specific to thiazide diuretics  Drugs to be adequately dosed  NOT for CAD, HF, CKD
  18. 18. RECOMMENDATION 7  Gen Black pop (+/- DM)  Initial drug:- Thiazide/CCB  Mod Recomm – Grade B (Gen Black)  Weak Recomm – Grade C (Black + DM)  PS:- Diuretic > CCB in preventing HF
  19. 19. RECOMMENDATION 8  Adults CKD (any race, +/- DM)  ACEi/ARB as initial/add-on  Mod Recomm – Grade B  PS – Only improves kidney outcomes
  20. 20. RECOMMENDATION 9  MAIN AIM – attain + maintain goal BP  Not at goal by 1 mth Rx:↑ dose initial drug / add-on 2nd drug  Continuous assessment and drug adjustment   Use drugs from other classes if:> 3 drugs needed  Contraindic/adverse effect of recomm classes   Exp Op – Grade E
  21. 21. COROLLARIES 1  Assess BP regularly  Evidence based lifestyle and adherence interventions  Adjust Rx till goal attained + maintained  Dose and titration not discussed (no RCTs)  Algorithm suggested – not validated for benefit
  22. 22. COROLLARIES 2  3 Strategies suggested: Initiate 1 drug – go to max – then add 2nd drug  Initiate 1 drug – add 2nd drug before 1st @ max  Initiate 2 drugs in single / fixed dose combo  Drugs may be substituted if: Not effective  Adverse effects
  23. 23. THANK YOU ALL For Your Kind Attention

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