8. Category Systolic Diastolic
Optimal <120 and >80
Normal 120-129 and/or 80–84
High normal 130-139 and/or 85–89
Grade 1 hypertension 140-159 and/or 90-99
Grade 2 hypertension 160-179 and/or 100-109
Grade 3 hypertension ≤180 and/or ≤110
Isolated systolic
hypertension
≤140 and >90
Definitions and classification of office BP levels (mmHg)
The blood pressure (BP) category is defined by the highest level of BP, whether
systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3
according to systolic BP values in the ranges indicated
9.
10. Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
Risk FactoRs
• Male sex
• Age (men ≥55 years; women ≥65
years)
• Smoking
• Dyslipidaemia
TC > 190 mg/dL, and/or
LDL >115 mg/dL, and/or
HDL: men <40 mg/dL, women < 46
mg/dL, and/or
Triglycerides >150 mg/dL
• Fasting plasma glucose 102–
125 mg/dL
• Abnormal glucose tolerance
test
• Obesity [BMI ≥30 kg/m²
(height²)]
• Abdominal obesity
(waist circumference: men ≥102
cm;women ≥88 cm)
• Family history of premature
CVD (men aged <55 years;
women aged <65 years)
11. Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
asymptomatic oRgaN Damage
• Pulse pressure (in the
elderly) ≥60 mmHg
• ECG :LVH (Sokolow–Lyon
index >3.5 mV;RaVL >1.1 mV;
Cornell voltage duration
product >244 mV x ms), or
• Echo: LVH [LVM index: men
>115 g/m²;women >95 g/m²
(BSA)]
• Carotid wall thickening (IMT
>0.9 mm) or plaque
• Carotid–femoral PWV >10 m/s
• Ankle-brachial index <0.9
• CKD with eGFR 30–60
ml/min/1.73 m² (BSA)
• Microalbuminuria (30–300
mg/24 h), or albumin–
creatinine ratio 30–300 mg/g;
(preferentially on morning spot
urine)
12. Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
Diabetes mellitus
• Fasting plasma glucose ≥126 mg/dL on two
repeated measurements, and/or
• HbA1c >7% , and/or
• Post-load plasma glucose >198 mg/dL
13. Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
EstablishEd CV or rEnal disEasE
• Cerebrovascular disease: stroke; TIA
• CHD:MI; angina; revascularization with PCI or CABG
• HF, including HF with preserved EF
• Symptomatic lower extremities PAD
• CKD with eGFR <30 mL/min/1.73m²(BSA);
proteinuria (>300 mg/24 h).
• Advanced retinopathy: haemorrhages or exudates,
papilledema
14. Blood Pressure (mmHg(
High normal
SBP 130–139
or DBP 85–89
Grade 1 HT
SBP 140–159
or DBP 90–99
Grade 2 HT
SBP 160–179
or DBP 100–109
Grade 3 HT
SBP ≥180
or DBP ≥110
Other risk factors,
asymptomatic organ
damage or disease
No other RF
1-2RF
≤3RF
OD, CKD stage 3 or
diabetes
Symptomatic CVD,
CKD stage ≥4 or
diabetes with OD/RFs
BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; CVD =
cardiovascular disease; DBP = diastolic blood pressure; HT = hypertension;
OD = organ damage; RF = risk factor; SBP = systolic blood pressure
Total CV RISK
15. Stratification of total CV risk in categories of low, moderate, high and very high
risk according to SBP and DBP
and prevalence of RFs,Asymptomatic OD,diabetes,CKD stage or symptomatic CVD.
16. Initiation of lifestyle changes and antihypertensive drug treatment.
Targets of treatment are also indicated(<140/90).
(in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)
17. Blood Pressure (mmHg(
High normal
SBP 130–139
or DBP 85–89
Grade 1 HT
SBP 140–159
or DBP 90–99
Grade 2 HT
SBP 160–179
or DBP 100–109
Grade 3 HT
SBP ≥180
or DBP ≥110
Other risk factors,
asymptomatic organ
damage
or disease
No other RF
1-2RF
≤3RF
OD, CKD stage 3 or
diabetes
Symptomatic CVD,
CKD stage ≥4 or
diabetes with OD/RFs
Com
pelling
indications
No Compelling indications
Choice of drug treatment
18. Any Body Can Dance
A B C D
2013 Indian dance film
20. Diuretics (thiazides,chlorthalidone and
indapamide), beta-blockers,calcium antagonists,
ACE inhibitors, and angiotensin receptor blockers
are all suitable and recommended for the initiation and
maintenance of antihypertensive treatment, either as
monotherapy or in some combinations with each other
Choice of drug treatment
No suggestion, all 5 classes
No ranking or classification of preferred
drugs
AA BB
CC DD
21. Possible combinations of classes of
antihypertensive drugs
Green continuous lines: preferred combinations;
green dashed line: useful combination (with some limitations);
black dashed lines: possible but less well-tested combinations;
red continuous line: not recommended combination.
DD
AA
AA
CC
BB
24. This JNC 8 guideline has not redefined high BP,
and considers the 140/90 mm Hg definition from
JNC 7 reasonable.
Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 < 80
Pre – hypertension 120-139 80-90
Hypertension
Stage 1 140 – 159 90 – 99
Stage 2 160 and above 100 and above
26. Questions guiding the JNC 8 review
This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management.
They address thresholds, goals for pharmacologic treatment, and whether particular
antihypertensive drugs or drug classes improve important health outcomes compared to others.
1.In adults with hypertension, does initiating antihypertensive pharmacologic
therapy at specific BP thresholds improve health outcomes?
2.In adults with hypertension, does treatment with antihypertensive
pharmacologic therapy to a specified BP goal lead to improvements in health
outcomes?
3.In adults with hypertension, do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on specific health outcomes?
The answers to these three questions are reflected in 9 recommendations
27. Recommendation 1
(Strong recommendation)
Recommendation 2
(Strong recommendation)
Recommendation 3
(Expert opinion)
General population
≥60 years
SBP ≥150 mm Hg
or DBP ≥90 mm Hg
SBP <150 mm Hg
and DBP <90 mm Hg
General population
<60 years
DBP ≥90 mm Hg DBP <90 mm Hg
General population
<60 years
SBP ≥140 mm Hg SBP <140 mm Hg
Recommendations
GoalsBP thresholds
28. Recommendation 4
(Expert opinion)
Recommendation 5
(Expert opinion)
Recommendation 6
(Moderate recommendation)
Population with CKD
≥18 years
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
Population with diabetes
≥18 years
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
General nonblack
population ( ± diabetes )
or
Recommendations
GoalsBP thresholds
Initial treatment
AA CC DDor
29. Recommendations
Recommendation 7
(Moderate recommendation)
Recommendation 8
(Moderate recommendation)
Recommendation 9
(Expert opinion)
General ( ± diabetes )
black population or
Population with CKD
≥18 years
Goal BP not reached
within a month of treatment
Increase the dose of the initial drug,
or add a second drug (from the list provided)
Goal BP not 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
Initial treatments
Initial or add-on treatments
Non control strategies
CC DD
AA
30. DM CKD
CC DD AA
BB
AA CC DD
Alone or in combination
Alone or in
combination with
other drug class
31. Focus on evidence based recommendations
Higher target SBP for patients over 60 y/o
Limited data to support either 150 or 140 mmHg
Removed special lower target BP
for those with CKD or DM
Liberalized initial drug choices
Major changes from JNC 7
AA CC DD
32.
33. Drug Selection in Hypertensive Patients
A. When hypertension is the only or main condition
Patient Type
Black patients
(African ancestry
First Drug Add Second Drug If
Needed to Achieve
a BP <140/90 mm Hg
If Third Drug is
Needed to Achieve
BP of <140/90 mm Hg
All ages
or
CC
DD
AA
CC
DD
+
+
Black CD
DD
AA CC
34. Drug Selection in Hypertensive Patients
A. When hypertension is the only or main condition
Patient Type
White and other
non- black Patients
First Drug Add Second Drug If
Needed to Achieve a
BP <140/90 mm Hg
If Third Drug is
Needed to
Achieve
a BP of <140/90
mm Hg
Younger than 60
60y and older
AA
CC
DD
or AA
CC
DD
CC DDor
AA
Also OK AA CC
DD
+
+
35. Drug Selection in Hypertensive Patients
B. When hypertension is associated with other conditions
Patient Type First Drug Add Second Drug If
Needed to Achieve a
BP <140/90 mm Hg
If Third Drug is Needed
to Achieve a BP of
<140/90 mm Hg
Hypertension
and diabetes
Note: in black patients,
it is acceptable to start
with
Hypertension
and CKD
AA
CC DD
AA CC DDor
AA
CC
DD
+
+
AA
CC DDor
36. Nonblack
Younger than 60
60y and older
Black
Diabetes Note: in black patients,
it is acceptable to start
with
CKD
ASH/ISH
Initial Drug
ChoicesJNC 8
AA
CC DD
CC DD
AA CC DD
AA
AA
CC DD
AA
Also OK
AA
CC DD
39. Population Goal BP,
mm Hg
Initial Drug Treatment Options
General nonelderly >140/90
General elderly <80 y
General ≥80 y >150/90
Diabetes >140/85
CKD >140/90
CKD + proteinuria >130/90
General <60 y >140/90 Nonblack
Black
General ≥60 y >150/90
Diabetes >140/90
CKD 140/90
ESH/ESC
JNC8
AA BB CC DD
AA
AA CC DD
CC DD
AA CC DD
AA
RAAS and angiotensin II are activated in the insulin resistance state, and RAAS inhibition has effects on insulin action and secretion. Indeed, the vasodilation induced by ACE inhibitors could improve the blood circulation in skeletal muscles, thus favoring peripheral insulin action, but also in the pancreas, promoting insulin secretion. Preserving cellular potassium and magnesium pools by blocking the aldosterone effects could also improve both cellular insulin action and insulin secretion. However, besides these classical effects, new mechanisms have been recently suggested. A direct effect of the inhibition of angiotensin and/or of the enhancement of bradykinin on various steps of the insulin cascade signaling has been described as well as an increase in GLUT4 glucose transporters after RAS inhibition. Furthermore, it has been demonstrated that angiotensin II inhibits adipogenic differentiation of human adipocytes and, therefore, it has been hypothesized that RAS blockade may prevent diabetes by promoting the recruitment and differentiation of adipocytes.
In conclusion, numerous physiological and biochemical mechanisms could explain the protective effect of RAS inhibition against the development of type 2 diabetes in individuals with arterial hypertension or congestive heart failure. What might be the main mechanism in the overall protection effect of ACEIs or ARBs remains an open question.
A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009.
A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users.
The primary end point was the cumulative incidence of new-onset diabetes mellitus.
A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009.
A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users.
The primary end point was the cumulative incidence of new-onset diabetes mellitus.
A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009.
A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users.
The primary end point was the cumulative incidence of new-onset diabetes mellitus.
