The JNC 8 guideline provides evidence-based recommendations for treating hypertension. It focuses on three key questions: 1) what BP thresholds should initiate treatment, 2) what treatment goals are appropriate, and 3) which drug classes are most effective and safe. Major recommendations include treating those over 60 to a goal of <150/90 mmHg, initiating treatment in others at 140/90 mmHg, and using thiazide diuretics, ACE inhibitors, ARBs, or CCBs as initial treatment. The guideline aims to simplify prior recommendations and focus on outcomes from randomized controlled trials.

1. HYPERTENSION JNC 8 GUIDELINE
Speaker- Dr. Chandan Kumar

2. • Hypertension definition :
Office blood pressure of 140/90 mm Hg or higher.
• Average awake blood pressure >135/85 and asleep
blood pressure >120/75 on 24 hr blood pressure
monitoring.
• Children and adolescents Hypertension - systolic
and/or diastolic BP consistently >95 percentile for age,
sex and height.
• Night time blood pressure are generally 10-20% lower
than daytime blood pressure

3. • Hypertension doubles the risk of cardiovascular
diseases , including coronary heart disease ,CHF,
ischemic and hemorrhagic stroke , renal failure ,
and peripheral arterial disease.
• Approximately 7.6 million deaths ( 13 - 15% of
the total) worldwide were attributable to high
blood pressure .
• Benefit of HTn treatment- 40% reduction in
stroke incidence, 25% reduction in myocardial
infarction, >50% reduction in heart failure

5. All population
Hypertensives
Diagnosed
Treated for high BP
Adequately treated
Rule of Halves

6. • Measurement technique :
• Tobacco, caffeine, exercise should be avoided for 30 min.
• Seated quietly in a chair with feet on the floor and back
supported for 5 min in a private , quiet setting with a
comfortable room temperature.
• Width of cuff bladder should equal at least 40% of the arm
circumference; the length should encircle at least 80% of the
arm circumference.
• Rate of deflation of the cuff (2 mmHg/s)

7. • Hemodynamic Subtypes
• Three distinctly different hemodynamic
subtypes that vary sharply by age
• Systolic Hypertension in Teenagers and Young
Adults : ISH main type in adult (17-25).
Increased cardiac output and stiff aorta due to
overactivity of sympathetic nervous system.
Male>Female.
Predispose to diastolic HTn in middle age.

8. +
36
. Diastolic Hypertension in Middle Age
30 to 50 of age, isolated diastolic or combined
systolic diastolic HTn.
Common in male associated with weight gain.
Due to elevated systemic vascular resistance
with normal cardiac output
. Isolated Systolic Hypertension in Older Adults
Stiffening of central aorta and rapid return of
reflected pulse wave from periphery

9. • Hypertensive crises characterized by severe
hypertension and acute target-organ damage to
the brain, heart, kidney, retina, or blood vessels.
Typically, BP is 220/130 mm Hg or higher but
may be much lower in women with
preeclampsia who do not have preexisting
hypertension
• Hypertensive urgency denotes severe
uncontrolled hypertension without evidence of
acute target-organ damage

10. • Severe hypertension, defined as a BP of
180/110 mm Hg to 220/130 mm Hg without
symptoms of acute target-organ damage-
Almost always occurs in patients with chronic
hypertension who stopped medication
• Resistant Hypertension
• High BP uncontrolled with three or controlled
with at least four antihypertensive drugs
(including a diuretic)—is associated with a
higher prevalence of secondary hypertension
and worse CV and renal outcomes

11. • Blood pressure : lateral force per unit area of
vascular wall
• BP in arrythmia : few cycles measured, average
taken
• BP in shock : direct intraarterial pressure
measurement
• Isotonic exercise : moderate increase in BP ,systolic
BP > mean
• Isometric exercise : abrupt increase in all systolic
diastolic and mean pressure

12. • Pseudohypertension : measured pressure far
higher than intraarterial pressure
Found in elderly
• White coat hypertension : 3 clinic BPs
>140/90 , 2 home BP <140/90 , without target
organ damage
• Masked hypertension : Normal clinic BP in
presence of target organ damage. Found in
peripheral artery disease.

13. Secondary causes of hypertension

14. JNC 8

15. • JNC 8 aims and objectives:
• The panel members appointed to JNC8 used ri
• To develop Evidence Statements
• To develop Recommendations for high blood
pressure(BP) treatment based on a systematic
review of the literature to meet user needs,
especially the needs of the primary clinician.

16. • In adults with hypertension, does initiating
antihypertensive pharmacologic therapy at specific BP
thresholds improve health outcomes?
1
• In adults with hypertension, does treatment with
antihypertensive pharmacologic therapy to a specified
goal lead to improvements in health outcomes?
2
• In adults with hypertension, do various antihypertensive
drugs or drug classes differ in comparative benefits and
harms on specific health outcomes?
3
The evidence-based hypertension guidelines focuses on the
three questions

17. • Inclusion Criteria
. Evidence review to Randomised controlled trials
only.
• focused on adults aged 18 years or older with
hypertension.
. Studies with the following prespecified subgroups:
diabetes, CAD, PAD, CHF, previous stroke, CKD,
proteinuria, older adults, men and women, racial
and ethnic groups, and smokers.

18. • Exclusion criteria :
• Studies with sample sizes <100
• Studies with follow up period < 1 year
• Studies that enrolled prehypertensive or
nonhypertensive individuals

19. Grades Strength of Recommendation
A Strong Recommendation
There is high certainty based on evidence that the net benefit is substantial.
B Moderate Recommendation
There is moderate certainty based on evidence that the net benefit is moderate to substantial or there is high
certainty that the net benefit is moderate.
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. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, but the committee thought it was important to
provide clinical guidance and make a recommendation. Further research is recommended in this area.
N No Recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)
Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, and the committee thought no recommendation
should be made. Further research is recommended in this area.

21. Recommendation 1
• In the general population aged 60 years or older, initiate
pharmacologic treatment to lower BP at systolic blood
pressure (SBP) of 150mmHg or higher or diastolic blood
pressure (DBP) of 90mmHg or higher and treat to a goal
SBP lower than 150mmHg and goal DBP lower than
90mmHg.
• Strong Recommendation – Grade A
Corollary Recommendation
• In the general population aged 60 years or older, if
pharmacologic treatment for high BP results in lower
achieved SBP (for example,<140mmHg) and treatment is
not associated with adverse effects on health or quality of
life, treatment does not need to be adjusted.
• Expert Opinion – Grade E

22. Recommendation 2
• In the general population younger than 60 years, initiate
pharmacologic treatment to lower BP at DBP of 90 mm Hg
or higher and treat to a goal DBP of lower than 90mmHg.
• For ages 30 through 59 years, Strong Recommendation –
Grade A
• For ages 18 through 29 years, Expert Opinion – Grade E
• Recommendation 3
• In the general population younger than 60 years, initiate
pharmacologic treatment to lower BP at SBP of 140 mm Hg
or higher and treat to a goal SBP of lower than 140mmHg.
• Expert Opinion – Grade E

23. Recommendation 4
• In the population aged 18 years or older with CKD, initiate
pharmacologic treatment to lower BP at SBP of
140mmHg or higher or DBP of 90mmHg or higher and
treat to goal SBP of lower than 140mmHg and goal DBP
lower than 90mmHg.
• Expert Opinion – Grade E
Recommendation 5
• In the population aged 18 years or older with diabetes,
initiate pharmacologic treatment to lower BP at SBP of
140mmHg or higher or DBP of 90 mm Hg or higher and
treat to a goal SBP of lower than 140mmHg and goal DBP
lower than 90mmHg.
• Expert Opinion – Grade E

24. • Recommendation 6
• In the 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
• Recommendation 7
• In the 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

25. Recommendation 8
• In the population aged 18 years or older with CKD
and hypertension, initial (or add-on )
antihypertensive treatment should include an ACE I
or ARB to improve kidney outcomes. This applies to
all CKD patients with hypertension regardless of
race or diabetes status.
• Moderate Recommendation – Grade B

26. • Recommendation 9
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 recommendation 6
Or
Start initially itself with 2 medication classes separately or as fixed dose
combinations
• 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 the drugs in recommendation
6,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.
• Expert Opinion – Grade E

27. TOPIC JNC 7 JNC 8
Methodology •Nonsystematic literature review by expert
committee.
•Included a range of study designs.
•Recommendations based on concensus.
•Critical questions & review criteria defined by
expert panel
•Systematic review by methodologists
restricted to RCT evidence
•Recommendations according to a
standardized protocol.
Definitions •Defined Hypertension & Prehypertension •Not redefined hypertentension
Treatment goals •Separate goals for uncomplicated HTN &
with various comorbid conditions
•Similar treatment goals for all hypertensive
populations except when evidence review
supports different goals for a particular
subpopulation
Lifestyle Recommendations •Recommended based on literature review &
expert opinion
•Recommended by supporting Lifestyle Work
Group
Drug therapy •Recommended 5 classes to be considered as
initial therapy.
•Recommended thiazide type diuretics as
initial therapy for most
•Specified compelling indications with
particular antihypertensives to be used
•Included comprehensive table of oral
antihypertensives.
•Recommended selection among 4 specific
medication classes
•Recommended specific medication only for
racial, CKD, & diabetics
•Panel created a table of drugs & doses used
in the outcome trials.
Scope of topics Broad Limited
Review prior to publication •NHBPEPCC
•Public
•Voluntary organizations
•7 federal agencies
•Experts affiliated with professional & public
organizations
•Federal agencies

31. JNC 8 Simplified
• Treat to 150/90 mm Hg in patients over age 60 and
140/90 for everybody else.
• No staging
• Non black population-Start with any of the 4 drug
classes (thiazide diuretics, CCBs,ACE I, ARBs)
• Black population-Start with a thiazide diuretic or
CCB. (in black C & D ).
• CKD>18yrs- Start with an ACEI or ARB

32. • ACEI & ARB should not be used together
• There are 3 strategies of drug therapy, choose
any of the three.

33. • REFERENCES
• Harrisons principles of internal medicine 19 th edition
• Braunwalds 10th edition
• Staessen JA, Fagard R, Thijs L, et al; The Systolic Hypertension in Europe (Syst-Eur) Trial
Investigators. Randomised double-blind comparison of placebo and active treatment for
older patients with isolated systolic hypertension.Lancet.
Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension
in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887-1898.
• SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug
treatment in older persons with isolated systolic hypertension:final results of the Systolic
Hypertension in the Elderly Program (SHEP). JAMA.
Institute of Medicine. Clinical Practice Guidelines We Can Trust.Washington, DC:
National Academies Press; 2011. http://www.iom.edu/Reports/2011 /Clinical-Practice-
Guidelines-We-Can-Trust.aspx. Accessed November 4, 2013.
Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res
Eval. 2007;12(10). http://pareonline.net/pdf/v12n10.pdf. Accessed October 28, 2013

34. Historical Comments about
Hypertension
“The greatest danger to
a man with
high blood pressure
lies in its discovery…….
because then some fool is certain to try his
hand and reduce it.”
Hay, Brit Med J, 1931

35. THANK YOU