Guidelines for treatment of hypertension based on JNC 8

1. Guidelines for treatment of
hypertension
Sanjay. S
PhD student
Department of Pharmacology

2. Overview
• Introduction
• JNC report on management of hypertension
 Definition and classification
 Patient evaluation
 Hypertension management
• Summary

3. • Hypertension- characterised by a sustained elevation of arterial
blood pressure (BP) of more than 140/90 mm Hg
• Contributing factor to many cardiovascular disease and organ
damage including
 myocardial infarction (MI)
 stroke
 heart failure
 renal failure
 retinopathy
 leading cause of death
Introduction

5. Introduction(Contd.)
• Although it is associated with high morbidity and mortality,
hypertension is a preventable and manageable disease
• Control of BP leads to
– Approximately 50% reduction in heart failure
– Approximately 40% reduction in stroke
– Approximately 20-25% reduction in MI
• Early diagnosis, lifestyle modifications and adherence to therapy
are the key for hypertension management

6. Guidelines for treatment of hypertension
• To assist the medical practitioners in making treatment decisions,
several health agencies have released guidelines for management of
hypertension
• Based on high quality research evidence and expert consensus
• Physician adherence to evidence based care results in achieving
adequate BP control among hypertensive patients.
• The most widely accepted are the JNC guidelines

7. • The US National Heart, Lung, and Blood Institute, (NHLBI)
administers the National High Blood Pressure Education Program
(NHBPEP) Coordinating Committee.
• NHBPEP issues guidelines and advisories to increase awareness,
prevention, treatment, and control of hypertension.
• The Joint National Committee (JNC) consists of a panel of experts
appointed by NHBPEP.
• The JNC panel prepares guidelines for hypertension based on
research evidence and expert consensus
• Latest report- JNC 8
JNC report on management of hypertension

8. Comparison of JNC 7 and JNC 8
Topic JNC 7 JNC 8
Methodology Nonsystematic literature
review and
Recommendations based on
consensus
Systematic review of RCT evidence
and recommendations by the
panel
Definitions Defined hypertension and
prehypertension
Definitions not addressed
Treatment
goals Separate treatment goals for
“uncomplicated” hypertension
and hypertension with
comorbid conditions
Similar treatment goals for all
hypertensive populations
except when evidence review
supports different goals in
subpopulation

9. Comparison of JNC 7 and JNC 8- contd.
Life style
recommendations
Recommendation based on
literature review and
expert opinion
endorsed the evidence
based recommendations of
the LifestyleWork Group
Drug therapy Recommended 5 classes to
be considered as initial
therapy (ACEI
or ARB, CCB, diuretics and
beta blockers)
Recommended selection
among 4 specific
medication classes (ACEI
or ARB, CCB or diuretics)

10. Definition and classification
JNC 7
Category Systolic and diastolic BP
Normal blood pressure 120 mm Hg and <80 mm Hg
Prehypertension 120-139 mm Hg and/or 80-89 mm Hg
Stage I hypertension 140-159 mm Hg and/or 90-99 mm Hg
Stage II hypertension 160 mm Hg and/or 100 mm Hg

11. • Silent disease
• Asymptomatic
• Check BP regularly
Patient evaluation

12. Diagnosing BP
• When considering a diagnosis of hypertension, blood pressure has
to be measured in both arms.
• If the difference in readings between arms is more than 20 mmHg,
the measurement has to be repeated.
• If the difference in blood pressure between the arms persists in
the next measurement, subsequent measurements have to be
taken in the arm with the higher reading.

13. Diagnosing BP(Contd.)
• when blood pressure is 140/90 mmHg or higher, Ambulatory blood
pressure monitoring (AMPM) can be used to confirm the diagnosis
• In cases of intolerance to ABPM, home blood pressure monitoring
(HBPM) is a suitable alternative.

14. Ambulatory Blood Pressure Monitoring

15. Evaluation of new hypertensive patient
• To assess lifestyle and identify other cardiovascular risk factors or
concomitant disorders that may affect prognosis and guide
treatment
• The major risk factors to be looked for are
Age (>55 year for men, >65 years for women)
Presence of obesity (BMI>30)
Diabetes mellitus
Cigarette smoking
Sedentary lifestyle
Dyslipidemia
Microalbuminuria
Family history of premature cardiovascular disease
(men <55 years or women 65 years).

16. Evaluation of new hypertensive patient (Contd.)
• To reveal identifiable causes of high BP (presence of secondary
hypertension) like
Chronic kidney disease,
Primary aldosteronism,
Renovascular disease,
Chronic steroid therapy and Cushing syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Sleep apnea

17. Evaluation of new hypertensive patient (Contd.)
• To assess the presence or absence of target organ damage and
CVD e.g.
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

18. Pharmacotherapy
Initiation and BP goals

19. General population < 60 years
• Initiate pharmacological treatment to lower BP of 140/90 mm Hg
or higher
• Treat to a goal BP of lower than 140/90 mm Hg.
• Reduces cerebrovascular events, heart failure, and overall
mortality

20. General population < 60 years(Contd)
• HOT trial found no benefit in treating patients to a DBP goal of
either 80 mm Hg or lower or 85 mm Hg or lower compared
with 90 mm Hg
• No evidence for SBP threshold in this population group
• So recommendation from previous guidelines were followed

21. Elderly population(>60)
• Initiate at 150/90 mm Hg or higher
• Treat to a goal BP of less than 150/90 mm Hg
• Higher SBP due to progressive stiffening and non-compliance of
larger arteries
• Setting a goal SBP of lower than 140 mm Hg provided no
additional benefit compared with a higher SBP goal of 140 to 160
mm Hg or 140 to 149 mm Hg
• Treating to goal BP reduces stroke, heart failure, and coronary
heart disease

22. Population18 years or older
with CKD
• Initiate pharmacological treatment to lower BP at 140/90 mm Hg
or higher
• Treat to goal BP of lower than 140/90 mm Hg
• By further lowering BP, no improvement was observed in renal
damage progression

23. Population 18 years or older
with diabetes
• Initiate pharmacological treatment to lower BP at 140/90 mm Hg
or higher
• Treat to a goal BP of lower than 140/90 mm Hg
• The panel also recognizes that an SBP goal of lower than 130 mm
Hg is commonly recommended for adults with diabetes and
hypertension. However, this lower SBP goal is not supported by
any RCT showing important health outcomes

24. Choice of Drugs

25. General nonblack population
• In general nonblack population, including those with diabetes,
initial antihypertensive treatment should include a thiazide-type
diuretic, CCB, ACEI, or ARB.
• Each of the 4 drugs yielded comparable effects on overall mortality
and cardiovascular, cerebrovascular, and kidney outcomes, with
one exception: heart failure.
• Initial treatment with a thiazide-type diuretic (chlorthalidone, and
indapamide) was more effective than other classes in improving
heart failure outcomes.

26. General nonblack population(Contd)
• β-blockers not recommended for the initial treatment of
hypertension
• Use of β-blockers resulted in a higher rate of cardiovascular death,
myocardial infarction and stroke compared to use of an ARB

27. General black population
• In the general black population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic
or CCB.

28. Summary of JNC 8 recommendations on BP goal
and drug usage
Population Goal BP, mm Hg Initial drug therapy
General ≥60 y <150/90 Nonblack: thiazide-type
diuretic, ACEI, ARB, or
CCB
Black: thiazide-type
diuretic or CCB
General <60 y <140/90
Diabetes <140/90 Thiazide-type diuretic,
ACEI, ARB, or CCB
CKD <140/90 ACEI or ARB

29. Drug dosing strategy
• The main objective of hypertension treatment is to attain and
maintain goal BP.
• If goal BP is not reached within a month of treatment, the dose of
the initial drug should be increased or a second drug should be
added.
• If goal BP cannot be reached with 2 drugs, a third drug should be
added and titrated.

30. Drug dosing strategy(Contd.)
• If goal BP cannot be reached using the recommended drugs
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

31. Lifestyle modifications
• Salt restriction
• Moderation of alcohol consumption
• High consumption of vegetables, fruits and low-fat and other
types of diet (DASH and Mediterranean diet)
• Weight reduction and maintenance
• Regular physical exercise
• Smoking cessation.

32. Salt restriction
• Causal relationship between salt intake and high BP
• Excessive salt consumption –risk factor for resistant hypertension
• Recommended intake- 5-6 g/ day

33. List of Sodium content of foods part of Indian diet
<25 mg Low 25–50 mg
Moderate
50–100 mg
Moderately High
>100 mg High
Amla
Bitter gourd
Brinjal
Cabbage
Lady finger
Cucumber
Peas
Onion
Potato
Tomato ripe
Ragi
Vermicelli
Wheat
Maida
Milk
Grapes
Papaya
Orange
Raisins
Broad beans
Carrots
Reddish white
Black gram dal
Green gram dal
Red gram dal
Lentil whole
Bengal gram whole
Banana
Pineapple
Apple
Mutton
Cauliflower
Fenugreek
Lettuce
Field beans
Beetroot
Water melon
Bengal gram dal
Red gram tender
Liver
Prawns
Beef
Chicken
Bacon
Egg
Lobster

34. List of foods to be avoided in hypertensives
Table salt
Mono sodium glutamate (Ajinomoto)
Baking powder
Sodium bicarbonate
Fried foods
Alcohol
Salt preserved foods
Pickles and canned foods
Ketchup and sauces
Prepared mixes
Ready to eat foods
Highly salted foods
Potato chips
Cheese
Peanut butter
Salted butter
Papads
Bakery products: Biscuits, cakes, breads
and pastries

35. Smoking cessation
• Smoking- major risk factor for atherosclerotic CVD
• Stimulates sympathetic nervous system at the central level and
at nerve endings
• A parallel change in plasma catecholamine and impairment of
baroreflex are also related to smoking
• So smoking cessation is one of the most effective lifestyle
modification for the prevention of CVDs

36. Follow up
• During initial stages- visit every 2-4 weeks
• If target BP reached- every 3-6 months
• If target BP maintained- gradual reduction of number and dosage
of drugs
• Check BP every 2 years

37. Adherence to treatment
• Patient education about treatment – important for adherence
• Provide information about benefits and possible side effects
• Provide details about self-help groups and forums

38. Summary
• Hypertension-major public health problem - contributing factor
for several cardiovascular, renal and other organ damage.
• Although hypertension is highly prevalent-preventable and
manageable.
• Various guidelines -to assist medical practitioners in making
treatment decisions.
• The most widely accepted guidelines is the JNC guidelines

39. Summary(Contd)
• JNC 8 offers clinicians an analysis of available information about BP
treatment thresholds, goals, and treatment strategies to achieve
those goals based on high quality research evidence from RCT.
• Guidelines-not a substitute for clinical judgment, and decisions
about care must carefully consider and incorporate the clinical
characteristics and circumstances of each individual patient

40. Thank you