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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
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