This slides are carefully created to understand the treatment guidelines for Hypertension

1. An Overview of Guidelines in the
Management of Hypertension
Dr. Jayaprakash S. Appajigol
Consultant Physician, KLE’s Dr. Prabhakar Kore Hospital
and MRC.
Associate professor of Medicine,
JNMC, Belgaum

2. Objectives
•Understand and critic JNC 8 guidelines
•Use clinical scenarios to discuss and understand
some of these recommendations
•Compare JNC-8 with other hypertension
guidelines
• SPRINT trial

3. JNC-7 Classification of HTN

5. • To allow the patients to sit for 3–5 minutes before beginning BP
measurements.
• To take at least two BP measurements, in the sitting position,
spaced 1–2 min apart, and additional measurements if the first two
are quite different. Consider the average BP if deemed appropriate.
• To take repeated measurements of BP to improve accuracy in
patients with arrhythmias (e,g. AF).
• To use a standard bladder (12–13 cm wide and 35 cm long), but
have a larger and a smaller bladder available for large (arm
circumference >32 cm) and thin arms, respectively.
• To have the cuff at the heart level, whatever the position of the
patient.
When measuring BP in the office, care should be taken

6. • When adopting the auscultatory method, use phase I and V
(disappearance) Korotkoff sounds to identify systolic and diastolic BP,
respectively.
• To measure BP in both arms at first visit to detect possible
differences. In this instance, take the arm with higher value as the
reference.
• To measure at the first visit, BP 1 and 3 min after assumption of the
standing position in elderly subjects, diabetic patients, and in other
conditions in which orthostatic hypotension may be frequent or
suspected.
When measuring BP in the office, care should be taken

8. 2003 2014
JNC-7 JNC-8
2005 2007 2009 2011
REIN-2
ESH/ESC
AHA
ACCOMPLISH
ONTARGET
HYVET ACCORD-BP
NICE
ACCF/AHA
ESH/ESC
ASH/ISH
CAMELOT
ALTITUDE
Growing Evidence
SPRINT study2015

10. The panel members appointed to JNC 8 were selected
from more than 400 nominees based on expertise in
hypertension (n = 14), primary care (n = 6), including
geriatrics (n = 2), cardiology (n = 2), nephrology (n = 3),
nursing (n = 1), pharmacology (n = 2), clinical trials (n =
6), evidence-based medicine (n = 3), epidemiology (n =
1), informatics (n = 4), and the development and
implementation of clinical guidelines in systems of care
(n = 4).
Who is the JNC-8

11. 2014 JAMA HTN Guidelines
Clinical Questions (JNC-8)

14. Case Scenario-1
A 67 year male is on regular treatment for HTN.
He does not have any complaints.
His average blood pressure in the last week is 136/88 mmHg
( Verified by repeated check ups).
What to do for him?

16. HTN in the Elderly
• Comparison of different guidelines
– 2014 JAMA: > 60 y/o = < 150/90
– ESH/ESC: >80 y/o or elderly < 80 y/o = < 150/90
– CHEP: >80 y/o = < 150/90
– NICE: > 80 y/o = < 150/90
– ASH/ISH: > 80 y/o = < 150/90

17. Case Scenario-1
A 67 year male is on regular treatment for HTN.
He does not have any complaints.
His average blood pressure in the last week is 136/88 mmHg
( Verified by repeated check ups).
What to do for him?
Continue the same medications

18. Case Scenario-2
A 40 year male is first time diagnosed to have increased blood
pressure while undergoing health checkup.
He does not have any complaints.
His average blood pressure in the last week is 150/94 mmHg.
His father and mother have Primary HTN
What to do for him?

21. Case Scenario-2
A 40 year male is first time diagnosed to have increased blood
pressure while undergoing health checkup.
He does not have any complaints.
His average blood pressure in the last week is 150/94 mmHg.
His father and mother have Primary HTN
What to do for him?
His DBP should be brought to <90 mm Hg
SBP should be brought <140 mm Hg

22. A 43 y/o woman with HTN returns for a follow up visit of her BP.
On exam today, her BP is 138/88 (and verified on repeat). Her
serum creatinine is 1.6 mg/dL, and her RUA reveals > 500
mg/dL of proteinuria. She is on Losartan 100 mg/day.
A. Change to ACE inhibitor like Ramipril
B. Add thiazide diuretic
C. Increase her ARB dose
D. Continue Same
Case Scenario-3

23. Comparison:
– ESH/ESC: no proteinuria = < 140/90
with proteinuria = < 130/90
-- CHEP: < 140/90 for all
-- KDIGO: no proteinuria = < 140/90
with proteinuria = < 130/80

24. A 43 y/o woman with HTN returns for a follow up visit of her BP.
On exam today, her BP is 138/88 (and verified on repeat). Her
serum creatinine is 1.6 mg/dL, and her RUA reveals > 500
mg/dL of proteinuria. She is on Losartan 100 mg/day.
A. Change to ACE inhibitor like Ramipril
B. Add thiazide diuretic
C. Increase her ARB dose
D. Continue Same
Case Scenario-3
KDIGO, ESH/ESC
JNC-8

25. A 43 y/o Type 2 DM and HTN, presents for follow up.
His medication regimen: Metformin 500mg BID, Lis/HCT 20/25mg daily,
Amlodipine 5mg, and ASA 81mg.
On exam, his BP = 138/88 mmHg.
On lab review, his CBC, BMP, and RUA are normal. His A1c=8.3%.
In addition to adjusting his Type 2 DM medication regimen, what additional
changes would you make?
A. None
B. Increase Amlodipine to 10mg
C. Increase Lisinopril to 40mg
D. Add an additional BP agent, such as a beta-blocker
Case Scenario-4

28. A 43 y/o Type 2 DM and HTN, presents for follow up.
His medication regimen: Metformin 500mg BID, Lis/HCT 20/25mg daily,
Amlodipine 5mg, and ASA 81mg.
On exam, his BP = 138/88 mmHg.
On lab review, his CBC, BMP, and RUA are normal. His A1c=8.3%.
In addition to adjusting his Type 2 DM medication regimen, what additional
changes would you make?
A. None
B. Increase Amlodipine to 10mg
C. Increase Lisinopril to 40mg
D. Add an additional BP agent, such as a beta-blocker
Case Scenario-4

30. “Demotion” of beta-blockers
Admittedly doesn’t include newer agents
“Demotion” of ACE-I and ARBs in African-Americans
Unless CKD
Absence of a specific recommendation for ACE-I and ARBs in Diabetics
In absence of albuminuria

35. Recommendation Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP
goal of 150/90 mmHg.
A
2. General population < 60 y/o, initiate medications and treat to
DBP goal of 90 mmHg.
A/E
3. General population < 60 y/o, initiate medications and treat to
SBP goal of 140 mmHg.
E
4. In population > 18 y/o with CKD, initiate medications and treat to
BP goal of 140/90 mmHg.
E
5. In population > 18 y/o with DM, initiate medication and treat to
BP goal of 140/90 mmHg.
E
2014 JAMA Hypertension Guideline
Recommendations

36. Recommendation Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
B
7. In general black population (including DM), initial anti-hypertensive
therapy should include thiazide diuretic or CCB.
C
8. In population with CKD, initial (or add-on) anti-hypertensive
therapy should include ACE-I or ARB.
B
9. Main objective of therapy is to attain and maintain a BP goal and
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
E
2014 JAMA Hypertension Guideline
Recommendations

37. Remarks JNC-8
Five of 9
recommendations
are “E” No recommendation
to decrease
medicines in well-
controlled elderlyOnly deals with
one risk
factor—BP

38. 9361 people
With Cardiovascular Risks
SBP>130 mm Hg
Non-DM
Systolic Blood Pressure Intervention Trial
NEJM Nov 9,2015
Intensive SBP
control
<120 mm Hg
Standard SBP
control
<140 mm Hg
121.4 mm Hg 136.2 mm Hg
After one year of study
Reduced Cardiovascular
Mortality and All cause
mortality
Increased rates of
Syncope, Hypotension,
electrolyte imbalances ,AKI

39. Conclusions
The risk of CVD beginning at
115/75 mmHg and
doubles with each increment of 20/10
mmHg
Individuals who are
normotensive at age 55 have a
90 percent lifetime risk for
developing hypertension
Diagnosing and starting
treatment is a challenge at
community level because many
of them are asymptomatic
Diagnose if >140/90
Treat to <140/90

40. The More We Learn, the Less We Know
Thank you
Diagnose if >=140/90
Treat to <140/90