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PGS.TS.NGUYN C CNG
GIM C BNH ViN THNG NHT
JNC 8

JAMA

Hng dn JNC 8 2014 da trn chng c v kim sot tng huyt p( THA)
ngi trng thnh

Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC8)

Mc thi gian v a l ca cc hng

dn v iu tr tng huyt p
Nc/ Nm

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

KDIGO

ADA

2014

USA
JNC7

JNC8

EU
ESH/ESC

UK
NICE

China
Update due in next 2 years

Japan
South
Korea

Trc y ch i JNC8 ra i

Trc y ch i JNC8 ra i

Taiwan
Canada
ISHIB

Worldwide

CHEP
3

Cc cu hi hng dn r sot JNC8

Hng dn iu tr Tng Huyt p ny tp trung vo 3 cu hi chnh. Cc tc gi tp

trung ngng khi tr, huyt p mc tiu khi dng thuc, v liu rng mt s thuc
hay nhm thuc h p nht nh c gip ci thin sc khe so vi cc thuc cn li hay
khng
1. Trn ngi THA trng thnh, liu khi tr bng thuc mt ngng HA nht nh
c gip ci thin sc khe?
2. Trn ngi THA trng thnh, liu iu tr h p n mc HA nht nh c gip ci
thin sc khe ?
3. Trn ngi trng thnh THA, liu cc thuc hay nhm thuc h p khc nhau c
li ch khc nhau hay nh hng khc nhau n kt cc sc khe ca ngi bnh?

Cu tr li cho cc cu hi trn c phn nh trong 9

khuyn co
JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.

Meta Analysis is the best

if RCTs the best

RCTs is gold standard

The panel limited the inclusion criteria of RCTs JNC 8

Randomized controlled trials (RCTs) are the gold standard for this
assessment and thus were the basis for providing the evidence for our
clinical recommendations.

1.
2.
3.
4.

The study was a major study in hypertension (eg ACCORD-BP).

The study had at least 2000 participants (multi-outcome).
The study was multicentered.
The study met all the other inclusion/exclusion criteria.

JNC 8,2014

So snh JNC 7 v JNC8 2014

Mc
Phng php

JNC 71
Cc tng hp y vn khng h thng ha ca t
chuyn gia v trn nhiu m hnh nghin cu
khc nhau
Khuyn co c a ra da trn ng thun
chung

nh ngha

nh ngha cao huyt p v tin cao huyt p

Mc tiu iu tr

Huyt p mc tiu ring bit cho tng nhm cao

huyt p cha bin chng v cc phn nhm
c bnh l km theo (tiu ng v bnh thn
mn)
Khuyn co iu chnh li sng da trn tng
hp y vn v kin chuyn gia

Khuyn co iu
chnh li sng

Hng dn 20142
Cc cu hi chnh yu v tiu ch r sot xc nh
bi ban chuyn gia vi ng gp t t phng
php nghin cu. Tng hp mang tnh h thng
c t phng php xng ch gii hn trong
cc nghin cu ngu nhin i chng( RCT)
R sot sau cng trn cc bng chng ngu nhin
i chng v cc khuyn co c a ra theo mt
cng chun ha.
nh ngha cao huyt p v tin cao huyt p khng
c cp chnh m ngng huyt p cho iu
tr bng thuc c nhn mnh
Huyt p mc tiu ging nhau cho tt c cc nhm
bnh nhn cao huyt p tr phi c bng chng
iu chnh huyt p mc tiu cho vi nhm bnh
nhn
Khuyn co iu chnh li sng da trn bng
chng t phn tch ca Ban Cng Tc V iu
Chnh Li Sng

Abbreviations: CKD, chronic kidney disease; JNC, Joint National Committee; RCT, randomized controlled trial

1. Chobanian et al. JAMA 2003;289:256072

2. James et al. JAMA doi:10.1001/jama.2013.284427

So snh JNC7 v JNC8 2014

Mc
Dng thuc

JNC 71

Hng dn 2014 2

Khuyn co 5 nhm thuc la chn nhng thiazide

c xem l la chn u tay nu khng c ch nh bt
buc cc nhm thuc khc

Khuyn co da trn bng chng RCT la chn u tay

1 trong 4 nhm: li tiu, chn knh calci, c ch men
chuyn, c ch th th angiotensin

Cc nhm thuc c ch nh theo bnh l km nh

tiu ng, bnh thn mn, suy tim, nhi mu c tim,
t qu, v nguy c tim mch cao.

Khuyn co tng nhm thuc c th da trn r sot

bng chng cho bnh thn mn, tiu ng, chng tc

Thng tin trnh by c th trong bng km theo.

Phm vi tho lun

cp nhiu vn (phng php o HA, nh gi

bnh nhn, cao huyt p th pht, tun tr, cao huyt
p khng tr, cao huyt p trn mt s nhm bnh
nhn) da trn tng hp y vn v kin chuyn gia

1. Chobanian et al. JAMA 2003;289:256072

2. James et al. JAMA doi:10.1001/jama.2013.284427

Cc thuc v liu lng c ly t cc nghin cu trn

kt cc tim mch
R sot bng chng t cc nghin cu ngu nhin i
chng gip gii hn cc ch tho lun trong cc ch
u tin

Cc khuyn co (1/3)
JNC8: mc tiu iu tr ging nhau cho tt c cc nhm bnh nhn1

Recommendation 1

Ngng HA
khi tr

HA mc
tiu

(Khuyn co mnh)

Dn s 60

tui

HATT 150 mm Hg
hay HATTr 90 mm Hg

HATT <150 mm Hg
and HATTr <90 mm Hg

Recommendation 2
(Khuyn co mnh)
HATTr 90 mm Hg

HATTr <90 mm Hg

HATT 140 mm Hg

HATT <140 mm Hg

Dn s <60tui

Recommendation 3
( kin chuyn gia)

Dn s <60tui

JAMA. doi:10.1001/jama.2013.284427. Published online December 18,

2013.

Cc khuyn co (2/3)
JNC8: mc tiu iu tr ging nhau cho tt c cc nhm bnh nhn1
Ngng HA
khi tr

HA mc
tiu

HATT 140 mm Hg
Hay HATTr 90 mm Hg

HATT <140 mm Hg
v HATTr <90 mm Hg

Khuyn co 4
( kin chuyn gia)

Dn s c Bnh Thn
Mn 18tui

Khuyn co 5
( kin chuyn gia)
HATT 140 mm Hg
Hay HATTr 90 mm Hg

Dn s c i Tho
ng18 tui

Thuc khi u

Khuyn co 6
(Khuyn co trung bnh)
Dn s khng-da en( c
tiu ng)

HATT <140 mm Hg
Hay HATTr <90 mm Hg

Li tiu dng Thiazide,

c ch knh calci(CCB),
c ch men chuyn(ACEI),
c ch th th angiotensin(ARB)

JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.

Cc khuyn co (3/3)
Recommendation 7

Thuc khi u

(Khuyn co trung bnh)

Dn s da en

Li tiu dng thiazide,

Hay CCB

(c tiu ng)

Recommendation 8

Thuc khi u

(Khuyn co trung bnh)

Dn s bnh thn mn
18 tui

ACEI hayARB

Recommendation 9

Chin lc dnh cho

THA khng kim sot

( kin chuyn gia)

HA mc tiu khng t sau 1
thng iu tr
HA mc tiu khng t khi dng 2
thuc

Tng liu thuc ban u,

Hay thm thuc th 2 (trong 4 nhm thuc)
Tng liu hay thm thuc th 3
Khng dng ACEI v ARB trn cng bnh nhn

JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013.

So snh huyt p mc tiu ngi cao tui

qua cc khuyn co hin hnh
JAMA. 2013;():. doi:10.1001/jama.2013.284427

JNC 8

12

La chn thuc h p
Khuyn co 6:
Trn dn s khng phi da en, bao gm nhng ngi c T, thuc khi tr nn l li tiu
dng thiazide hay CCB, ACEI, hoc ARB

o Khuyn co trung bnhGrade B

o JNC 7 khuyn co li tiu dng thiazide cho hu ht bnh nhn
Khuyn co cng p dng cho ngi i tho ng do cc nghin cu cho thy i tng
ny khng khc bit v bin c tim mch v mch mu no so vi dn s chung

C s
o Lu tm ch yu ca khuyn co ny ch yu l cc bng chng ng h vic kim sot
huyt p ca cc thuc ch khng phi thuc chuyn bit no

o Bng chng s dng t cc nghin cu i u trc tip ch khng phi i chng gi

dc

o c ch khng c khuyn co cho iu tr khi u do lm gia tng cc kt cc chnh

lin quan t vong chung do tim mch, nhi mu c tim v t qu so vi ARB(ch yu
lin quan t qu gia tng)1
1. Dahlof13
et al. Lancet 2002;359:9951003

La chn thuc h p
Khuyn co 6( tip tc):
Cc lu chnh t ban son tho:
o Nhiu ngi cn hn 1 thuc h p kim sot HA n mc tiu, v khuyn co
ny ch cp n thuc khi u iu tr, ban son tho khuyn ngh rng bt
c 1 trong 4 nhm thuc c bn u c th l thuc km theo l tng

o Khuyn co ny nhn mnh chuyn bit n li tiu dng thiazide ( vd

chlorthalidone v indapamide) khng phi li tiu quai hay tit kim kali

o Cc thuc cn chnh liu y theo cc nghin cu RCT t huyt p mc

tiu

o Cc nghin cu RCTs trn cc i tng khng c THA nh bnh mch vnh,

suy tim khng nm trong phm vi ca khuyn co ny

James et
14al. JAMA doi:10.1001/jama.2013.2844270

La chn thuc h p
Khuyn co 7:

Trn dn s da en bao gm nhng ngi T, thuc khi u nn bao gm 1 thuc

li tiu dng thiazide hay CCB

Dn s da en chung: Khuyn co trung bnhGrade B

Da vo bng chng phn tch trn phn tch phn nhm nh sn ca n/c
ALLHAT1 , li tiu dng thiazide hiu qu hn trong vic ci thin kt cc tai bin
mch no, suy tim, kt cc tim mch chung so vi ACEI trn phn nhm da en c
c ngi T v khng T

Mc d CCB t hiu qu hn li tiu trong vic ngn nga suy tim trn phn nhm
da en trong nghin cu ALLHAT1, khng c s khc bit trong cc kt cc khc
(tai bin mch mu no, bnh mch vnh, kt cc chung tim mch , kt cc v
thn v t vong chung).

Ban son tho khuyn co CCB hn hn ACEI trong vic khi tr trn dn da en
v trong nghin cu ALLHAT c s gia tng 51% nguy c t qu nhm dng
ACEIso vi nhm dng CCB nh l thuc khi u

ACEI cng t hiu qu h p hn so vi CCB trn dn da en

Dn s da en c T: Khuyn co yuGrade C

Cc bng chng c ngoi suy t cc kt qu quan st nhng ngi da en

tham gia nghin cu ALLHAT, 46% c T

1. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. JAMA 2002;288:298197

15

La chn thuc h p
Khuyn co 8:

Trn dn s 18 tui c bnh thn mn, khi tr (hay kt hp) thuc h p nn bao gm
ACEI hay ARB ci thin kt cc v thn. iu ny p dng cho ton b ngi c bnh
thn mn, bt k chng tc hay T

p dng cho bnh thn mn 18 v <75 tui c hay khng c protine niu, v cc nghin cu ch
ra rng ACEIs hay ARBs u gip ci thin kt cc thn trn c 2 nhm

o
o

Khuyn co trung bnhGrade B

Khng c bng chng ng h c ch h thng renin-angiotensin cho bnh nhn trn 75 tui
S dng ACEI hay ARB c th c li cho bnh nhn >75 tui nhng li tiu dng thiazide
hay CCB cng c th l chn la tt cho bnh thn mn mc tui ny

C s

C bng chng mc trung bnh ng h vic dng ACEI hay ARB gip ci thin kt cc thn
ca bnh nhn

Nghin cu AASK cho thy li ch ca ACEI trn kt cc thn trn bnh nhn bnh thn mn
da en1

t bng chng ng h ACEI hay ARB gip ci thin kt cc tim mch ca bnh nhn c bnh
thn mn. ACEIs hay ARBs u khng ci thin kt cc tim mch so vic ch hay CCB

1. Wright
16et al. JAMA 2002;288:242131

La chn thuc h p
Khuyn co 8( tip tc):

Nghch l: phi dng thuc g nu ngi da en c bnh thn mn?

kin chuyn giaGrade E

Bnh nhn da en c bnh thn mn v m niu, ACEI hay ARB c khuyn co

lm thuc ban u v kh nng tin trin thnh bnh thn mn giai on cui( ESRD)1

Bnh nhn da en c bnh thn mn v KHNG C m niu, la chn thuc ban u

vn cha r rng v c th bao gm li tiu dng thiazide, CCB, ACEI, hay ARB

Nu ACEI hay ARB khng c chn l thuc khi u th c th c chn lm thuc

th 2 nu cn t HA mc tiu

ACEI hay ARB thung lm tng creatinine huyt tng v c th c cc tc dng ph khc nh
tng kali mu

S dng thuc c ch h renin-angiotensin trn bnh nhn suy thn mn cn theo di cht
ch in gii v creatinin huyt tng v i khi phi gim liu hay ngng thuc do tc dng
ph

17
1. Wright et al. JAMA 2002;288:242131

Chn la thuc theo JNC 8

Khuyn co 9
(Chin lc chnh liu)
Chin lc
A

M t
Khi u bng 1 thuc, tng ln
liu ti a v thm thuc th 2

Chi tit
S dng 1 trong 4 nhm khuyn co lm thuc khi u
Thuc th 2 s dng khi thuc th 1 t liu i a m cha t HA mc tiu. Thuc
th 2 l thuc khc trong cc nhm khuyn co
Thuc th 3 cng c thm theo cch tng t
Sau khi thm thuc th 2 m khng t mc tiu c th tng ln liu ti a ca thuc
th 2
Thuc th 3 cng c thm theo cch tng t

Khi u bng 1 thuc v thm

thuc th 2 khi thuc khi u
cha t liu ti a

Khi u ngay bng 2 thuc, bt Mt vi thnh vin ca ban son tho khuyn co dng 2 thuc khi u khi HATT >160
k 2 vin ring bit hay vin kt mm Hg v/ hoc HATTr >100 mm Hg, hay nu HATT >20 mm Hg so vi mc tiu v/
hp 2 thuc
hoc HATTr >10 mm Hg so vi mc tiu. Nu 2 thuc liu ti a khng kim sot c
HA th thm thuc th 3

Abbreviations: ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel
blocker; DBP, diastolic blood pressure; SBP, systolic blood pressure.

19

James et al. JAMA doi:10.1001/jama.2013.284427

Cc thuc cn c dng liu nh trong cc RCTs

Antihypertensive Medication

Initial Daily Dose, mg

Target Dose
in RCTs Reviewed, mg

No. of Doses per Day

50
5
10

150-200
20
40

2
1-2
1

400
4
50
40-80
75

600-800
12-32
100
160-320
300

1-2
1
1-2
1
1

25-50
50

100
100-200

1
1-2

2.5
120-180
10

10
360
20

1
1
1-2

5
12.5
12.5-25
1.25

10
12.5-25
25-100a
1.25-2.5

1
1
1-2
1

ACE inhibitors
Captopril
Enalapril
Lisinopril
Angiotensin receptor blockers
Eprosartan
Candesartan
Losartan
Valsartan
Irbesartan
-Blockers
Atenolol
Metoprolol
Calcium channel blockers
Amlodipine
Diltiazem extended release
Nitrendipine
Thiazide-type diuretics
Bendroflumethiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide

Abbreviations: ACE, angiotensin-converting enzyme; RCT, randomized controlled trial.

aCurrent recommended evidence-based dose that balances efficacy and safety is 25-50 mg daily.
James et al. JAMA doi:10.1001/jama.2013.2844270

20

Cc thuc cn c dng liu nh trong cc RCTs

Antihypertensive Medication

Initial Daily Dose, mg

Target Dose
in RCTs Reviewed, mg

No. of Doses per Day

50
5
10

150-200
20
40

2
1-2
1

400
4
50
40-80
75

600-800
12-32
100
160-320
300

1-2
1
1-2
1
1

25-50
50

100
100-200

1
1-2

2.5
120-180
10

10
360
20

1
1
1-2

5
12.5
12.5-25
1.25

10
12.5-25
25-100a
1.25-2.5

1
1
1-2
1

ACE inhibitors
Captopril
Enalapril
Lisinopril
Angiotensin receptor blockers
Eprosartan
Candesartan
Losartan
Valsartan
Irbesartan
-Blockers
Atenolol
Metoprolol
Calcium channel blockers
Amlodipine
Diltiazem extended release
Nitrendipine
Thiazide-type diuretics
Bendroflumethiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide

Abbreviations: ACE, angiotensin-converting enzyme; RCT, randomized controlled trial.

aCurrent recommended evidence-based dose that balances efficacy and safety is 25-50 mg daily.
James et al. JAMA doi:10.1001/jama.2013.2844270

21

Chin lc iu tr: Khuyn co 9

Algorithm 1

aACEIs

and ARBs should not be used in combination

James et al. JAMA doi:10.1001/jama.2013.284427

22

Chin lc iu tr: Khuyn co 9

Algorithm 1

aACEIs

and ARBs should not be used in combination

James et al. JAMA doi:10.1001/jama.2013.284427

23

Chin lc iu tr: Khuyn co 9

Algorithm 2

bIf

BP fails to be maintained at goal, reenter the algorithm where appropriate based on the individual therapeutic plan.
James et al. JAMA doi:10.1001/jama.2013.284427

24

Chin lc iu tr: Khuyn co 9

Algorithm 2

bIf

BP fails to be maintained at goal, reenter the algorithm where appropriate based on the individual therapeutic plan.
James et al. JAMA doi:10.1001/jama.2013.284427

25

Bin php iu tr THA ngoi thuc theo JNC 8 ?

Thay i li sng:

Gim n mui
Gim cn nng
n :tng tri cy v rau xanh; gim cht bo
Gim ung ru
Tng hot ng th lc
Ngng ht thuc

Vn tun th iu tr ? JNC 8
Treatment adherence and medication costs were
thought to be beyond the scope of this review, but the
panel acknowledges the importance of both issues.
Treatment adherence based on observational data (not
RCTs) to make treatment decisions

Tun tr thuc iu tr THA

Drugs dont work in
patients who dont take them.
C. Everett Koop

T l tun th iu tr trong cc bnh mn tnh nh

THA ch khong 30% [1]
WHO c lng mc BN tun tr THA thay i
t 50-70% v cho rng km tun tr iu tr l
nguyn nhn quan trng nht trong vic khng
kim sot c HA [2]
1. Dezii CM. Manag Care 2000, 9:712.
2. WHO; 2003. Chapter XIII, 108-113

Tm tt

JNC8 2014 tp trung 3 lnh vc u tin trong iu tr

1 Ngng HA khi tr
2) HA mc tiu

Ban son tho ra mc HA mc tiu t rng buc hn so vi JNC VII trn bnh nhn cao tui(
t 140/90 mmHg n 150/90 mmHg) v bnh nhn <60 tui c bnh thn mn v tiu ng(
t 130/80 mmHg n 140/90 mmHg)
y l hng dn duy nht dng mc 60 tui lm im ct( cut-off point) cho khi tr v mc
tiu iu tr
3) Cc nhm h p khc nhau cho cc nhm bnh nhn khc nhau
Li tiu thiazide vn tip tc l la chn hng u nhng nhng nhm khc bao gm CCBs
cng c khuy co la chn first-line
BB khng cn l la chn hng th nht
CCBs by gi l la chn u tay mi i tng tr bnh thn mn di 75 tui
iu chnh li sng vn tip tc c nhn mnh

29

James et al. JAMA doi:10.1001/jama.2013.284427

XIN CM N
30