Hypertension 2014-2015 guidelines Blood pressure targets JNC8 Controversy

1. Magdy El-Masry
Prof. of Cardiology
Tanta University

2. Blood Pressure Targets
What Do the New Guidelines Say ?

3. Guidelines For Hypertension 2011-2014
A Flood of Hypertension Guidelines

4. Plethora of HTN guidelines
Oct 2011
Oct 2014
Jun 2013

5. US Hypertension Guideline Mania
Nov 2013
2014 20102012
Dec 2013
Dec 2013
2014

6. The multitude of guidelines from respected
professional bodies and individuals have caused,
in my opinion, needless confusion bordering on
chaos.
C. Venkata S. Ram, MD The Journal of Clinical Hypertension Vol 16 | No 4 | April 2014

7. A Flurry of Guidelines for High Blood
Pressure Management
“Flurry of guidelines,
which offer different
recommendations on BP
targets.”

8. *ADA: < 140/80
**KDIGO: <140/90 w/o albuminuria
≤130/80 if >30 mg/24hr
Hypertension Goals of Various Organizations

9. 2014 CHEP

10. 1
1977
2
1980
3
1984
4
1988
5
1993
6
1997
7
2003
8
2014
The Joint National Committee (JNC )

11.  JNC 7 recommended a treatment threshold of
140/90 mm Hg regardless of age, whereas JNC 8
raises the systolic threshold at age 60.
 In addition, JNC 7 recommended a lower
treatment threshold (130/80 mm Hg) for
patients with diabetes or chronic kidney disease,
but JNC 8 does not.
JNC 8 Has Finally Arrived
What's Changed : JNC 7 vs JNC 8
Controversy surrounds long-awaited JNC 8 guideline

12. The controversial JNC 8
relaxed BP goals from
140/90 to 150/90

13. Is JNC 8’s
hypertension
treatment threshold
too high ?

14. Blood pressure targets:
are clinical guidelines wrong?
JNC 8 Headlines
Despite Controversy, JNC 8
Guideline Provides Much-
needed Standards for
Hypertension Management
The JNC 8 Hypertension
Guidelines: An In-Depth Guide
A call to retract the JNC-8 hypertension
guidelines
Hypertension Guidelines: Clear as Mud

15. AHA: JNC 8 Putting Older Adults at Risk?
Analysis warns of potential harm from BP
guideline change.
New Analysis Questions
Higher JNC 8's SBP Target
for Patients Over 60

16. Proportion of US Adults Potentially Affected by the 2014
Hypertension Guideline
JAMA. 2014;311(14):1424-1429.
If the JNC 8 recommendations are used, 6 million adults in
the US aged 60 years and older would be ineligible for
treatment with antihypertensive drugs,
and treatment intensity would be decreased for an
additional 13.5 million older persons,
leading to increased incidences of coronary events, stroke,
heart failure, cardiovascular mortality, and other adverse
events associated with inadequate control of
hypertension.

17. Impact of the 2014 Expert Panel Recommendations
for Management of High Blood Pressure on
Contemporary Cardiovascular Practice :
Insights From the NCDR PINNACLE Registry
J Am Coll Cardiol. 2014 Dec 2;64(21):2196-203
Of 1,185,253 patients in the study cohort, 706,859 (59.6%)
achieved the 2003 JNC-7 goals. Using the 2014
recommendations, 880,378 (74.3%) patients were at goal.
Among U.S. ambulatory cardiology patients with
hypertension, nearly 1 in 7 who did not meet JNC-7
recommendations would now meet the 2014
treatment goals.
NCDR, National Cardiovascular Data Registry;
PINNACLE, Practice Innovation and Clinical Excellence

18. 2014 Eighth Joint National Committee Panel Recommendation for
Blood Pressure Targets Revisited :Results From the INVEST Study
J Am Coll Cardiol. 2014;64(8):784-793.
The International Verapamil SR-Trandolapril Study (INVEST)
8,345 Patients 60 years of age or older with CAD and
baseline SBP >150 mm Hg randomized to a treatment
strategy on the basis of either
atenolol/hydrochlorothiazide or verapamil-SR
/trandolapril were categorized into 3 groups on the basis
of achieved on-treatment SBP:
group 1, <140 mm Hg; group 2, 140 to <150 mm Hg; and
group 3, ≥150 mm Hg.

19. Date of download:
5/25/2015
Copyright © The American College of Cardiology.
All rights reserved.
From: 2014 Eighth Joint National Committee Panel Recommendation for BloodPressure Targets Revisited:
Results From the INVEST Study
J Am Coll Cardiol. 2014;64(8):784-793.doi:10.1016/j.jacc.2014.05.044
Study Design and Main Outcomes
Patients who achieved a systolic blood pressure <140 mmHg had the lowest rate of the primary outcome, cardiovascular mortality,
and fatal and nonfatal stroke compared with the groups with achieved systolic blood pressure≥140 mm Hg. BP = blood pressure;
CV = cardiovascular; INVEST= INternational VErapamil SR Trandolapril STudy; MI = myocardial infarction; SBP =systolic blood
pressure.
Figure Legend:
In hypertensive patients
with CAD who are ≥60
years of age, achieving a
SBP target of 140 to
<150 mm Hg as
recommended by the
JNC-8 panel was
associated with less
benefit than the
previously recommended
target of <140 mm Hg.

20. “New Hypertension Recommendations
Anticipated in 2016”
The AHA and the ACC, in collaboration with nine other
medical societies, will be releasing new hypertension
guidelines that will serve as an update to those
released by the JNC 7 in 2003.

21. Blood Pressure Targets in CAD Patients
JNC 8 : Simple but not complete
JNC 8 does not address the
optimal treatment
of hypertension in patients
with coronary artery disease

22. On March 31, 2015, the AHA, the ACC, and the ASH issued a new scientific statement
entitled “Treatment of Hypertension in Patients with Coronary Heart Disease.”

23. Class/Level of EvidenceConditionBP Goal (mmHg)
IIa/BAge >80 years< 150/90
I/A
IIa/C
IIa/B
CAD
ACS
HF
< 140/90
IIb/C
IIb/C
CAD
Post-MI, stroke, TIA
CAD, PAD, AAA
< 130/80
BP Goals
March 31, 2015

24.  Goals for target BP level or reduction from
pretreatment baseline are uncertain and should be
individualized, but it is reasonable to achieve a
SBP<140 mm Hg and a DBP<90 mm Hg
(Class IIa; Level of Evidence B).
 For patients with a recent lacunar stroke, it might be
reasonable to target a SBP of <130 mm Hg
(Class IIb;Level of Evidence B).
2014

26.  There is no consensus among new HTN
practice guidelines as to target treatment BP
among various subpopulations of patients.

27.  While most guidelines have a target BP < 140/90
for the general population, the JNC-8 task force
favors a target BP < 150/90 mm Hg for persons
age ≥ 60y.
 Most guidelines now target a BP < 150/90 for
persons age ≥ 80y.
 Most guidelines now target a BP < 140/90 for
patients with diabetes or CKD, while a few
others target a BP < 130/80 if diabetes,
albuminuria, or high stroke risk is present.
What are the current blood pressure targets?

28. BP goals in patients with CAD
AHA/ACC/ASH 2015
• The <140/90 mm Hg BP target is reasonable for the
secondary prevention of CVD in patients with
hypertension and CAD.
• A lower target BP of <130/80 mm Hg may be
appropriate in some individuals with CAD or those
with previous MI, stroke, or transient ischemic
attack, or CAD risk equivalents (carotid artery
disease, peripheral arterial disease, or abdominal
aortic aneurysm).
• A BP goal of <150/90 mm Hg is recommended in
those who are >80 years of age

29. The new
recommendations
are expected in 2016