JNC VIII Hypertension Aurora Health Care Inc Hypertension

Hypertension Management: JNC VIII Guidelines Ashwani Bhatia M. D. Clinical Hypertension Specialist 2014 ©

OBJECTIVES: Participants will be able to… • Discuss the basics of HTN management per

“Hypertension is the most common condition seen in primary care and leads to myocardial

• Patients want to be assured that blood pressure (BP) treatment will reduce

Introduction • Hypertension remains one of the most important preventable contributors to disease and

“Abundant evidence from randomized controlled trials(RCTs) has shown benefit of antihypertensive drug treatment in

Why Changes were made: 1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy

Recommendations © Aurora Health Care, Inc.

Appendix. Go A S et al. Hypertension. 2014; 63: 878 -885 Copyright © American

Lifestyle Modifications Exercise, reduce sodium intake, lose weight, and decrease stress © Aurora Health

Recommendation 1 • General population aged 60 years or older Initiate Treatment at :

Recommendation 2 • General population < 60 years Initiate Treatment at : DBP ≥

Recommendation 3 • General population < 60 years Initiate Treatment at : SBP ≥

Recommendation 4 • Population aged 18 years or older with CKD Initiate Treatment at:

Recommendation 5 • Population aged 18 years or older with diabetes Initiate Treatment at:

Recommendation 6 • In General Caucasian population, including those with diabetes: o Initial antihypertensive

Recommendation 7 • In general African American population, including those with diabetes: o Initial

Recommendation 8 • Population aged 18 years or older with CKD and hypertension: o

Recommendation 9 (slide 1 of 3) • The main objective of hypertension treatment is

Recommendation 9 (slide 2 of 3) • If goal BP cannot be reached with

Recommendation 9 (Slide 3 of 3) • For patients in whom goal BP cannot

JNC 8 ASH/ISH AHA/ACC 150/90 (≥ 60 yrs) 150/90(≥ 80 yrs) Lower targets may

Conclusion �Guidelines offer clinicians an analysis of what is known and not known about

JNC VIII in a nutshell: �Treat to 150/90 mm Hg in patients over age

REFERENCES: - Journal of the American Medical Association, 2014 Evidence-Based Guideline for the

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JNC VIII Hypertension © Aurora Health Care, Inc.

Hypertension Management: JNC VIII Guidelines Ashwani Bhatia M. D. Clinical Hypertension Specialist 2014 © Aurora Health Care, Inc.

OBJECTIVES: Participants will be able to… • Discuss the basics of HTN management per JNC VIII Guidelines • State changes from JNC VII • Identify the rationale behind current blood pressure targets • Compare JNC VIII to other national and international guidelines © Aurora Health Care, Inc.

“Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. ” • Hypertension is the most common clinical condition for office visits of non-pregnant adults to physicians in the US and for use of prescription drugs. • Nearly 1 in 3 adults in the US have hypertension (approximately 73 million people). • Hypertension, or high blood pressure, is one of the nation’s leading causes of death, responsible for roughly one in six deaths among adults annually. • Despite considerable improvements in increasing awareness, treatment and control of hypertension, over half of adults with HTN do NOT have their blood pressure under control • Racial/ethnic and socioeconomic © Aurora Health Care, Inc.

• Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden as hypertension is a silent disease. • Providers want guidance on hypertension management using the best scientific evidence. © Aurora Health Care, Inc.

Introduction • Hypertension remains one of the most important preventable contributors to disease and death. • Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes. • This report highlights the Evidence-Based Guideline for the Management of High Blood Pressure in Adults. © Aurora Health Care, Inc.

“Abundant evidence from randomized controlled trials(RCTs) has shown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension. ” © Aurora Health Care, Inc.

Why Changes were made: 1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? GOAL 2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? OUTCOMES 3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? MEDICAL MANAGEMENT © Aurora Health Care, Inc.

Recommendations © Aurora Health Care, Inc.

Lifestyle Modifications Exercise, reduce sodium intake, lose weight, and decrease stress © Aurora Health Care, Inc.

Recommendation 1 • General population aged 60 years or older Initiate Treatment at : SBP ≥ 150 mm. Hg Or DBP ≥ 90 mm. Hg Goal of Treatment : SBP <150 mm. Hg OR DBP of < 90 mm. Hg. © Aurora Health Care, Inc.

Recommendation 2 • General population < 60 years Initiate Treatment at : DBP ≥ 90 mm. Hg Goal of Treatment : DBP of < 90 mm. Hg. © Aurora Health Care, Inc.

Recommendation 3 • General population < 60 years Initiate Treatment at : SBP ≥ 140 mm. Hg Goal of Treatment : SBP of < 140 mm. Hg. © Aurora Health Care, Inc.

Recommendation 4 • Population aged 18 years or older with CKD Initiate Treatment at: SBP ≥ 140 mm. Hg Or DBP ≥ 90 mm. Hg Goal of Treatment : SBP < 140 mm. Hg Or DBP < 90 mm. Hg © Aurora Health Care, Inc.

Recommendation 5 • Population aged 18 years or older with diabetes Initiate Treatment at: SBP ≥ 140 mm. Hg Or DBP ≥ 90 mm. Hg Goal of Treatment : SBP < 140 mm. Hg Or DBP < 90 mm. Hg © Aurora Health Care, Inc.

Recommendation 6 • In General Caucasian population, including those with diabetes: o Initial antihypertensive treatment should include any of the following: Ø A thiazide-type diuretic Ø Calcium channel blocker (CCB) Ø Angiotensin-converting enzyme inhibitor (ACEI) or Ø Angiotensin receptor blocker (ARB). © Aurora Health Care, Inc.

Recommendation 7 • In general African American population, including those with diabetes: o Initial antihypertensive treatment should include : ØThiazide-type Diuretic ØCalcium Channel Blocker © Aurora Health Care, Inc.

Recommendation 8 • Population aged 18 years or older with CKD and hypertension: o Initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. o This applies to all CKD patients with hypertension regardless of race or diabetes status. © Aurora Health Care, Inc.

Recommendation 9 (slide 1 of 3) • The main objective of hypertension treatment is to attain and maintain goal BP. • If goal BP is not reached within a month of treatment: – increase the dose of the initial drug OR – Add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). • The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. © Aurora Health Care, Inc.

Recommendation 9 (slide 2 of 3) • If goal BP cannot be reached with 2 drugs: – Add and titrate a third drug from the list provided. • Do not use an ACEI and an ARB together in the same patient. • If goal BP cannot be reached using the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP: - Antihypertensive drugs from other classes can be used. © Aurora Health Care, Inc.

Recommendation 9 (Slide 3 of 3) • For patients in whom goal BP cannot be attained using the above strategy OR • The management of complicated patients for whom additional clinical consultation is needed: o Referral to a hypertension specialist may be indicated © Aurora Health Care, Inc.

JNC 8 ASH/ISH AHA/ACC 150/90 (≥ 60 yrs) 150/90(≥ 80 yrs) Lower targets may be appropriate for LVD, LVH, DM, CKD Lower targets for the elderly Initiate Thiazide-type Diuretic or ACEI or ARB or CCB Stage 1 HTN: ACEI or ARB Stage 1 HTN: Thiazide for most patients Published on: Target Goal For general patients including DM/CKD For elderly people 18 -Dec-13 <140/90 Treatment Preference General <60 yrs General ≥ 60 yrs Hypertension with Diabetes Hypertension with CKD Hypertension with CAD For uptitration, any possible combination from above (avoid ACEI+ARB) Same as Above ACEI or ARB alone Or in combination with other Hypertension with Stroke Hypertension with HF 19 -Dec-13 <140/90 21 -Nov-13 <140/90 (If needed, add CCB or Thiazide-type or ACEI, ARB, CCB, (or combination, if Diuretic) uncontrolled) Stage 2 HTN: ACEI or ARB + CCB or Thiazide-type Thiazide with ACEI/ARB/CCB, or ACEI with Diuretic CCB Stage 1 HTN: Same as Above CCB or Thiazide (If needed, add ACEI or ARB) ACEI or ARB, Thiazide, BB, CCB If needed add CCB or Thiazide-type Diuretic ACEI or ARB If needed add CCB or Thiazide-type Diuretic BB plus ARB or ACE inhibitor BB, ACEI If needed add CCB or Thiazide-type Diuretic ACE Inhibiitor or ARB Thiazide, ACEI If needed add CCB or Thiazide-type Diuretic ARB or ACE inhibitor+BB +Diuretic +Spironolactone reglardless of BP ACEI or ARB, BB, Aldosterone Antagonist, Thiazide

Conclusion �Guidelines offer clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies. �Provides evidence-based recommendations for the management of high BP. �Should meet the clinical needs of most patients. �However, these recommendations are not a substitute for clinical judgment, and decisions must carefully consider and incorporate the clinical characteristics of each individual. © Aurora Health Care, Inc.

JNC VIII in a nutshell: �Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else. �Any of 4 classes of drugs could be chosen. �Destination is important and not the journey. �No stages please. �In African American population C and D (Calcium Channel Blockers and Diuretics) THANK YOU © Aurora Health Care, Inc.

REFERENCES: - Journal of the American Medical Association, 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) {December 18, 2013} -International Society of Hypertension, WHO/ISH Hypertension guidelines - An Effective approach to High Blood pressure control. A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention © Aurora Health Care, Inc.