A very very concise presentation of the JNC8 recommendations. A quick reference for busy clinicians, if they find it useful, i.e!

1. JNC 8
Evidence to the fore?

2. PROCESS

>400 nominees

Members selected

Guidelines first draft - January 2013

Reviewed by 20 reviewers + 16 federal agencies February 2013

Revised document - June 2013

3. QUESTIONS
In adults with HTN:•Starting
Pharmac Rx @ specific BP threshold =
benefit?
•Treating
•Diff
to specific BP goal = benefit?
anti-HTN drugs/classes = Diff benefit or harm
in specific health outcomes?

4. EVIDENCE
SELECTION

5. POPULATION CRITERIA
•
•
Adults ≥ 18 years with HTN
Subgroups
•
•
•
•
•
•
•
•
•
•
DM
CAD
PAD
HF
Prev Stroke
CKD
Proteinuria
Older adults
Men/Women
Racial/ethnic groups,

6. OUTCOMES CONSIDERED
•
Mortality: overall, CVD related, CKD related
•
MI, HF, Hospitalization for HF, stroke
•
Revasc: Coronary (Plasty/Bypass), others
(carotid, renal, limb)
•
ESRD, Creat x 2, GFR/2

7. TRIALS

Only RCTs

Period Jan 1, 1966 to Dec 31, 2009

Secondary search
 PubMed
& CINAHL
 Dec 2009 – Aug 2013
 Major study in HTN, ≥ 2000 subjects, multicentric,
met incl/excl criteria

8. COLLATION
•
•
•
•
Data tabulated
Evidence summarized
Evidence statements crafted
Voting
Agree/disagree with evidence statement
• Quality of evidence
•
•
•
Clinical recommendations crafted
Voting
Agree/disagree with recomm
• Strength of recomm
•

9. RESULTANT

9 recommendations

Strength of recommendation for each

Recomm 1 – 5
 Threshold

Recomm 6 – 8
 Selection

and goals
of antiHTN drugs
Recomm 9
 Summary
of strategies (expert opinion)

10. RECOMMENDATIONS

11. RECOMMENDATION 1

Gen pop ≥ 60 years

Start at SBP>150 OR DBP>90

Goal SBP<150 AND DBP<90

Strong – Grade A

PS: If
already having lower values + no adverse effects =
continue present Rx
 Exp Op – Grade E

12. RECOMMENDATION 2

Gen pop < 60 years

Start at DBP ≥ 90

Goal DBP < 90

Strong – Grade A (30-59 years)

Exp Op – Grade E (18-29 years)

13. RECOMMENDATION 3

Gen pop < 60 years

Start at SBP ≥ 140

Goal SBP < 140

Exp Op – Grade E

14. RECOMMENDATION 4

CKD ≥ 18 years

Start at SBP ≥ 140 OR DBP ≥ 90

Goal SBP < 140 and DBP < 90

Exp Op – Grade E

PS: No
evid for BP goal – CKD > 70 years
 Induvidualize Rx

15. RECOMMENDATION 5

DM ≥ 18 years

Start at SBP ≥ 140 OR DBP ≥ 90

Goal SBP < 140 AND DBP < 90

Exp Op – Grade E

16. RECOMMENDATION 6

Gen pop non-black (+/- DM)

Initial drug: Thiazide
diuretic
 CCB
 ACEi
 ARB

Mod Recomm – Grade B

17. CAVEATS

Only for initial drug choice. Add-on any will do

Specific to thiazide diuretics

Drugs to be adequately dosed

NOT for CAD, HF, CKD

18. RECOMMENDATION 7

Gen Black pop (+/- DM)

Initial drug:- Thiazide/CCB

Mod Recomm – Grade B (Gen Black)

Weak Recomm – Grade C (Black + DM)

PS:- Diuretic > CCB in preventing HF

19. RECOMMENDATION 8

Adults CKD (any race, +/- DM)

ACEi/ARB as initial/add-on

Mod Recomm – Grade B

PS – Only improves kidney outcomes

20. RECOMMENDATION 9

MAIN AIM – attain + maintain goal BP

Not at goal by 1 mth Rx:↑ dose initial drug / add-on 2nd drug
 Continuous assessment and drug adjustment


Use drugs from other classes if:> 3 drugs needed
 Contraindic/adverse effect of recomm classes


Exp Op – Grade E

21. COROLLARIES 1

Assess BP regularly

Evidence based lifestyle and adherence
interventions

Adjust Rx till goal attained + maintained

Dose and titration not discussed (no RCTs)

Algorithm suggested – not validated for benefit

22. COROLLARIES 2

3 Strategies suggested: Initiate
1 drug – go to max – then add 2nd drug
 Initiate 1 drug – add 2nd drug before 1st @ max
 Initiate 2 drugs in single / fixed dose combo

Drugs may be substituted if: Not
effective
 Adverse effects

23. THANK YOU
ALL
For Your Kind Attention