The document discusses guidelines for the management of high blood pressure from JNC 8 (2014). It provides: 1) Recommendations on when to initiate pharmacologic treatment based on systolic and diastolic blood pressure thresholds for general populations aged 60 years and older, younger than 60 years, and those with chronic kidney disease or diabetes. 2) Recommendations on treatment goals for different populations. 3) Recommendations on initial drug treatment options based on population, including thiazide-type diuretics, calcium channel blockers, ACE inhibitors, and ARBs.

1. JNC 8
2014 Evidence-Based Guideline for
the Management of
High Blood Pressure in Adults
Dr. Asif Mehmood R.Ph
Pharm. D

2. Hypertension (HTN) is a major public health concern, affecting
26% of adults worldwide1
Number of
people with HTN
worldwide in 20001
972 million
Increase in the
number of adults with
HTN globally by 20251
60%
Percent of all global
healthcare spending
attributable to high
blood pressure2
10%
Annual worldwide cost of
hypertension2
$370 billion
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The
global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.
1.6 Billion
HTN patients estimated
by 2025

3. EU Prevalence of Hypertension
~81 MillionAdults have elevated Blood Pressure
Lloyd-Jones D: Circulation 2010;121:e46 – e215
Persell SD: Hypertension 2011;57:1076-1080
EU Patients with HTN 81.0M
Diagnosed HTN 78%
Treated HTN 68%
Uncontrolled HTN 38%
Resistant HTN 9% - $7.2M
81M
Patients with HTN
Diagnosed HTN
Treated HTN
Uncontrolled HTN
HTN=Hypertension

4. • % age of Pakistani
adults with HTN
18%
• %age of Pakistani
above 45 years of
age
33%
• are only adequately
controlled HTN
Cases.
12.5%
Fahad Saleem et al; Br J Gen Pract. 2010 June 1; 60(575): 449–450. doi: 10.3399/bjgp10X502182
Time to take some
serious action

5. 0
1
2
3
4
5
6
7
8
9
120/80 140/90 160/100 180/110
HTN leads to an increased risk of death from stroke and heart
disease
Systolic BP / Diastolic BP (mmHg)
8x
4x
2x
CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2
Cardiovascular
Mortality
Risk
Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913

6. Risk Factors for Cardiovascular Disease
• Smoking
• Hyperlipidaemia
• High salt intake
• Homocysteinaemia
• Lack of exercise
• Obesity
• Diabetes
• Alcohol >4pints of beer/day
• Genetic

7. Accurate Reading of Blood Pressure
sphygmomanometer
Siting comfortably
Back supported
Legs uncrossed
Upper arm bared
Arm at heart level
Cuff bladder encircle >80%
pts arm
Deflate 2-3mm per
second
SBP INACCURATELY HIGH IF: patient is supine, crossed legs, arm below
the heart, arm unsupported, undersized cuff.
AHA guidelines

9. Question-1
• Specific BP thresholds for
• Start of antihypertensive pharmacologic therapy
• Improvement in health outcomes?
• 1) > 160 mm Hg
• 2) > 150 mm Hg
• 3) > 140 mm Hg
• 4) > 130 mm Hg

10. Question-2
• Does a specified BP goal lead to improvements in
health outcomes?
• 1) 130/80 mm Hg in a diabetic
• 2) < 140/90 in an 84 year old female
• 3) < 140/90 in a patient with CKD
• 4) < 120/80 in a 38 year old male

11. Question-3
• Do various antihypertensive drugs or drug
classes
• differ in comparative benefits and harms on
• Specific health outcomes

12. Level of Recommendation
JAMA. 2013;():. doi:10.1001/jama.2013.284427
Grade Strength of Recommendation
A Strong Recommendation
B Moderate Recommendation
C Weak Recommendation
There is at least moderate certainty based on evidence that there is a small net benefit.
D Recommendation against
There is at least moderate certainty based on evidence that it has no net benefit or that
risks/harms outweigh benefits.
E Expert Opinion
(“There is insufficient evidence or evidence is unclear or conflicting, but this is what the
committee recommends.”) Net benefit is unclear.

13. 2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
1

14. JAMA. 2013;():. doi:10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
JNC 8 (2014 Hypertension Guideline Management Algorithm)
2

15. JAMA. 2013;():. doi:10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
JNC 8 (2014 Hypertension Guideline Management Algorithm)
3

16. JNC 8 (2014 Hypertension Guideline Management Algorithm)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not
be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan.
Full

17. Start one drug, titrate to maximum dose, and then
add a second drug
Start one drug and then add a second drug
before achieving maximum dose of the initial
drug
Begin with 2 drugs at the same time, either as 2
separate pills or as a single pill combination
Strategies to Dose of Antihypertensive Drugs

18. RECOMMENDATIONS FOR
MANAGEMENT OF
HYPERTENSION
JNC-8
2014 Guideline for Management of High Blood Pressure

19. Recommendation 1
• In the general population aged ≥60 years
• Initiate pharmacologic treatment to lower blood pressure
(BP) at systolic blood pressure (SBP)150 mmHg or diastolic
blood pressure (DBP)90mmHg
• Treatment goal SBP <150 mm Hg and goal DBP <90
mmHg.
• (Strong Recommendation – Grade A)

20. Recommendation 1Corollary Recommendation
• In the general population aged ≥60years
•
• Treatment does not need to be adjusted
• if pharmacologic treatment for high BP results in
lower achieved SBP (eg, <140mmHg) and
treatment is well tolerated and without adverse
effects on health or quality of life.
• (Expert Opinion – Grade E)

21. Recommendation 2
•In the general population <60 years
• Initiate pharmacologic treatment to lower
BP at DBP 90mmHg
• Treatment goal DBP<90mmHg.
• For ages 30-59 years
• Strong Recommendation – Grade A
• For ages 18-29 years
• Expert Opinion – Grade E

22. Recommendation 3
• In the general population <60 years
• Initiate pharmacologic treatment to lower BP at
SBP ≥ 140mmHg
• Treatment goal SBP <140mmHg.
• (Expert Opinion – Grade E)

23. Recommendation 4
• In the population aged ≥18 years with chronic kidney
disease (CKD)
• Initiate pharmacologic treatment to lower BP at SBP ≥
140mmHg or DBP ≥ 90mmHg
•
• Treatment goal SBP<140mmHg and goal DBP<90mmHg.
• (Expert Opinion – Grade E)

24. Recommendation 5
• In the population aged ≥18years with diabetes
• Initiate pharmacologic treatment to lower BP at SBP ≥
140mmHg or DBP ≥ 90mmHg
• Treatment goal SBP <140mmHg and DBP <90mmHg.
• (Expert Opinion –Grade E)

25. Recommendation 6
• General nonblack population, including those with diabetes
• Initial antihypertensive treatment should include:
• A thiazide-type diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor (ACEI), or
angiotensin receptor blocker (ARB).
• Moderate Recommendation – Grade B

26. Recommendation 7
• General black population, including those with diabetes
• Initial antihypertensive treatment should include a
thiazide-type diuretic or CCB.
• For general black population
• Moderate Recommendation –Grade B
• For black patients with diabetes
• Weak Recommendation – Grade C)

27. Recommendation 8
• In the population aged ≥18 years with CKD
• Initial (or add-on) antihypertensive treatment
• Should include an ACEI or ARB to improve kidney outcomes.
• Applies to all CKD patients with hypertension regardless
of race or diabetes status.
• Moderate Recommendation – Grade B

28. 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 recommendation6 (thiazide-type diuretic, CCB, ACEI, or ARB).
• The clinician should continue to assess BP and adjust the treatment regimen until
goal BP is reached.
• 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 only 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. Referral to a hypertension specialist may be indicated for patients in
• Whom goal BP cannot be attained using the above strategy or for the
management
• of complicated patients for whom additional clinical consultation
• is needed. (Expert Opinion – Grade E)

30. JNC 7
• Nonsystematic literature
review by expert committee
including a range of study
designs
• Recommendations based on
consensus
JNC 8 (2014 Hypertension Guideline)
• Critical questions and review
criteria defined by expert panel
with input from methodology
team
• Initial systematic review by
methodologists restricted to
RCT evidence
• Subsequent review of RCT
evidence and recommendations
by the panel according to a
standardized protocol

31. JNC 7
• Defined hypertension and
prehypertension
JNC 8 (2014 Hypertension Guideline)
• Definitions of hypertension
and prehypertension not
addressed
• But thresholds for
pharmacologic treatment
were defined

32. JNC 7
• Separate treatment goals
defined for
• “uncomplicated”hypertension
• Subsets with various
comorbid conditions
• (diabetes and CKD)
JNC 8 (2014 Hypertension Guideline)
• Similar treatment goals
defined for all hypertensive
populations
• Except when evidence
review supports different
goals for a particular
subpopulation

33. JNC 7
• Recommended lifestyle
modifications
• Based on literature review
and expert opinion
JNC 8 (2014 Hypertension Guideline)
• Lifestyle modifications
recommended by endorsing
the evidence based
Recommendations of the
Lifestyle Work Group

34. JNC 7
• Recommended 5 classes to be
considered as initial therapy
• Recommended thiazide-type
diuretics as initial therapy for most
patients without compelling
indication for another class
• Specified particular antihypertensive
medication classes for patients with
compelling indications, ie, diabetes,
CKD, heart failure, myocardial
infarction, stroke, and high CVD risk
• Included a comprehensive table of
oral antihypertensive drugs including
names and usual dose ranges
JNC 8 (2014 Hypertension Guideline)
• Recommended selection
among 4 specific medication
classes
• ACEI or ARB, CCB or diuretics
• Doses based on RCT evidence
• Recommended specific
medication classes based on
evidence review for racial, CKD,
and diabetic subgroups
• Panel created a table of drugs
and doses used in the outcome
trials

35. JNC 7
• Addressed multiple issues
• blood pressure measurement
methods
• Patient evaluation components
• Secondary hypertension
• Adherence to regimens
• Resistant hypertension
• Hypertension in special
populations
• Based on literature review
and expert opinion
JNC 8 (2014 Hypertension Guideline)
• Addressed a limited number
of questions
• Those judged by the panel to be
of highest priority.
• Evidence review of RCTs

36. JNC 7
• Reviewed by the National High
Blood Pressure Education
Program
• Coordinating Committee
• a coalition of 39 major professional
• Public and voluntary organizations
and 7 federal agencies
JNC 8 (2014 Hypertension Guideline)
• Reviewed by experts
including those affiliated with
• Professional
• Public organizations
• Federal agencies
• No official sponsorship by
any organization should be
inferred

37. JAMA. 2013;():. doi:10.1001/jama.2013.284427
Guideline Population Goal BP,
mm Hg
Initial Drug Treatment Options
JNC 8
2014 Hypertension
guideline
General ≥60 y <150/90 Nonblack: thiazide-type diuretic, ACEI, ARB, or CCB
General <60 y <140/90 Black: thiazide-type diuretic or CCB
Diabetes <140/90 Thiazide-type diuretic, ACEI, ARB, or CCB
CKD <140/90 ACEI or ARB
NICE 2011 General <80 y <140/90 <55 y: ACEI or ARB
General ≥80 y <150/90 ≥55 y or black: CCB
KDIGO 2012 CKD no
proteinuria
≤140/90 ACEI or ARB
CKD + proteinuria ≤130/80