Hypertension Today: JNC-8 Evidence-Based Guidelines

Event Type Live Online Expiration Date 7/16/2016 Credits 1 Contact Hour Target Audience Nurses, Pharmacists, Pharmacy Technicians

Program Overview Hypertension (HTN) is a prevalent disease state throughout the United States and is one of the risk factors for developing cardiovascular disease. Cardiovascular disease is the leading cause of death in the United States. The optimal way to treat hypertension has been the focus of many studies and has led to many conflicting opinions and guidelines over the past decade. Most recently, in December 2013, the Eighth Joint National Committee (JNC8) released their newest guidelines to address when to initiate therapy, what the optimal BP goal is for patients, and what drug therapies we should be using to control hypertension. Nurse/Pharmacist Educational Objectives Review the historical goals and treatment of patients with hypertension Determine optimal threshold for initiating treatment in patients with hypertension Establish evidence based treatment goals for patients with hypertension Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination therapy, and beta blockers Pharmacy Technician Educational Objectives List signs and symptoms of hypertension List medications used to treat hypertension Activity Type Knowledge

Accreditation Nurse Pharmacist Pharmacy Technician

N-875 0798-0000-14-275-L01-P 0798-0000-13-275-L01-T

PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. PharmCon, Inc. has been approved as a provider of continuing education for nurses by the Maryland Nurses Association which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation.

Faculty

Kate Moore, PharmD Associate Professor, Presbyterian College School of Pharmacy Financial Support Received From Pharmaceutical Education Consultants, Inc. Disclaimer PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, authors may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this activity and other unrelated sources.

Page 1

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Hypertension Today: JNC-8 Evidence-Based Guidelines

Accreditation
Pharmacists: 0798-0000-14-275-L01-P Pharmacy Technicians: 0798-0000-14-275-L01-T Nurses: N-875

Faculty

Kate Moore, PharmD

Presbyterian School of Pharmacy

CE Credit(s)
1.0 contact hour(s)

Faculty Disclosure
Dr. Moore has no actual or potential conflicts of interest in relation to this program.

Learning Objectives
Review the historical goals and treatment of patients with hypertension Determine optimal threshold for initiating treatment in patients with hypertension Establish evidence based treatment goals for patients with hypertension Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination therapy, and beta blockers

Legal Disclaimer
The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

Objectives
Review the historical goals and treatment of patients with hypertension Determine optimal threshold for initiating treatment in patients with hypertension Establish evidence based treatment goals for patients with hypertension Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination therapy, and beta blockers

Disclosures
I have no financial disclosures

Page 2

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Defining the Burden: Cardiovascular Disease

Leading cause of death in US Responsible for 17% of national health expenditures 2 million heart attacks annually Projected:
By 2030, 40.5% of US will have CVD Will account for $1 trillion/year

Risk Factors for Cardiovascular Disease

Cigarette smoking Hypertension Elevated LDL Cholesterol Family history of premature CHD (<55 years in male, <65 years in female) Age >45 men, >55 women Diabetes Obesity Physical inactivity Excessive alcohol use
MMWR 2011;60(36):124851

Defining the Burden: Risk Factor-Hypertension (2011)

Hypertension and Cardiovascular Disease

Risk factor for heart disease and stroke
BP >140/90 mmHg DBP more potent predictor <50 yrs old SBP more important >50 yrs old

Two-fold increase in risk of CVD with BP 130139/85-89 vs <120/80

Primary or contributing cause of death for 348,000 Americans in 2008
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm, accessed 1/30/2013 N Engl J Med 2001;345:1291-7 Circulation 2001;103:1245-9 Circulation. 2012;125(1):e2220.

Page 3

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Historical Review: BP Goals

Co-morbid Condition None Diabetes Chronic kidney disease Known CAD Non-coronary atherosclerotic vascular disease Framingham risk assessment >10% Left ventricular dysfunction (heart failure) JNC-7 <140/90 <130/80 <130/80 ------------AHA <140/90 <130/80 <130/80 <130/80 <130/80 <130/80 120/80

Historical Review: Compelling Indications

Compelling Indication Diabetes Post Myocardial Infarction Heart Failure Chronic Kidney Disease Stroke High Coronary Risk Antihypertensive ACEI, ARB, BB, CCB, diuretic BB, ACEI, Aldo Ant ACEI, ARB, diuretic, BB, Aldo Ant ACEI, ARB ACEI, diuretic ACEI, BB, CCB, diuretic

Discrepancy across guidelines

JNC-7 vs AHA

Lower not always better

Mortality may increase with lower DBP
NHLBI, JNC 7, Aug 2004; Circulation 2007;115:2761-88 NHLBI, JNC 7, Aug 2004

Historical Review: Treatment Algorithm

Lifestyle Modifications
Not at goal blood pressure (<140/90 or <130/80)

Where are we now?

JNC-8
Systematic review based process Critical Questions:
Does initiating antihypertensive pharmacological therapy at specific BP thresholds improve health outcomes? When should you initiate treatment? Does treatment with an antihypertensive pharmacological therapy to a specified BP goal lead to improvements in health outcomes? How low should you go? Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? How do you get there?

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 (140159/90-99): Thiazide-type diuretic for most, May consider ACEI, ARB, BB,CCB or combination

Stage 2 (160/100): Two-drug combination for most (usually thiazide-type diuretic and ACEI, ARB, BB,CCB or combination

Use therapies for the compelling indications and other antihypertensive drugs as needed

NHLBI, JNC 7, Aug 2004

JAMA 2013. doi:10.1001/jama.2013.284427

Page 4

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Patient Case-Harry T. Nabb

Pt is 49 years old Caucasian male with no significant past medical history. He presents today for his routine yearly physical. Vitals
BP 136/88 (first reading), 134/84 (second reading) Height 510 Weight 198 lbs (BMI 28.4)

When should we initiate treatment?

Treat Pre-hypertension? The TROPHY Study

Objective:
to determine whether patients with pre-hypertension treated for two years with candesartan reduces the incidence of hypertension for up to two years after the discontinuation of active treatment.
Outcome

Treat Pre-hypertension? The TROPHY Study

Candesartan N=391 208 13.6 53.2 Placebo N=381 240 40.4 63 <0.001 0.007 0.34 (0.25-0.44) 0.84 (0.75-0.95) P-value Relative Risk (95% CI) Developed Hypertension Hypertension at 2 years, % Hypertension at 4 years, %

Comparison
Candesartan vs placebo

Adverse effects
Similar between groups

Patients
age 30-65 BP 130-139/89 mmHg or <139/85-89 mmHg Not treated

Conclusion
Treating pre-hypertension can decrease the development of hypertension No information on cost effectiveness No information on outcome impact (death, hospitalizations, NEJM 2006;354:1685-97 stroke, MI)

Endpoint
Development of hypertension (SBP >140 or DBP >90)
NEJM 2006;354:1685-97

Page 5

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Cochrane Review of Mild Hypertension

Effect of treatment vs no treatment in patients with no history of CV events and BP 140-159/9099mmHg on CV events, stroke, mortality Withdrawals due to adverse effects of therapy Trials included
VA-NHLBI 1997 (chlorthalidone vs placebo) ANBP 1984 (chlorthiazide vs placebo) MRC 1981 (Bendrofluazide, propranolol vs placebo) SHEP 2000 (chlorthalidone vs placebo)

Cochrane Review of Mild Hypertension

Outcome Mortality Stroke Coronary Heart Disease Total CV Events Withdrawal due to Adverse Events No. of Trials included 4
3

Number of Subjects 8912

7080

Relative Risk (95% CI) 0.85 (0.65-1.15)

0.51 (0.24-1.08)

3 3 1

7080 7080 17354

1.12 (0.8-1.57) 0.97 (0.72-1.32) 4.80 (4.14-5.57)

Cochrane Database of Systematic Reviews 2012, Issue 8.

Cochrane Database of Systematic Reviews 2012, Issue 8.

Cochrane Review of Mild Hypertension

Conclusion
Treatment of mild hypertension for 5 years does not reduce mortality, stroke, CHD, or CV events

JNC-8: When should we initiate treatment?

Age 60 years
SBP 150mmHg DBP 90 mmHg

Thoughts to ponder
Therapies included do not match current practice Many other trials show outcomes benefit with similar baseline BP
ALLHAT-baseline BP 146/86 ACCOMPLISH-baseline BP 145/80

Age < 60 years

SBP 140mmHg DBP 90 mmHg

Negative impact of hypertension may take >5 years to develop Does not apply to those with history of CV disease!
Cochrane Database of Systematic Reviews 2012, Issue 8.

Strong recommendations to reduce risk of stroke, heart failure, coronary heart disease
JAMA 2013. doi:10.1001/jama.2013.284427

Page 6

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Patient Case-Harry T. Nabb

What is our optimal blood pressure goal?

1 year has passed and Mr. Nabb returns for another physical. He did not make any lifestyle changes as recommended before and is currently not taking any medications Vitals
BP 144/88 (first reading), 142/84 (second reading) Height 510 Weight 215 lbs (BMI 30.8)

Labs
A1c 7.8, fasting BG 142 TC 201, LDL 140, HDL 32, TG 142

Hypertension Optimal Treatment (HOT) Trial

Comparison
Target DBP <90 vs <85 vs <80
Patients all >100mmHg at baseline

HOT Trial Patient Characteristics

<90mmHg n=6264 Age (years) Males (%) BMI (kg/m2) Blood Pressure (mmHg)
Total Cholesterol

<85mmHg n=6264 61.5 53 28.5 170/105 52.7 1.5 1.2 8

<80mmHg n=6262 61.5 53 28.4 170/105 52.6 1.5 1.2 8

Lancet 1998;351:1755-62

61.5 53 28.4 170/105 52.3 1.6 1.2 8

Treatment
Step 1: felodipine 5mg Step 2: ACE inhibitor or Beta Blocker Steps 3-5: dose titrations

Endpoint
Incidence of major CV event
Fatal & non-fatal MI, stroke, CV death
Lancet 1998;351:1755-62

Previous BP treatment (%) History of MI (%) History of Stroke (%) Diabetes (%)

Page 7

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

HOT Trial Results-Overall Population

<90mmHg n=6264 SBP achieved DBP achieved Major CV events* Myocardial Infarction* Stroke* CV Mortality* Total Mortality* <85mmHg n=6264 <80mmHg n=6262 P-value for trend

HOT Trial Results-Diabetes Population

<90mmHg n=6264 SBP achieved <85mmHg n=6264 <80mmHg n=6262 p-value for trend

143.7 (11.3) 85.2 (5.1) 9.9 3.6 4 3.7 7.9

141.4 (11.7) 83.2 (4.8) 10 2.7 4.7 3.8 8.2

139.7 (11.7) 81.1 (5.3) 9.3 2.6 3.8 4.1 8.8 0.50 0.05 0.74 0.49 0.32
Lancet 1998;351:1755-62

143.7 (11.3) 85.2 (5.1)

24.4

141.4 (11.7) 83.2 (4.8)

18.6

139.7 (11.7) 81.1 (5.3)

11.9 0.005

DBP achieved
Major CV events*

Myocardial Infarction* Stroke* CV Mortality* Total Mortality*

7.5 9.1 11.1 15.9

4.3 7 11.2 15.5

3.7 6.4 3.7 9

0.11 0.34 0.016 0.068

Lancet 1998;351:1755-62

*events per 1000 patient years

*events per 1000 patient years

ACCORD-BP
Comparison
Intensive therapy (SBP <120mmHg) vs standard therapy (SBP <140mmHg)

ACCORD-BP Patient Baseline Characteristics

Characteristic Age (yr) Female (%) History of CV event (%) Weight (kg) Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)

Overall N=4733 62.2 (6.9) 47.7 33.7 92 (18.6) 139.2 (15.8)

76 (10.4)

Patients
Type 2 Diabetes (A1c >7.5%) >40 years with CV disease or >55 with risk factors

Endpoint
First occurrence of major cardiovascular event
Nonfatal MI, nonfatal stroke, CV death
NEJM 2010;362:1575-85

HbA1c (%) LDL (mg/dL) Estimated GFR (ml/min/1.73m2)

8.3 110 (36.7) 91.6 (28.8)

NEJM 2010;362:1575-85

Page 8

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

ACCORD-BP Results-Primary Outcome

ACCORD-BP Results-Primary & Secondary Outcomes

Outcome Intensive Therapy # events (%/yr) Standard Therapy # events (%/yr) Hazard Ratio (95% CI) p-value

Mean SBP Achieved: Intensive group119mmHg Control group133mmHg

Primary Outcome
Nonfatal MI

208 (1.87)
126 (1.13)

237 (2.09)
146 (1.28)

0.88 (0.73-1.06)
0.87 (0.68-1.10)

0.2
0.25

Stroke
HR= 0.88 (0.73-1.06)

36 (0.32) 150 (1.28) 60 (0.52)

62 (0.53) 144 (1.19) 58 (0.49)

0.59 (0.39-0.89) 1.07 (0.85-1.35) 1.06 (0.74-1.52)

0.01 0.55 0.74

Death-all cause Death-CV cause

NEJM 2010;362:1575-85

NEJM 2010;362:1575-85

ACCORD-BP Results-Adverse Events

Event Intensive Therapy # events (%) Standard Therapy # events (%) p-value

Summary of trials in Diabetes

Difference found Difference in subgroups only No difference found

Event attributed to BP medication Hypotension Syncope Bradycardia, arrythmia Hyperkalemia Angiodemia

Renal failure

77 (3.3) 17 (0.7) 12 (0.5) 12 (0.5) 9 (0.4) 6 (0.3) 5 (0.2)

30 (1.27) 1 (0.04) 5 (0.02) 3 (0.13) 1 (0.04) 4 (0.17) 1 (0.04)

<0.001 <0.001 0.1 0.02 0.01 0.55 0.12

NEJM 2010;362:1575-85 Journal of Hypertension 2009; 27: 929.

Page 9

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

JNC-8: What is our Optimal BP Goal?

Age 60 years
Goal <150/90mmHg Optional <140 systolic if treatment well tolerated

Age < 60 years

Goal <140/90mmHg

Age 18 years with diabetes

Goal <140/90mmHg

Is one agent or combination of agents better than another?

Age 18 years with CKD

Goal <140/90mmHg
JAMA 2013. doi:10.1001/jama.2013.284427

Anti-Hypertensive Therapies
Thiazide and Thiazide-Type Diuretics Angiotensin Converting Enzyme Inhibitors (ACE) Angiotensin Receptor Blockers (ARB) Beta Blocker (BB) Calcium Channel Blocker (CCB) Alpha agonists Vasodilators Aldosterone Receptor Antagonists Loop Diuretics Direct Renin Inhibitors

Thiazide-type Diuretics
JNC-8: Similar benefit on overall mortality and coronary heart disease outcomes compared to ACE, CCB, BB or alpha 1-blocker ALLHAT
Lower 6 year rate of stroke (p=0.02) No difference in combined fatal or nonfatal MI (p=0.81) No difference in overall mortality vs ACE (p=0.9) or CCB (p=0.2) Greater reduction in stroke in black population vs ACE

ANBP2
No difference in coronary events vs ACE inhibitor (p=0.16)
JAMA 2013. doi:10.1001/jama.2013.284427 JAMA. 2002;288:29812997; NEJM 2003;348:583-92

Page 10

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Thiazide-type Diuretics Clinical Trial Overview

Chlorthalidone (CTD)
Trial HDFP MRFIT10yr f/u SHEP TOMHS Comparator PCP choice Usual care Placebo acebutolol doxazosin amlodipine enalapril amlodipine lisinopril Result CTD care better CTD better CTD better No difference
MRC-E MIDAS
INSIGHT

Chlorthalidone vs Hydrochlorothiazide
Mean Change from Week 0 to Week 8 in Mean Hourly Ambulatory SBP
Result HCTZ better No difference
Metoprolol better

Hydrochlorothiazide (HCTZ)
Trial VA II EWPHBPE HAPPHY
MAPPHY

Comparator placebo Placebo

metoprolol

Beta-blockers No difference

Placebo Atenolol CCB

Nifedipine

Atenolol better No difference

No difference

ALLHAT

CTD better

PATS ANBP

Placebo Enalapril

HCTZ better Enalapril better

Hypertension 2006;47:352-358.

Thiazide-type Diuretics Clinical Pearls

Chlorthalidone has a longer half-life & duration of action and is ~2x as potent Doses >25mg of chlorthalidone & HCTZ do not offer significant benefit No difference in hypokalemia
Dose related side effect

Beta Blockers and Hypertension

2004 Meta-analysis
Atenolol vs placebo
Decreased BP No difference in all-cause or CV mortality, MI Non-significant decrease in stroke

Atenolol vs other antihypertensives

No difference in BP lowering Higher mortality with atenolol

Are not beneficial in renal dysfunction

Lancet 2004;364:1684-89

Page 11

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Beta Blockers and Hypertension

Outcome Total mortality Comparator Placebo Diuretic CCB RAS agent Placebo Diuretic CCB RAS agent Placebo Diuretic CCB RAS agent Placebo Diuretic CCB RAS agent # of studies (pts) 4 (23613) 5 (18241) 4 (44825) 3 (10828) 4 (23613) 4 (18135) 3 (44167) 2 (9951) 4 (23613) 4 (18135) 3 (44167) 2 (9951) 2 (16372) 3 (11566) 2 (21591) 2 (9951) Risk Ratio (95% CI) 0.99 (0.88-1.11) 1.04 (0.82-1.54) 1.07 (1.00-1.14) 1.10 (0.98-1.24) 0.8 (0.66-0.96) 1.17 (0.65-2.09) 1.24 (1.11-1.40) 1.30 (1.11-1.53) 0.93 (0.81-1.07) 1.12 (0.82-1.54) 1.05 (0.96-1.15) 0.90 (0.76-1.06) 6.35 (3.94-10.22) 1.69 (0.95-3.00) 1.20 (0.71-2.04) 1.41 (1.29-1.54)
Cochrane Database of Systematic Reviews 2012, Issue 11

Decline of Beta Blockers

Limited role for first line therapy unless compelling indication
HF (with ACE) Post MI
Duration recently questioned

Stroke

Coronary Heart Disease

Less tolerated than other agents

Fatigue, exercise intolerance Bradycardia Sexual dysfunction Bronchospasm

Withdrawal due to AE

Beta Blocker Clinical Pearls

Not created equal
Selectivity Route of elimination Indications

ACE Inhibitors
JNC-8: ACE reduce incidence of heart failure, but similar effect on other cardiovascular, cerebrovascular, kidney outcomes and mortality compared to CCB
ACE lead to higher incidence of stroke in general black population compared to CCB ACE improves kidney outcomes compared to CCB or BB, however does not improve cardiovascular outcomes

Monitor HR carefully Caution initiation/titration in symptomatic heart failure Selectivity lost at higher doses Taper off slowly
Risk of rebound hypertension, angina, sudden cardiac death 1-2 weeks minimum

JAMA 2013. doi:10.1001/jama.2013.284427

Page 12

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Angiotensin Receptor Blockers

JNC-8: No trials of sufficient quality to determine whether initial therapy with ARB improves outcomes compared to other therapies in general population
ARB improves kidney outcomes in those with proteinuria and hypertension compared to CCB, however does not improve cardiovascular outcomes

Renin-Angiotensin Agent Clinical Pearls

Combination therapy (ACE + ARB/DRI)
Increased hyperkalemia No difference in clinical outcomes for hypertension Avoid ACE or ARB + DRI in patients with DM & renal insufficiency

Angioedema
ACE > ARB, DRI Can happen with all 3 classes

Discontinue if increase in SCr >30% Avoid in pregnancy or childbearing years

JAMA 2013. doi:10.1001/jama.2013.284427

JNC-8: What Initial Agent should be Started?

General Non-black population (including diabetes)
Thiazide-type diuretic, CCB, ACE or ARB

What Combination Therapy is Best? The ACCOMPLISH Trial

High risk patients: SBP 160 or on therapy, >60 with 1 risk factor, or 55-59 with 2 risk factors
Benazepril 20mg + HCTZ 12.5mg Benazepril 40mg + HCTZ 12.5mg Benazepril 40mg + HCTZ 25mg Add on from any other class Benazepril 20mg+ Amlodipine 5mg Benazepril 40mg+ Amlodipine 5mg Benazepril 40mg+ Amlodipine 10mg Add on from any other class
NEJM2008;359:2417-28.

General black population (including diabetes)

Thiazide-type diuretic or CCB

Age 18 years with CKD

ACE or ARB

Main objective is to reach and maintain goal BP

JAMA 2013. doi:10.1001/jama.2013.284427

Primary endpoint: CV event or death from CV cause

Page 13

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

What Combination Therapy is Best to Initiate?

A Constant: Lifestyle Modifications

DASH Diet
Fresh fruit, vegetables Low-fat dairy Whole grains, poultry, fish, nuts Low in fat, red meat, sweets 8-14 mmHg decrease

Limit alcohol
2-8 mmHg
HR 0.80 (0.72-0.9), p<0.001 NNT: 46
P<0.001

Exercise
Cardiovascular exercise ~30 minutes most days of the week 4-9 mmHg

Weight reduction
NEJM2008;359:2417-28.

5-20 mmHg decrease per 10kg loss

NHLBI, JNC 7, Aug 2004

JNC-8 Algorithm
18 years with HTN Lifestyle modifications Age 60 Goal <150/90 Age < 60 Goal <140/90
Non-black Black

Summary
CKD +/Diabetes Goal <140/90

Diabetes, no CKD Goal <140/90

Initiate therapy when BP is above 140/90mmHg Goal BP for most patients is <140/90mmHg Initial treatment depends on race and comorbidities, however for most it is recommended to select thiazide-type diuretic, ACE, ARB or CCB

Initiate thiazidetype diuretic, ACE, ARB, CCB alone or combination

Initiate thiazidetype diuretic or CCB alone or combination

Initiate ACE or ARB alone or in combination with other class

JAMA 2013. doi:10.1001/jama.2013.284427 JAMA 2013. doi:10.1001/jama.2013.284427

Page 14

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permission is prohibited.

NOTES:

NOTES:

JAMA 2013. doi:10.1001/jama.2013.284427

JAMA 2013. doi:10.1001/jama.2013.284427