Hypertension Management

Hypertension Management
Dr. Aparna Sen Chaudhary
13-05-2018 1

Contents
1. Introduction
2. Management of Hypertension
3. Classification of Antihypertensive Drugs
4. HTN associated clinical conditions
5. DASH Diet
6. National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke
7. Primary Prevention
8. Public health approach
9. AYUSH Intervention
10. Joint National Committee 8 report: How it differ from JNC 7
13-05-2018 2

Introduction
•Most common controllable disease affecting around 40% of adult
population worldwide.¹
•It is reported to be fourth contributor of premature mortality in
developed and seventh in developing countries.¹
•In India, overall prevalence of 29.8% (urban: 33.8% vs. rural: 27.6%).²
13-05-2018 3

Introduction
13-05-2018 4
•Half (55%)
were aware of
their disease
state.
one third (36%)
of these are
under
treatment
a quarter
(28.2%) of
these had their
BP values
under control
*Raj GM, Priyadarshini R, Mathaiyan J. Current Perspectives in the Management of Hypertension. SAJ Cardiol.2015;1:101

Hypertension
•Definition :
• Chronic elevation in BP (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg).
13-05-2018 5

Hypertension
•Types:
• Essential Hypertension (80-95%)
Ethnicity (African, Americans
and Japanese)
Genetic Factors
High salt intake
Alcohol excess
Obesity
Lack of exercise
Impaired intrauterine growth
•Secondary Hypertension (5-20%)
Renal disease
Endocrine disorders
Pregnancy
Drugs
Coarctation of the aorta
13-05-2018 6

Treatment Guidelines
•Joint National Committee of America (JNC) – 8th (2014)
•National Institute for Health and Clinical Excellence (NICE) – 2011
•AHA/ACC/ASH Guidelines for Management of Hypertension in Patients
With Coronary Artery Disease – 2015
•Guidelines for the Management of Hypertension by International Society
of Hypertension – 2013
•Indian Guidelines for Management of Hypertension – III (2013)
13-05-2018 7

Classification of Blood Pressure (mmHg)
Category Systolic (mmHg) Diastolic (mmHg)
Optimal < 120 and < 80
Pre hypertension 120-139 and/or 80-89
Stage – 1
hypertension
140-159 and/or 90-99
Stage – 2
hypertension
≥160 and/or ≥100
JNC – 7 GUIDELINES
13-05-2018 8

13-05-2018 9
Category Systolic (mmHg) Diastolic (mmHg)
Optimal <120 And <80
Normal 120-129 And/or 80-84
High Normal 130-139 And/or 85-89
Grade 1 140-159 And/or 90-99
Grade 2 160-179 And/or 100-109
Grade 3 ≥180 And/or ≥110
Isolated systolic hypertension ≥ 140 and <90
Hypertensive urgency >180 and/or >110
Hypertensive emergency >180 and/or >110-120
*The Association of Physicians of India (2007)

Risk Stratification of Patients with Hypertension
Blood Pressure (mm Hg)
Stage Other risk factors and
disease history
Stage 1 Stage 2 Stage 3 (severe
hypertension
SBP - 140-159
or
DBP – 90-99
SBP- 160-179 or
DBP 100-109
SBP ≥ 180 or
DBP ≥ 110
I No other risk factor LOW –RISK MEDIUM RISK HIGH- RISK
II 1-2 risk factors MEDIUM RISK MEDIUM RISK VERY HIGH-RISK
III 3 or more risk factors HIGH- RISK HIGH- RISK VERY HIGH-RISK
IV Comorbid conditions :
Diabetes, CKD, CAD, CVD
VERY HIGH-
RISK
VERY HIGH-RISK VERY HIGH-RISK
13-05-2018 10*The Association of Physicians of India (2007)

13-05-2018 11
Standardized BP measurement procedure
Patient preparation
and position
i. Relaxed state for 5 minute before measurement
ii. Should not have had caffeine in past 1hour or smoked in past 30 mins.
iii. Seated comfortably with back supported
Choice of BP device Mercury sphygmomanometer or any other device which has been validated
Cuff size and placement i. Length of bladder - 80% of arm circumference; width – 40% of arm
circumference
ii. Large adult cuff for obese patients
iii. Constrictive clothing to be avoided
iv. Place the cuff over the pulsating brachial artery 2-3 cm above cubital fossa
Procedure to measure
systolic and diastolic
pressure
i. Inflate the cuff to 30 mm beyond the disappearance of the radial pulse
ii. Deflate 2-3 mm/sec and record the first and last sounds as the systolic and
diastolic pressure with the stethoscope
No. of measurements
and recording
i. Atleast 2 readings should be taken at an interval of 1 minute. If the readings
differ by more than 5 mm Hg take a third reading.
ii. The lower of the readings should be taken as the representative.

Source of Error during measurement of Blood Pressure
Source of measurement
error
Increase in Blood Pressure
Back is not supported Diastolic BP may increase by 6mm
Arm not at level of heart Increase BP by 10-12 mmHg
Legs are crossed Systolic BP increases by 2-8mm Hg
Caffeine in last 1hr Transient increase in BP
Smoking in previous 30 mins Transient increase in BP
Cuff size not appropriate Overestimate BP in Obese patients by 10-50 mmHg
Rapid deflation (>3mm/sec) Underestimate systolic BP and over estimate diastolic BP
Presence of anxiety Elevated BP readings (“WHITE COAT HYPERTENSION” or
“ISOLATED OFFICE HYPERTENSION”)
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RISK FACTORS
•Age (M>55yrs; W>65 yrs)
•Smoking
•Dyslipidaemia
• TC > 190mg/dl
• LCL-C > 115 mg/dl
• HDL-C: M < 40mg/dl ; W < 46mg/dl
• TG > 150 mg/dl
•Fasting plasma glucose – 102-125mg/dl
•Abnormal glucose tolerance
•Abnormal obesity (WC > 102cm (M); >88cm (W))
•Family history of premature CV disease
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Management of Hypertension
•Aim :
• Reduction of BP to the target level
• Lower the risk of cardiovascular risk in the patient.
•Target :
• Gradual reduction of BP
13-05-2018 14*Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

Suggested response to Initial BP readings
Initial BP reading on
Screening
Advice and Recommendation for Follow up
SBP mmHg DBP mmHg
<130 <85 Lifestyle modification : Recheck in 2 years
130-139 85-89 Lifestyle modification : Recheck in 1 year
140-159 90-99 Recheck BP within 1-2 weeks. Advise lifestyle modification. Refer
to nearest health facility within 1 month for diagnosis and
assessment.
160-179 100-109 Recheck BP within 1 week. Advise lifestyle modifications. Refer to
nearest health facility for confirmation of diagnosis and initiation
of treatment.
>180 >110 Check for any signs/symptoms of any target organ damage.
In cases of acute target organ damage, treat as hypertensive
emergency.
Refer to PHC/CHC for evaluation and treatment

Treatment Strategies
•Lifestyle measures
•Drug therapy
•Patient’s Education

•Lifestyle measures
• Heart – healthy diet with reduction of salt intake, fat intake, stoppage of
tobacco products , regular exercise and body weight reduction.
• Sufficient for treatment of Grade 1 hypertension, and will also it reduces the
cardiovascular risk.
• A trial of 1-3 months is given following the diagnosis of Grade 1 Hypertension.

Modification Recommendation Approximate SBP Reduction
Range
Weight Reduction Maintain normal body weight
(BMI < 23 kg/m²)
5-20 mm Hg/ 10 kg weight
loss
DASH* eating plan Diet rich in fruits, vegetables,
low fat dairy products, low in
salt
8-14 mm Hg
Dietary sodium restriction <6g salt or <2.4g sodium 2-8 mm Hg
Physical Activity Regular aerobic physical
activity for at least 30 min
most days of the week
4-9 mm Hg
Alcohol moderation Men <60 ml per day , twice a
week
Women <30 ml per day, twice
a week.
2-4 mm Hg
Tobacco Total abstinence
*DASH = Dietary Approach to Stop Hypertension13-05-2018 18

•Drug therapy
• In patients with Grade 1 hypertension (140-159/90-99 mmHg) with
i. Organ failure
ii. Coronary artery disease, congestive heart failure, cerebrovascular disease, peripheral
arterial disease
iii. Diabetes
iv. Chronic kidney disease
v. 3 or more risk factors
vi. After trial of 1-3 months of lifestyle modifications.
• In all patients with Grade 2(160-179/100-109mmHg) and Grade 3 hypertension
(≥ 180/≥110mmHg) and should be combined with lifestyle measure.

Treatment goals for management of Hypertension
TARGET
< 80 years: Systolic BP < 140
mmHg
Diastolic BP <90 mm Hg
>80 years : Systolic BP < 150
mm Hg
Diastolic BP < 90 mm Hg
Diabetics : Systolic BP < 140
mm Hg
Diastolic BP < 90 mm Hg
13-05-2018 20
*Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

Principles of Drug Treatment
•Optimal lowering of blood pressure along with overall well being of the
patient.
•Choice of an antihypertensive is influenced by age, risk factors, target
organ damage, co-existing disease, socioeconomic factors, availability of
drugs and past experience of the physician.
•Combining low doses of two or more drugs to produce BP control with
lesser side effects.

Principles of Drug Treatment
•Fixed dose formulations for better compliance
•Long acting drugs providing 24-hour efficacy provide greater protection
and improves compliance.
•Decrease the dosage and number of antihypertensive drugs after effective
control of hypertension. (step-down therapy).

Treatment regimen
•Increasing the dosage of the drug or addition of the new drug to control
BP should be done at an interval of 2-4 weeks.
•Addition of new drug in patients with Grade 1 or Grade 2 hypertension is
preferable to maximising the dose of the initial drug.
•If the second drug fails to reduce BP to target levels then the third class of
previously unutilized should be added.

Treatment regimen
•Aim for patients to reach target BP levels with an effective treatment
regimen, whether 1,2or 3 drugs within 6 to 8 weeks.
•If the BP is not controlled despite use of 3 anti-hypertensives, the
hypertension is termed RESISTANT and the patient should be referred to
specialist for further evaluation and management.

Patient’s Education
Nature of
disease
Therapy
BP
control
Lifestyle
measures

13-05-2018 26
GRADE 1 & 2 HYPERTENSION –
Drug therapy - A or C or D
Add second Drug - A+C or C+D or D+A
Add third drug – A+C+D
ALL PATIENTS REQUIRE LIFE-LONG LIFESTYLE
MODIFICATION
GRADE 3 HYPERTENSION –
Drug therapy – A+C or C+D or D+A
Add third drug – A+C+D
MANAGEMENT OF HYPERTENSION
(Standard Treatment Guideline)
A – ACE inhibitors
C – CCB
D – Diuretics

Medication Pathway
Initiation with
Single drug
STEP 1
Initiation with 2 drugs or titration of drugs in a patient not
controlled on a single drug:
STEP 2
Use of three drugs
in a patient not
controlled with 2
drugs
STEP 3
CCB (AMLODIPINE) Diuretic
(HYDROCHLOROTH
IAZIDE)
ACE inhibitor
(ENALAPRIL)
ACE inhibitor
(ENALAPRIL 5mg)
OR
Enalapril 5mg +
Amlodipine 2.5mg
(later rise to 5mg)
Enalapril 5mg+
Hydrochlorothiazid
e 12.5mg
Enalapril 10mg
(less preferred)
ACE inhibitor
(Enalapril 5/10mg
+
CCB (Amlodipine
5/10 mg)
+
Thiazide
(hydrochlorothiazi
de 12.5/25mg)
CCB
(AMLODIPINE 5mg)
OR
Amlodipine 10 mg
(less preferred)
Amlodipine 5mg +
Thiazide 12.5mg
Amlodipine 5mg +
Enalapril 5mg
Thiazide diuretic
(HYDROCHLOROTH
IAZIDE 12.5mg)
Diuretic + CCB Hydrochlorothiazid
e 25mg (less
preferred)
Hydrochlorothiazid
e 12.5mg +
Enalapril 2.5 mg
(later 5mg)

13-05-2018 28
MANAGEMENT OF HYPERTENSION
(JNC 8 Algorithm)

Classes of Antihypertensive drugs
Class of
drugs
Definite Indication/s Possible
indication/s
Definite
contraindication/s
Relative
contraindication/s
Diuretics Heart failure
Elderly patients
Systolic hypertension
Diabetes Gout Dyslipidaemia
Β- blockers Angina
Post-myocardial
infarction
Heart failure
Pregnancy
Diabetes
Heart block Dyslipidaemia
PVD
Asthma and COPD
Elderly > 50 years
CCBs Metabolic Syndrome
Angina
Elderly
Diabetes
Systolic hypertension
Peripheral
vascular disease
Heart block * Congestive Heart
Failure*
• First line Antihypertensive drugs
* Verapamil or diltiazem13-05-2018 30

Class of drugs Definite indication/s Possible
indications/s
Definite
contraindication/s
Relative
contraindication/s
ACE inhibitors Metabolic syndrome
Heart failure
Left ventricular
dysfunction
Post-myocardial
Infarction
Diabetes
CVA Pregnancy and
lactation
Bilateral renal artery
stenosis
Hyperkalaemia
Moderate renal
failure (Creatinine
levels >3 mg/dl)
Angiotensin II
Receptor
Blockers (ARBs)
Metabolic syndrome
Diabetes
Proteinuria
LV dysfunction
ACE inhibitor induced
cough
Heart failure
CVA
Pregnancy and
Lactation
Bilateral; renal artery
stenosis
Hyperkalaemia
Moderate renal
failure (Creatinine
levels >3 mg/dl)
• First line Antihypertensive drugs
13-05-2018 31

Class of Drugs Definite indication/s Possible
indication/s
Definite
contraindication/s
Relative
contraindication/s
α blockers Prostatic hypertrophy
Chronic kidney disease
Glucose
intolerance
Dyslipidaemia
Orthostatic
hypertension
Congestive heart failure
Centrally acting agents
• α methyl dopa Hypertension in
pregnancy
Resistant
hypertension
Acute or chronic liver
disease
• Clonidine Resistant Hypertension CKD Pregnancy, Lactation
• Vasodilators Resistant Hypertension CAD
Direct renin inhibitors
• liskiren Resistant Hypertension Pregnancy, lactation Moderate renal
failure
• Other Antihypertensive drugs
13-05-2018 32

Hypertension with Associated Clinical Conditions
CLINICAL CONDITION PREFERRED DRUG SECOND DRUG THIRD DRUG
Isolated systolic
hypertension
CCB/Thiazide diuretic ACE Inhibitors Thiazide diuretic +
ACE+ CCB
Hypertension with
Diabetes
ACE inhibitors CCB or Thiazide
diuretic
Thiazide diuretic +
ACE+ CCB
Hypertension with
chronic kidney
disease
ACE inhibitors (close
monitoring) else CCB
CCB or Thiazide
diuretic
( loop diuretic – e GFR
< 30mi/min)
Thiazide diuretic +
ACE+ CCB
Hypertension and
previous MI
BB, ACE Inhibitors CCB or diuretic
Hypertension with
Heart Failure
Thiazide/ loop diuretics + ACE Inhibitor+ BB+ spironolactone
Hypertension with
previous stroke
ACE Inhibitor Diuretic or CCB Diuretic + ACE+ CCB

Interventions to reduce Cardiovascular Risks
•Low dose aspirin (75mg/day)
• Controlled hypertension with previous history of cardiovascular event
• Controlled hypertension with high cardiovascular risk
•Statins
• Aged more than 40 years, with LDL >190mg/dl.
• Diabetic and in age group of 40-79 years
•Glycaemic control
•Cessation of Tobacco consumption.

DASH Diet (Dietary Approach to stop hypertension)
•Rich in important nutrients and fibre.
•Include foods that contain two and a half times the amounts of
electrolyte, potassium, calcium and magnesium.
13-05-2018 35

DASH Diet (Dietary Approach to stop hypertension)
•Recommendation of DASH diet include :
• Avoid saturated fats
• Include monounsaturated fatty acids (Omega 9 MUFA)
• Include polyunsaturated fatty acids (Omega 3 and 6 PUFA)
• Whole grains in place of white flour
• Include fresh fruits and vegetables
• Include nuts, seeds or legumes
• Moderate amount of protein - fish or poultry
13-05-2018 36

Food items to be avoided in hypertensives
Salt preserved foods Pickles and canned foods; Ketchup;
Prepared mixes
Highly salted foods Potato chips; cheese; peanut butter;
papads
Bakery products Biscuits; cakes; breads and pastries
Fried foods
Alcohol
13-05-2018 37
*Management of Hypertension. JAPI.2013;61:17-23.

Sodium content in common foods per 100 gm
< 25 mg
Low
25-50 mg
Moderate
50-100 gm
Moderately high
>100mg
High
Amla Ragi Raisins Cauliflower Bacon
Bitter gourd Vermicelli Carrots Fenugreek Egg
Brinjal Wheat Black gram dal Lettuce Lobster
Cabbage Maida Red gram dal Beetroot
Cucumber Milk Banana Water melon
Peas Grapes Bengal gram Bengal gram dal
Onion Papaya Apple Liver
Potato Orange Pineapple Chicken
Tomato ripe Prawns
13-05-2018 38*Management of Hypertension. JAPI.2013;61:17-23.

Food with high Potassium
Fruits Vegetables
Amla Plums Cabbage Potato
Peaches Lemons Bitter gourd Brinjal
Oranges Pineapple Ladies finger Pumpkin
Papaya Apple Cauliflower French beans
Banana Watermelon Spinach Tapioca
13-05-2018 39
*Management of Hypertension. JAPI.2013;61:17-23.

National Programme for Prevention and Control
of Diabetes, Cardiovascular Disease and Stroke (NPCDCS)
•MANAGEMENT OF HYPERTENSION:
The Risk assessment should cover:
Assessment of medical history
Physical Examination
Laboratory Investigation
13-05-2018 40

Medical history:
a) Risk factors
b) Family history
c) Symptoms
d) Frequent intake of pain relieving drugs (NSAIDS)
e) Steroid intake for asthma
f) Breathing difficulty particularly on exertion
g) Swelling of feet
h) Urinary difficulties, history of passing stones in the past
13-05-2018 41

Physical examination :
•BP measurement at least in one upper and one lower limb
•Measurement of Body weight and height to obtain BMI
•Measurement of Waist circumference
•Palpating all peripheral pulses
•Auscultation for bruit (renal, carotid, abdominal and others)
•Eye evaluation if ophthalmology facility is available
13-05-2018 42

Laboratory Tests under NPCDCS:
Essential:
• Blood Sugar
• Urine analysis for proteinuria
Desirable: (at CHC/sub-district/district
level hospitals)
• Haemogram,
• Serum creatinine
• Serum sodium and potassium levels
• Lipid profile
• Complete Urine analysis
• Electrocardiogram(ECG)
• X-Ray chest
13-05-2018 43

Treatment Goals under NPCDCS
1. Initial aim should be to obtain blood pressure level less than 130/85 mm Hg
2. Ideally the aim should be to get to blood pressure levels of less than 120/80
without bothersome side-effects.
3. Don't accept blood pressure levels of 140/90 mm Hg or more
4. Maintain healthy blood pressure throughout the person’s lives
5. Prevent and control risk factors which could give rise to high blood pressure.
6. Always make sure that risk factors are controlled.
7. Prevent and control risk factors which could increase risk of complications
due to high blood pressure.
13-05-2018 44

Hypertension Management under NPCDCS
•Life style advice is advocated for the first six month after the diagnosis of high BP
in the following situations:
I. If the BP is less than 160/100 mm of Hg
II. There is no diabetes, co-existing heart disease stroke or peripheral vascular disease
III. No evidence of LVH on ECG
IV. Absence of urinary proteinuria and
V. Serum creatinine <1.6mg/dl
•Start with calcium channel blockers in the person is older than 55 years and ACE
inhibitors if less than 55 years.
13-05-2018 45

Prevention of Hypertension
•Primary Prevention
Population strategy
High – risk strategy
Secondary Prevention
Early case detection
Treatment
Patient compliance
13-05-2018 46

Primary Prevention
•Population strategy :
Directed to whole population
Involves health promotive measures :
i. Dietary changes
ii. DASH Diet
iii. Weight reduction
iv. Behavioural changes
v. Health education
vi. Self-care
13-05-2018 47

Primary Prevention
•High-risk strategy:
Screening of all ‘high-risk’ cases by recording BP.
Aim is to prevent the attainment of levels of blood pressure at which
treatment has to be started
13-05-2018 48

Public Health Approach
Prevention Screening Diagnosis Management
Follow-up &
Adherence
monitoring

13-05-2018 54
Essential assessment
Desirable assessment
Comprehensive assessment

Essential Assessment
• For Grade 1
Hypertension:
• History and
Physical Examination
of risk factors and
assessment for
cardiovascular
disease and diabetes.
Desirable Assessment
• For Grade 2
Hypertension:
Essential assessment
+ Serum creatinine
level; lipid profile;
ECG
Comprehensive
Assessment
• For Grade 3
hypertension:
• Desirable assessment
+ Serum Na and K;
ultrasound kidney;
Echocardiography

AYUSH interventions for Hypertension Management
Ayurveda interventions:
1. Nidana parivarjana - avoidance of causative factors is the first line of
treatment.
2. Samshodhana chikikitsa - Bio-cleansing therapies followed by Samana
chikitsa (Palliative therapy) should be advocated.
13-05-2018 56

13-05-2018 57
Plant name Dosage(perdose) Vehicle Duration
Sarpagandha Powder 1 -3 gm Water 15 days
Ashvagandha Powder 3-6 gm Milk 15 days
Jatamansi Powder 1-3 gm Water 15 days
Arjuna Bark Powder 3-6 gm Water 15 days
Arjuna Bark ksheerapaka 10 -30ml 15 days
Rasona ksheerapaka 10-30 ml 15 days
Common medicinal plants
*Ksheerapaka is a preparation in which the milk is processed with the desired plant part.

13-05-2018 58
Drug Dosage Vehicle Duration
Mamsyadi kvatha 10-20 ml Water 15 days
Sarpagandha ghana
vati
125-250 mg Water 15 days
Brahmi vati 125-250 mg Water 15 days
Prabhakara vati 125-250 mg Water/Milk 15 days
Arjunarishta 10-15 ml Water 15 days
Abhayarisha 10-15 ml Water 15 days
Pravala pishti 250-500 mg Water 15 days
shveta parpati 125-250 mg Water 15 days
Nagarjun!bhra rasa 125-250 mg Water/Honey 15 days
Hridayarnava rasa 125-250 mg Honey/ Triphala 15 days
Common Ayurvedic Drug Formulation used
for Hypertension Management

Yoga Interventions: following yoga practices are beneficial for
hypertension management.
◦ Breathing exercises
◦ Asana- Shavasana, Vajrasana, Bhujangasana, Vakrasana, Gomukhasana,
◦ Pranayama
13-05-2018 59

13-05-2018 60
Medication Indication
Aconitum high blood pressure of sudden origin
Argentum nitricum essential hypertension caused by anxiety
Natrum muriaticum high blood pressure caused by suppressed anger
Veratum viride lowers arterial tension, and treats atrial fibrillation
Baryta carbonica Treats high blood pressure in elderly 50 yrs and older
Berberis vulgaris Secondary hypertension caused by kidney disease.
Aurum muriaticum treats high blood pressure due to disturbed function of the nervous
mechanism
Ignatia High blood pressure caused from emotional upset
Lycopodium Recommended if blood pressure goes up when one goes to the doctor.
Nux vomica Indicated for high blood pressure due to overeating
Homeopathic Medication for Hypertension Management:

13-05-2018 61
Topic JNC 7 JNC 8
Methodology  Non systematic literature review by
expert committee.
 Initial systematic review by methodologists
restricted to RCT evidence.
 Subsequent review of RCT evidence and
recommendations by the panel according to a
standardized protocol.
Definitions  Defined hypertension and pre-
hypertension.
 Definitions of hypertension and prehypertension
not addressed, thresholds for pharmacologic
treatment were defined.
Treatment Goals  Separate treatment goals defined for
“uncomplicated” hypertension and for
subsets with various comorbid conditions
 Similar treatment goals defined for all hypertensive
populations.
Lifestyle
recommendations
 Based on literature review and expert
opinion
 Recommended by endorsing the evidence based
recommendations
Joint National Committee 8 report: How it differ from JNC 7
Source: James PA, Oparil S, Carter BL. Evidence-based guideline for the management of high blood pressure in adults.
Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 311(5), 2014, 507-20.

13-05-2018 62
Joint National Committee 8 report: How it differ from JNC 7
Topic JNC 7 JNC 8
Drug therapy  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.
 Included a comprehensive table of oral
antihypertensive drugs including names and
usual dose range.
 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.
Scope of topics  Addressed multiple issues (blood pressure
measurement, secondary hypertension,
adherence to regimens, resistant
hypertension, and hypertension in special
populations) based on literature review and
expert opinion.
 Evidence review of RCTs addressed a limited
number of questions, those judged by the
panel to be of highest priority.
Source: James PA, Oparil S, Carter BL. Evidence-based guideline for the management of high blood pressure in adults.
Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 311(5), 2014, 507-20.

References
•Raj GM, Priyadarshini R, Mathaiyan J. Current Perspectives in the Management of Hypertension. SAJ
Cardiol.2015;1:101.
•Standard Treatment Guidelines. Screening, diagnosis, assessment, and Management of Primary Hypertension
in Adults in India. Ministry of Health & Family Welfare Government of India. 2016.
•Chandarana A. Hypertension Guidelines. Gujarat Medical Journal.2010;65(2):27-35.
•Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood
pressure for primary prevention. Arch Intern Med. 1995;155:701-9.
•Your guide to lowering Blood Pressure. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National
Institutes of Health.National Heart, Lung, and Blood Institute.2003
•Management of Hypertension. JAPI.2013;61:17-23.
•Park K. Textbook of Preventive and Social Medicine. 23rd Edition. Jabalpur: Bhanot;2015
13-05-2018 64

References
•Kumanyika SK, Cook NR, Cutler JA, Belden L, Brewer A, Cohen JD., etal. Sodium reduction for hypertension
prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II. J Hum
Hypertens. 2005 ;19(1):33-45.
•Stevens VJ, Obarzanek E, Cook NR, Lee IM, Appel LJ, Smith West D, etal. Long-term weight loss and changes in
blood pressure: results of the Trials of Hypertension Prevention, phase II. Ann Intern Med. 2001 Jan 2;134(1):1-11.
•Paul K. Whelton, MD; Lawrence Appel, MD; Jeanne Charleston, RN; et al. Long-term weight loss and changes in
blood pressure: results of the Trials of Hypertension Prevention, phase II. JAMA. 1992;267(9):1213-20.
•National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke. A Manual for
Medical Officer. Developed under the Government of India – WHO Collaborative Programme 2008-2009: 29-33.
•Suryakantha AH. Community Medicine with Recent Advances. 4th Edition. New Delhi:Jaypee Brothers;2017
•Joseph AC, Karthik MS, Sivasakthi R, Venkatanarayanan R, Chander SJU. JNC 8 versus JNC 7 – Understanding the
Evidences. Int. J. Pharm. Sci. Rev. Res.2016;36(1):38-43.
13-05-2018 65

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