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J NC V

Optimal110

120

130

140

150

160

170

180

190200

210

220

J NC BP Classifications: SBP

J NC I. JAMA. 1977;237:255-261.J NC II.Arch Intern Med. 1980;140:1280-1285.

J NC III.Arch Intern Med. 1984;144:1047-1057.

J NC IV.Arch Intern Med. 1988;148:1023-1038.J NC V.Arch Intern Med. 1993;153:154-183.J NC VI.Arch Intern Med. 1997;157:2413-2446.

J NC 7. JAMA. 2003;289:2560-2572.

J NC I J NC II J NC III J NC IV J NC VI

Border- l ine

ISH

Stage 1 Stage 1

Stage 2

Stage 3

High-normal

High-normal

NormalNormal

Optimal

SBP(mm Hg)

Normal

Border- l ine

ISH

Stage 4

No recommendations

for SBP in JNC I

or JNC II

J NC 7

Stage 1

Stage 2

Prehyper-tension

Normal

Stage 3

Stage 2

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J NC BP Classifications: DBP

80

85

90

95100

105

110

115120

125

130

J NC I J NC II J NC III J NC IV J NC V J NC VI

Considertherapy

Hyper-tensive

Mild Mild Mild

Stage 1 Stage 1

Moderate Moderate Moderate

Stage 2

Severe Severe SevereStage 3 Stage 3

Stage 2

Stage 4

High-normal

High-normal

High-normal

High-normal

Normal Normal Normal Normal

Optimal

DBP(mm Hg)

Optimal

J NC 7

Stage 1

Stage 2

Prehyper-tension

Normal

J NC I. JAMA. 1977;237:255-261.J NC II.Arch Intern Med. 1980;140:1280-1285.

J NC III.Arch Intern Med. 1984;144:1047-1057.

J NC IV.Arch Intern Med. 1988;148:1023-1038.J NC V.Arch Intern Med. 1993;153:154-183.J NC VI.Arch Intern Med. 1997;157:2413-2446.

J NC 7. JAMA. 2003;289:2560-2572.

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JNC 8 is not just JNC 7 Retooled or Repainted ,

but Imploded and Reconstructed

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National High Blood Pressure

Education ProgramCoordinating Committee

American Academy of Family Physicians

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician AssistantsAmerican Association of Occupational Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational and Environmental Medicine

American College of Physicians

American Society of Internal Medicine

American College of Preventive MedicineAmerican Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses AssociationAmerican Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

American Society of Nephrology

Association of Black CardiologistsCitizens for Public Action on High Blood Pressure and Cholesterol, Inc.

Hypertension Education Foundation, Inc.

International Society on Hypertension in Blacks

National Black Nurses Association, Inc.

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical AssociationNational Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on Minority Populations

Society for Nutrition Education

The Society of Geriatric Cardiology

Federal Agencies:

Agency for Healthcare Research and QualityCenters for Medicare & Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

National Center for Health Statistics

National Heart, Lung, and Blood Institute

National Institute of Diabetes and Digestive and Kidney Diseases

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National High Blood Pressure

Education ProgramCoordinating Committee

American Academy of Family Physicians

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician AssistantsAmerican Association of Occupational Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational and Environmental Medicine

American College of Physicians

American Society of Internal Medicine

American College of Preventive MedicineAmerican Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses AssociationAmerican Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

American Society of Nephrology

Association of Black CardiologistsCitizens for Public Action on High Blood Pressure and Cholesterol, Inc.

Hypertension Education Foundation, Inc.

International Society on Hypertension in Blacks

National Black Nurses Association, Inc.

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical AssociationNational Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on Minority Populations

Society for Nutrition Education

The Society of Geriatric Cardiology

Federal Agencies:

Agency for Healthcare Research and QualityCenters for Medicare & Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

National Center for Health Statistics

National Heart, Lung, and Blood Institute

National Institute of Diabetes and Digestive and Kidney Diseases

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J NC 7 Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usuallythiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling

Indications

Not at Goal

Blood Pressure

Optimize dosages or add additional drugsuntil goal blood pressure is achieved.

Consider consultation with hypertension specialist.

J NC 7. JAMA. 2003;289:2560-2572.

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J NC 7 Compelling Indications

BB, beta blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker;CCB, calcium channel blocker; AA, aldosterone antagonist; HF, Heart Failure;MI, myocardial infarction; CAD, coronary artery disease; DM, diabetes mellitus

J NC 7. JAMA. 2003;289:2560-2572.

Heart Failure

Post MI

CAD risk

Diabetes Mellitus

Renal disease

Recurrent strokeprevention

BB

ACEI

ARB

CCB

AADiuretic

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ACC/AHA Clinical Practice Guidelines

Hierarchical Grading System

ACC/AHA Clinical Practice Guidelines

Hierarchical Grading SystemClass I

( Useful &

Effective )

(Benefit >>>risk)(Highly

recommended)

Class II

( Conflicting Evidence )

Class III

(Not useful/

effective, may

be harmful )(No benefit/Harm)(Not

recommended)

IIa

(Benefit >>risk)(Reasonably

recommended)

IIb

(Benefit ?risk)

(May be

considered)

Level A

(Multiplerandomized

clinical trials)

Level B(Single

randomized trial

ornonrandomized

studies

Level C(Consensus

opinion, case

studies, orstandard of care)

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Scientific Evidence Underlying the

ACC/AHA Clinical Practice Guidelines Among ACC/AHA guidelines updated by Sept. 2008:

48% increase (1330 to 1973) in # of recommendationsoccurred, the largest # being Class II (conflictingevidence)

Of 16 current guidelines with level of evidence recs:

12% (314/2711) are Level A (multiple RCTs)46% (1246/2711) are Level C (expert opinion, no

RCTs)

Only 9% (245/2711) are Class I and Level A

Increased Resources($) are needed to fund trialssupporting guideline development

Tricoci, et al. JAMA. 2009; 301: 831 - 841

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Update clinical recommendations on BP, cholesterol, and obesity

Use systematic evidence review process

Use evidence & recommendations grading Standardize & coordinate approaches Develop consistent recommendations for lifestyle & risk

assessment

Create integrated CV risk reduction recommendations Individual risk factor guidelines + lifestyle and risk assessment

+ additional CVD risk reduction approaches

Develop comprehensive approach to implementation

Write guidelines clearly so they are implementable Address patient, clinician, and systems levels Develop and disseminate materials & tools Develop an evidence-based implementation plan

Establish a National Program to Reduce Cardiovascular Risk

NHLBI Cardiovascular Prevention Guidelines

New Directions

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NHLBI Systematic Review and

Guideline Development Process

Literature Searched;Eligible Studies

Identified

Studies Quality Rated;Data Abstracted

Evidence Tables

Developed;

Body of Evidence

Summarized

External Review

of Recommendation

Drafts; Revisedas Needed

GuidelinesDisseminated &

Implemented

Graded Evidence

Statements &

Recommendations

Developed

Expert PanelSelected

Topic Area

Identified

Critical Questions&Study Eligibility

Criteria Identi fied

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NHLBI Evidence Quality Rating and

Recommendation Strength

Evidence Quality

High Well-designed andconducted RCTs

Moderate RCTs with minor limitations

Well-conductedobservational studies

Low RCTs with major limitations

Observational studies withmajor limitations

Recommendation Strength

A Strong

B Moderate

C Weak

D Against

E Expert Opinion

N No Recommendation

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JNC 2013:

Initial Question Areas Being Addressed Among adults, does treatment with antihypertensive

pharmacological therapy to a specific BP goal lead to

improvements in health outcomes? (how low shouldyou go)

Among adults with hypertension, does initiating

antihypertensive pharmacological therapy at specific BPthresholds improve health outcomes? (when to initiatedrug treatment)

In adults with hypertension, do various antihypertensive

drugs or drug classes differ in comparative benefits andharms on specific health outcomes? (How do we getthere?)

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Inclusion/Exclusion Criteria for Studies

Randomized Controlled trials

1966-present

Minimum one year follow-up

Studies with samples size

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JNC 2013:

Initial Question Areas Being Addressed

(how low should you go) N=56

(when to initiate drug treatment) N=26

(How do we get there?) N=66

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BP Level-How Low to go General population

Elderly

Kidney Disease

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2013 BP Guideline Goal

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ONTARGET: Relationships Between

Outcome Risks and In-Trial BP

J-shaped curve (nadir 130 mm Hg) for primary outcomea, MI, CV mortality (not st roke) Continual risk increase (no J-shaped curve) for stroke Suggests increased risk of events in patients with extensive vascular disease when BP is

decreased below a cr itical level

Ad

justed4.5-yRisk

ofEvents(%

)

In-treatment SBP, deciles (mmHg)

Sleight P, et al. J Hypertens. 2009;27:1360-1369.

HR,

95%ConfidenceInterval

Primary study outcome

a

Composite of cardiovascular death, MI, stroke, orhospitalization for congestive heart failure (CHF).

112 121 126 130 133 136 140 144 149 161

0

5

10

15

20

25

30

0

0.5

1

1.5

2

2.5

3

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Weber M et.al. submitted Am J Med.

CV outcomes from the ACCOMPLISH trial

16.3

8.6

9.6

5.1

9.9

5.3

0

5

10

15

20

Primary Endpoint

Death/MI/stroke/revascularization

All-causemortality

Outcome(%)

SBP > 140 mmHg

SBP 130140 mmHg

SBP < 130 mmHg

OUTCOMES: (MI, stroke, revascularization, all-cause mortality)

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ACCF/AHA 2011 Expert Consensus

Document on Hypertension in theElderly

A Report of the American College of CardiologyFoundation Task Force on Expert ConsensusDocuments

Aronow W et.al. JACC 2011;57:2037-2114

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Percentage of People in Outcome Trials of the

Elderly Taking > 2 Antihypertensive Medication

STONE (147 mmHg)

MRCelderly (153 mmHg)

EWPHE (151 mmHg)Australian HTN (142 mmHg)

INVEST (136 mm Hg)

ALLHAT (138 mm Hg)

ACCOMPLISH (131 mmHg)

STOP2 (151 mmHg)

SYSTChina (not reported)

SystEur (151 mmHg)

HYVET (138 mmHg)

CONVINCE (136 mmHg)SHEP (146 mmHg)

LIFE (143 mmHg)

Trial/SBP Achieved

%patientsN=14 studies;43% >2 drugs

ACC Guidelines in Elderly 2011- J ACC 2011

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Major Take Home Message of Elderly

Guidelines-Management1) Original goal by evidence

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BP level and CKD

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Composite Ranking for Relative Risks by glomerularfi ltration rate (GFR) and Albuminuria (Kidney Disease:

Improving Global Outcomes (KDIGO) 2009

25

Levey AS et.al. Kidney Int 2010; doi: 10.1038/ki.2010.483

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RiskofcoronaryeventsinpeoplewithCKDcompared

with

diabetes:

a

population

level

cohort

study

Tonelli Met.al.TheLancet2012;380:807812;Polonsky&BakrisLancet2012;380:783785

NHANES20032006

48monthFU

N=1,268,029

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AssociationsofCKDwithmortalityandendstagerenaldisease

inindividualswithandwithouthypertension:ametaanalysis

Mahmoodi Ket.al.LancetSept24 2012 Ref.pt.=eGFR95withouthypertension

Interaction

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Steno-2: Intensive Multiple Risk FactorManagement

Cardiovascular Events

Years of Follow-up

No. at RiskIntensive therapy 80 72 65 61 56 50 47 31Conventional therapy 80 70 60 46 38 29 25 14

Intensive

Therapy

Conventional

Therapy

0 1 2 3 4 5 6 7 8 9 10 11 12 13CumulativeI

ncidenceofAny

Cardiovasc

ularEvent(%

)

0

1

0

2

0

30

4

0

5

0

6

0

70

8

0

HR=0.41; p< 0.001

Absolute RR= 29%HR for TotalMortality: 0.54;p=0.02Absolute RR= 20%

Gaede P, et al. NEJM. 2008;358:580-591.

Ch i S l t d Ri k F t d i th

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Changes in Selected Risk Factors during theInterventional Study and Follow-up Period (13.3 years).

Gde P et al. N Engl J Med 2008;358:580-591.

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WhatistheGoalBPandInitialTherapyinKidneyDiseaseorDiabetestoReduceCVRisk?

* Indicates use with d iuretic

GroupGoal BP

(mmHg)Initial Therapy

ADA(2012)

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SBP=systolic blood pressure. *Target blood pressure control groups in ACCORD defined as

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Blood Pressure Targets in Chronic Kidney

Disease: Proteinuria as an Effect Modifier 3 RCTs (8 reports) with a total of 2272 participants

MDRD (Modification of Diet in Renal Disease)

Study

AASK (African American Study of Kidney Disease

and Hypertension) Trial

REIN-2 (Ramipril Efficacy in Nephropathy 2) trial

2- to 4-year trial follow-up

Upadhyay A, et al. Annals Intern Med 3/2011

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G id t KDIGO G d

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GuidetoKDIGOGrades

GRADE PATIENTS CLINICIANS POLICY

1

WeRecommend

Mostpeopleinyour

situationwouldwantthe

recommendedcourseof

actionandonlyafew

wouldnot.

Mostpatients

shouldreceivetherecommended

courseofaction.

The

recommendation

canbeevaluatedas

acandidatefor

developingapolicy

oraperformance

measure.

2

WeSuggestThemajorityofpeoplein

yoursituationwould

wanttherecommended

courseofaction,but

manywouldnot.

Differentchoiceswill

beappropriatefor

differentpatients.

Eachpatientneedshelptoarriveata

management

decisionconsistent

withherorhisvalues

andpreferences.

Thereisaneedfor

substantialdebate

andinvolvement

ofstakeholders.

I m p l i c a t i o n s

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Grade Qualityof

Evidence

Meaning

A High Weareconfidentthatthetrueeffectliesclosetothatoftheestimateofthe

effect.

B Moderate Thetrueeffectislikelytobeclosetotheestimateoftheeffect,butthereisa

possibilitythatitissubstantially

different.

C Low Thetrueeffectmaybesubstantially

differentfromtheestimateoftheeffect.

D VeryLow Theestimateofeffectisveryuncertain

and

often

will

be

far

from

the

truth.

GuidetoKDIGOGrades

KDIGO BP G id li 2012

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KDIGO BP Guidelines 2012-BLOODPRESSUREMANAGEMENTINCKDWITHOUTDIABETES WerecommendthatnondiabeticadultswithCKDandurine

albuminexcretion140mmHgduringsystoleor>90mmHgduringdiastolebetreatedwithBPloweringdrugstomaintainaBPthat

isconsistently 140mmHgsystolicand 90mmHgdiastolic.

GRADE1B

WesuggestthatnondiabeticadultswithCKDandwithurine

albuminexcretionof30to300mg/24h(orequivalent*)whose

officeBPisconsistently>130mmHgduringsystoleor>80mmHg

duringdiastolebetreatedwithBPloweringdrugstomaintainaBPthatisconsistently 130mmHgsystolicand 80mmHg

diastolic.

GRADE2D

Kidney Int Suppl Dec 2012

KDIGO BP G id li 2012 OO SS

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KDIGO BP Guidelines 2012-BLOODPRESSUREMANAGEMENTINCKDWITHOUTDIABETES WesuggestthatnondiabeticadultswithCKDandurine

albuminexcretion>300mg/24h(orequivalent*)whoseoffice

BP

is

consistently

>130

mm

Hg

during

systole

or

>80

mm

Hg

duringdiastolebetreatedwithBPloweringdrugstomaintaina

BPthatisconsistently 130mmHgsystolicand 80mmHg

diastolic.

GRADE2C

WesuggestthatanARBorACEIbeusedasfirstlinetherapyin

nondiabeticadultswithCKDandwithurinealbuminexcretion

of30to300mg/24h(orequivalent*)inwhomtreatmentwithBPloweringdrugsisindicated.

GRADE2D

Kidney Int Suppl Dec 2012

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Initial Combinations of Medications*

Thiazide-Like Diuretics

ACE inhibitorsor

ARBs

Calciumantagonists

* Compelling indications may modify this.

-blockers should be included in the regimen ifthere is a compelling indication for a -blocker

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Conclusion (my opinion) The BP for everyone will be 60- 20/10

mmHg above goal