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Explore JNC 8 Hypertension Guidelines from JAMA Network
Patients will be asking about the new Joint National Committee (JNC 8) hypertension guidelines, which were published in the Journal of the American Medical Association on December The new guidelines emphasize control of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with age- and comorbidity-specific treatment cutoffs. The new guidelines also introduce new recommendations. (PDF) JNC 8 Hypertension Guideline Algorithm | Witri Chan jnc 8. (PDF) JNC 8 Hypertension Guideline Algorithm | Witri Chan jnc 8.
Jnc 8 guidelines for hypertension pdf download
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.
Patients want to be assured that blood pressure BP treatment will reduce their disease burden, jnc 8 guidelines for hypertension pdf download, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults.
Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes, jnc 8 guidelines for hypertension pdf download. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease CKD as for the general hypertensive population younger than 60 years.
There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy.
There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.
Hypertension remains one of the most important preventable contributors to disease and death. Abundant evidence from randomized controlled trials RCTs has shown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension. The Institute of Medicine Report Clinical Practice Guidelines We Can Trust outlined a pathway to guideline development and is the approach that this panel aspired to in the creation of this report.
The panel members appointed to the Eighth Joint National Committee JNC 8 used rigorous evidence-based methods, developing Evidence Statements and recommendations for blood pressure BP treatment based on a systematic review of the literature to meet user needs, especially the needs of the primary care clinician.
This report is an executive summary of the evidence and is designed to provide clear recommendations for all clinicians. Major differences from the previous JNC report are summarized in Table 1. The complete evidence summary and detailed description of the evidence review and methods are provided online see Supplement. Two members left the panel early in the process before the evidence review because of new job commitments that prevented them from continuing to serve. Panel members disclosed any potential conflicts of interest including studies evaluated in this report and relationships with industry.
Those with conflicts were allowed to participate in discussions as long as they declared their relationships, but they recused themselves from voting on evidence statements and recommendations relevant to their relationships or conflicts. In Januarythe guideline was submitted for external peer review by NHLBI to 20 reviewers, all of whom had expertise in hypertension, and to 16 federal agencies. Reviewers also had expertise in cardiology, nephrology, primary care, pharmacology, research including clinical trialsbiostatistics, jnc 8 guidelines for hypertension pdf download, and other important related fields.
Sixteen individual reviewers and 5 federal agencies responded. Comments were reviewed and discussed by the panel from March through June and incorporated into a revised document.
These questions address thresholds and goals for pharmacologic treatment of hypertension and whether particular antihypertensive drugs or drug classes improve important health outcomes compared with other drug classes.
In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?
The evidence review focused on adults aged 18 years or older with hypertension and included studies with the following prespecified subgroups: diabetes, coronary artery disease, peripheral artery disease, heart failure, previous stroke, chronic kidney disease CKDproteinuria, older adults, men and women, racial and ethnic groups, and smokers.
Studies with sample sizes smaller than were excluded, as were studies with a follow-up period of less than 1 year, because small studies of brief duration are unlikely to yield enough health-related outcome information to permit interpretation of treatment effects.
Studies were included in the evidence review only if they reported the effects of the studied interventions on any of these important health outcomes:.
Coronary revascularization includes coronary artery bypass surgery, coronary angioplasty and coronary stent placementother revascularization includes carotid, renal, and lower extremity revascularization, jnc 8 guidelines for hypertension pdf download. End-stage renal disease ESRD ie, kidney failure resulting in dialysis or transplantationdoubling of creatinine level, halving of glomerular filtration rate GFR.
Quiz Ref ID The panel limited its evidence review to RCTs because they are less subject to bias than other study designs and represent the gold jnc 8 guidelines for hypertension pdf download for determining efficacy and effectiveness.
These studies were used to create evidence tables and summary tables that were used by the panel for their deliberations see Supplement. Because the panel conducted its own systematic review using original studies, systematic reviews and meta-analyses of RCTs conducted and published by other groups were not included in the formal evidence review.
Initial search dates for the literature review were January 1,through December 31, To ensure that no major relevant studies published after December 31,were excluded from consideration, 2 independent searches of PubMed and CINAHL between December and August were conducted with the same MeSH terms jnc 8 guidelines for hypertension pdf download the original search, jnc 8 guidelines for hypertension pdf download.
Three panel members reviewed the results. The panel limited the inclusion criteria of this second search to the following. The relatively high threshold of participants was used because of the markedly lower event rates observed in recent RCTs such as ACCORD, suggesting that larger study populations are needed to obtain interpretable results.
Additionally, all panel members were asked to identify newly published studies for consideration if they met the above criteria. No additional clinical trials met the previously described inclusion criteria. An external methodology team performed the literature review, jnc 8 guidelines for hypertension pdf download, summarized data from selected papers into evidence tables, and provided a summary of the evidence.
From this evidence review, the panel crafted evidence statements and voted on agreement or disagreement with each statement. For approved evidence statements, the panel then voted on the quality of the evidence Table 2. Once all evidence statements for each critical question were identified, the panel reviewed the evidence statements to craft the clinical recommendations, voting on each recommendation and on the strength of the recommendation Table 3.
For both evidence statements and recommendations, a record of the vote count for, against, or recusal was made without attribution. The following recommendations are based on the systematic evidence review described above Box. Recommendations 1 through 5 address questions 1 and 2 concerning thresholds and goals for BP treatment. Recommendations 6, 7, and 8 address question 3 concerning selection of antihypertensive drugs.
Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs. The evidence statements supporting the recommendations are in the online Supplement. Strong Recommendation — Grade A. Expert Opinion — Grade E. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker CCBangiotensin-converting enzyme inhibitor ACEIor angiotensin receptor blocker ARB.
Moderate Recommendation — Grade B. In the general black population, including those with diabetes, jnc 8 guidelines for hypertension pdf download, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.
This applies to all CKD patients with hypertension regardless of race or diabetes status. The main objective of hypertension treatment is to attain and maintain goal BP. The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.
If goal BP jnc 8 guidelines for hypertension pdf download be reached with 2 drugs, add and titrate a third drug from the list provided. If goal BP cannot be reached using only 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. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.
There is also evidence albeit low quality from evidence statement 6, question 2 that setting a goal SBP of lower than mm Hg in this age group provides no additional benefit compared with a higher goal SBP of to mm Hg or to mm Hg.
To answer question 2 about goal BP, the panel reviewed all RCTs that met the eligibility criteria and that either compared treatment with a particular goal vs no treatment or placebo or compared treatment with one BP goal with treatment to another BP goal.
The corollary to recommendation 1 reflects that there are many treated hypertensive patients aged 60 years or older in whom SBP is currently lower than mm Hg, based on implementation of previous guideline recommendations. Two other trials 9 jnc 8 guidelines for hypertension pdf download, 10 suggest there was no benefit for an SBP goal lower than mm Hg, but the confidence intervals around the effect sizes were wide and did not exclude the possibility of a clinically important benefit.
Therefore, the panel included a corollary recommendation based on expert opinion that treatment for hypertension does not need to be adjusted if treatment results in SBP lower than mm Hg and is not associated with adverse effects on health or quality of life. While all panel members agreed that the evidence supporting recommendation 1 is very strong, the panel was unable to reach unanimity on the recommendation of a goal SBP of lower than mm Hg, jnc 8 guidelines for hypertension pdf download.
Some members recommended continuing the JNC 7 SBP goal of lower than mm Hg for individuals older than 60 years based on expert opinion. The panel agreed that more research is needed to identify optimal goals of SBP for patients with high BP. In further support for a DBP goal of lower than 90 mm Hg, the panel found evidence that there is no benefit in treating patients to a goal of either 80 mm Hg or lower or 85 mm Hg or lower compared with 90 mm Hg or lower based on the HOT trial, in which patients were randomized to these 3 goals without statistically significant differences between treatment groups in the primary or secondary outcomes question 2, evidence statement In adults younger than 30 years, there are no good- or fair-quality RCTs that assessed the benefits of treating elevated DBP on health outcomes question 1, evidence statement Recommendation 3 jnc 8 guidelines for hypertension pdf download based on expert opinion.
While there is high-quality evidence to support a specific SBP threshold and goal for persons aged 60 years or older See recommendation 1the panel found insufficient evidence from good- or fair-quality RCTs to support a specific SBP threshold or goal for persons younger than 60 years.
In the absence of such evidence, the panel recommends an SBP treatment threshold of mm Hg or higher and an SBP treatment goal of lower than mm Hg based on several factors. First, in the absence of any RCTs that compared the current SBP standard of mm Hg with another higher or lower standard in this age group, there was no compelling reason to change current recommendations.
Third, given the recommended SBP goal of lower than mm Hg in adults with diabetes or CKD recommendations 4 and 5a similar SBP goal for the general population younger than 60 years may facilitate guideline implementation. Recommendation 4 is based jnc 8 guidelines for hypertension pdf download evidence statements from question 2.
Three trials that met our criteria for review addressed the effect of antihypertensive drug therapy on change in GFR or time to development of ESRD, but only one trial addressed cardiovascular disease end points.
The commonly used estimating equations for GFR were not developed in populations with significant numbers of people older than 70 years and have not jnc 8 guidelines for hypertension pdf download validated in older adults. No outcome trials reviewed by the panel included large numbers of adults older than 70 years with CKD. Further, the diagnostic criteria for CKD do not consider age-related decline in kidney function as reflected in estimated GFR.
Recommendation 5 is based on evidence statements from question 2, which address BP goals in adults with both diabetes and hypertension. There is moderate-quality evidence from 3 trials SHEP, Syst-Eur, jnc 8 guidelines for hypertension pdf download, and UKPDS that treatment to an SBP goal of lower than mm Hg improves cardiovascular and cerebrovascular health outcomes and lowers mortality see question 2, evidence statement 18 in adults with diabetes and hypertension.
In the absence of such evidence, the panel recommends an SBP goal of lower than mm Hg and a DBP goal lower than 90 mm Hg in this population based on expert opinion, jnc 8 guidelines for hypertension pdf download, consistent with the BP goals in recommendation 3 for the general population younger than 60 years with hypertension. Use of a consistent BP goal in the general population younger than 60 years and in adults with diabetes of any age may facilitate guideline implementation.
This recommendation for an SBP goal of lower than mm Hg in patients with diabetes is also supported by the ACCORD-BP trial, in which the control group used this goal and had similar outcomes compared with a lower goal. The panel also recognizes that an SBP goal of lower than mm Hg is commonly recommended for adults with diabetes and hypertension. However, this lower SBP goal is not supported by any RCT that randomized participants into 2 or more groups in which treatment was initiated at a lower SBP threshold than mm Hg or into treatment jnc 8 guidelines for hypertension pdf download in which the SBP goal was lower than mm Hg and that assessed the effects of a lower SBP threshold or goal on important health outcomes.
There were also no differences in any of the secondary outcomes except for a reduction in stroke. However, the incidence of stroke in the group treated to lower than mm Hg was much lower than expected, so the absolute difference in fatal and nonfatal stroke between the 2 groups was only 0. Despite some existing recommendations that adults with diabetes and hypertension should be treated to a DBP goal of lower than 80 mm Hg, the panel did not find sufficient evidence to support such a recommendation.
For example, jnc 8 guidelines for hypertension pdf download, there are no good- or fair-quality RCTs with mortality as a primary or secondary prespecified outcome that compared a DBP goal of lower than 90 mm Hg with a lower goal evidence statement As a result, the evidence was graded as low quality.
UKPDS did show that treatment in the lower goal BP group was associated with a significantly lower rate of stroke, heart failure, diabetes-related end points, and deaths related to diabetes. For this recommendation, only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed; placebo-controlled RCTs were not included.
Quiz Ref ID Each of the 4 drug classes recommended by jnc 8 guidelines for hypertension pdf download panel in recommendation 6 yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes, with one exception: heart failure.
2017 Hypertension Guidelines Update
, time: 5:58Jnc 8 guidelines for hypertension pdf download
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) The new guideline has simpliļ¬ ed the treatment of hypertension. Patients are categorized ac-cording to age and the presence of diabetes (DM) or/and chronic kidney disease. In subsequent years, a series of Joint National Committee (JNC) BP guidelines were published to assist the practice community and improve prevention, awareness, treatment, and control of high BP. The present guideline updates prior JNC reports. Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy. (PDF) JNC 8 Hypertension Guideline Algorithm | Witri Chan jnc 8.
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