Transcript Vulnerable phase post-discharge

Report from the panel members appointed to the Eighth Joint National Committee (JNC 8)
2014 evidence-based guidelines
for the management
of high blood pressure in adults
Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; Cheryl DennisonHimmelfarb, RN, ANP, PhD; Joel Handler, MD; Daniel T. Lackland, DrPH; Michael L. LeFevre, MD, MSPH; Thomas D.
MacKenzie, MD, MSPH; Olugbenga Ogedegbe, MD, MPH, MS; Sidney C. Smith Jr, MD; Laura P. Svetkey, MD, MHS; Sandra
J. Taler, MD; Raymond R. Townsend, MD; Jackson T. Wright Jr, MD, PhD; Andrew S. Narva, MD; Eduardo Ortiz, MD, MPH
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.
Questions guiding the JNC8 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
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.
Recommendations (1/3)
 Recommendation 1
BP thresholds
Goals
SBP ≥150 mm Hg
or DBP ≥90 mm Hg
SBP <150 mm Hg
and DBP <90 mm Hg
DBP ≥90 mm Hg
DBP <90 mm Hg
SBP ≥140 mm Hg
SBP <140 mm Hg
(Strong recommendation)
General population
≥60 years
 Recommendation 2
(Strong recommendation)
General population
<60 years
 Recommendation 3
(Expert opinion)
General population
<60 years
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.
Recommendations (2/3)
BP thresholds
Goals
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
 Recommendation 4
(Expert opinion)
Population with CKD
≥18 years
CKD: chronic kidney disease
 Recommendation 5
(Expert opinion)
Population with diabetes
≥18 years
Initial treatment
 Recommendation 6
(Moderate recommendation)
General nonblack
population (with diabetes)
Thiazide-type diuretic,
calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor (ACEI),
or angiotensin receptor blocker (ARB)
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.
Recommendations (3/3)
 Recommendation 7
Initial treatments
(Moderate recommendation)
General (with diabetes)
Thiazide-type diuretic,
or calcium channel blocker (CCB)
black population
 Recommendation 8
Initial or add-on treatments
(Moderate recommendation)
Angiotensin-converting enzyme inhibitor (ACEI),
or angiotensin receptor blocker (ARB)
Population with CKD
≥18 years
 Recommendation 9
Non control strategies
(Expert opinion)
Goal BP not reached
within a month of treatment
Goal BP not reached
with 2 drugs
Increase the dose of the initial drug,
or add a second drug (from the list provided)
Add and titrate a third drug (from the list provided)
Do not use an ACEI and an ARB together in the same patient
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.
Conclusions
• This JNC8 guideline has not redefined high BP, and considers the 140/90
mm Hg definition from JNC 7 reasonable.
• It offers clinicians an analysis of what is known and not known about BP
treatment thresholds, goals, and drug treatment strategies to achieve
those goals.
• However these recommendations are not a substitute for clinical
judgment, and decisions about care must carefully consider and
incorporate the clinical characteristics and circumstances of each
individual patient.