Ernst, Michael - ACC AHA Hypertension Guideline and How it ... · JNC‐II 1980 JNC‐V 1992 JNC‐IV 1988 JNC‐III 1984 JNC‐VI 1997 JNC 7 2003 JNC 8 2014 JNC‐I 1977 [JNC: Mostly

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ACC/AHA Hypertension Guidelineand How it Might Change Your Practice

Michael Ernst, PharmD, BCPS, BCGPAHSCP‐CHC: American Hypertension Specialist Program –

Certified Hypertension Clinician&

Clinical ProfessorDepartment of Pharmacy Practice & Science, College of Pharmacy, and

Department of Family Medicine, Carver College of Medicine

Disclosures

• Dr. Ernst reports no actual or potential conflicts of interest associated with this presentation.

Case Vignette• A 68‐year‐old Caucasian female presents for general follow‐up after a

recent wrist fracture which occurred from a fall while participating in a hot yoga class. She walks on a treadmill three times/week for 45 minutes and follows a vegan diet. She is a lifetime nonsmoker.

• Meds: lisinopril‐HCT 10/12.5 mg/d; simvastatin 10 mg/d

• BP = 142/78 mmHg (repeated to verify) and other vital signs are normal. She reports her home BP taken every once in awhile usually range in the 130s/70s.

• Her cardiovascular and eye exam are unremarkable. Her BMI is 30. She is not orthostatic and has no complaints.

• Labs: normal CBC, SCr=1.2 mg/dL (no proteinuria on urinalysis), Potassium=3.5 mEq/L, Tchol=175 mg/dL, LDL=98 mg/dL, HDL = 64 mg/dL fasting glucose=103 mg/dL.

• Her 10‐year ASCVD risk calculates out to 11.4%.

• SHOULD HER ANTIHYPERTENSIVE REGIMEN BE ADJUSTED?

• WHAT IF SHE WAS NOT PREVIOUSLY TREATED? SHOULD WE START TREATMENT?

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Objectives

At the end of this presentation, the awake participant should be able to:• Define hypertension based on the 2017 AHA/ACC Hypertension

Guideline.• Describe the clinical trial evidence underpinning the new blood

pressure goal recommendations.• Recognize potential problems with uniform adoption of a singular

blood pressure goal in all individuals.• Recommend effective non‐pharmacologic management strategies.• Advise patients how to obtain helpful home/out‐of‐office blood

pressure readings.• Individualize blood pressure goals based on age, comorbidities, and

other CV‐and related risk factors.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood

Pressure in Adults

Paul K. Whelton, MB, MD, MSc, FAHA, Chair

Robert M. Carey, MD, FAHA, Vice Chair

Wilbert S. Aronow, MD, FACC, FAHA*

Donald E. Casey, Jr, MD, MPH, MBA, FAHA†

Karen J. Collins, MBA‡

Bruce Ovbiagele, MD, MSc, MAS, MBA,FAHA†

Sidney C. Smith, Jr, MD, MACC, FAHA††

Crystal C. Spencer, JD‡

Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA§

Sondra M. DePalma, MHS, PA‐C, CLS, AACC║Samuel Gidding, MD, FACC, FAHA¶

Kenneth A. Jamerson, MD#

Daniel W. Jones, MD, FAHA†

Eric J. MacLaughlin, PharmD**

Paul Muntner, PhD, FAHA†

Randall S. Stafford, MD, PhD‡‡

Sandra J. Taler, MD, FAHA§§

Randal J. Thomas, MD, MS, FACC, FAHA║║Kim A. Williams, Sr, MD, MACC, FAHA†

Jeff D. Williamson, MD, MHS¶¶

Jackson T. Wright, Jr, MD, PhD, FAHA##

*American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ║American Academy of Physician Assistants Representative. ¶Task

Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of

Hypertension Representative. ║║Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative.

Published Nov 13, 2017Available at:https://www.ahajournals.org/lookup/doi/10.1161/HYP.0000000000000066

Evolution of U.S. BP Guidelines

JNC‐II 1980

JNC‐V 1992

JNC‐IV 1988

JNC‐III 1984

JNC‐VI1997

JNC 7 2003

JNC 8 2014

JNC‐I 1977

[JNC: Mostly expert opinion, but progressively more comprehensive based on expanding amount of observational and clinical trial evidence]

AHA/ACC2017

NHLBI exits guideline development, transfers responsibility to AHA/ACC

“Unofficial” guideline

JNC = Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure • A committee of experts appointed through the National Heart, Lung,

and Blood Institute (NHLBI), High Blood Pressure Education Program

2008: NHLBI appoints panel to update guidelines. New process employed: defined questions, systematic review of evidence, grading of evidence

<140/90 mmHgSBP: <150 mmHg if age ≥60

Diabetics: <135/85 mmHgSBP: <130 mmHg

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With the distribution of BP shifting downward in the population, the epidemiology of hypertension‐related CVD is changing.

AHA Guideline Summarized102‐pages (or 55 if exec summary!)

DIAGNOSIS– [New] classifications of BP (eliminated “prehypertension” category)– Emphasis on accurate measurements and use of out‐of‐office measurements

to confirm diagnosis and for titration of meds

INITIATING THERAPY– Non‐pharmacologic recommended for all persons with elevated BP or

hypertension– [New] incorporates use of ASCVD risk calculator for risk stratification

• Recommend meds in patients with clinical CVD or estimated 10‐year ASCVD risk of 10% or higher with SBP 130 mmHg or higher or DBP 80 mmHg or higher

• For 10‐year ASCVD risk of <10%, then recommended when SBP 140 mmHg or higher or DBP 90 mmHg or higher

MANAGEMENT– [New] BP target of <130/80 mmHg in nearly everyone– Thiazides, CCBs, ACEi or ARBs remain recommended first‐line– [New] Stage 2 hypertension (>140/90 mmHg): consider starting 2 first‐line

agents of different classes

2017 Updated Categories of BP in Adults*

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as

detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm Hg

and <80 mm Hg

Hypertension

Stage 1 130–139 mm Hg

or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg

Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13‐e115.

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Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†

SBP/DBP ≥130/80 mm Hg or Self-Reported

Antihypertensive Medication†

SBP/DBP ≥140/90 mm Hg or Self-Reported Antihypertensive

Medication‡Overall, crude 46% 32%

Men(n=4717)

Women(n=4906)

Men(n=4717)

Women(n=4906)

Overall, age-sex adjusted

48% 43% 31% 32%

Age group, y20–44 30% 19% 11% 10%45–54 50% 44% 33% 27%55–64 70% 63% 53% 52%65–74 77% 75% 64% 63%75+ 79% 85% 71% 78%

Race-ethnicity§Non-Hispanic White 47% 41% 31% 30%Non-Hispanic Black 59% 56% 42% 46%Non-Hispanic Asian 45% 36% 29% 27%

Hispanic 44% 42% 27% 32%

The prevalence estimates have been rounded to the nearest full percentage.*130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.†BP cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition of hypertension in JNC 7.§Adjusted to the 2010 age‐sex distribution of the U.S. adult population.BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health

and Nutrition Examination Survey; and SBP, systolic blood pressure.

Paul Muntner et al. Circulation. 2018;137:109-118

EstimatedPrevalenceofHypertensionintheU.S.

Measurement of BP

2017 ACC/AHA Hypertension Guideline

Major point of emphasis in 2017 guideline

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Blood Pressure Is Highly Variable Over a 24‐Hour Period

18:00 22:00 02:00 06:00 10:00 14:00 18:00

Blood pressure (mmHg)

Time of awakeningSleep

180

160

140

120

100

80

200

Systolic BP

Diastolic BP

Adapted from: Millar‐Craig MW, et al. Lancet. 1978;15:795‐797.

Time of day

Checklist for Accurate Measurement of BP

Key Steps for Proper BP Measurements

Step 1: Properly prepare the patient. • Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min.

• Make sure patient avoids caffeine, exercise, and smoking for at least 30 min prior

Step 2: Use proper technique for BP measurements.

• Support the patient’s arm• Using the correct cuff, position the middle of

the cuff on the patient’s upper arm at the midpoint of the sternum

Step 3: Take the proper measurements needed for

diagnosis and treatment of elevated

BP/hypertension.

• At the first visit, record BP in both arms, and use

the arm with the higher reading

• Use a palpated estimate of radial pulse

obliteration pressure for systolic BP and inflate

the cuff 20‐30 mmHg above this level

• Deflate the cuff pressure 2 mmHg per second

Step 4: Properly document accurate BP readings. • Record systolic BP at the onset of first Korotkoff

sound and diastolic BP at the disappearance of all

Korotkoff sounds

Step 5: Average the readings. • Use an average based on ≥2 readings obtained on

≥2 occasions to estimate the individual’s level of

BP

Step 6: Provide BP readings to patient. • Provide patients the systolic/diastolic BP readings

both verbally and in writing

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“Only 1/159 medical students correctly performed all 11 elements in a BP check challenge with simulated patients!”

From: Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis

JAMA Intern Med. Published online February 04, 2019. doi:10.1001/jamainternmed.2018.6551

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From: Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures?

Ann Intern Med. 2011;154(12):781-788. doi:10.1059/0003-4819-154-12-201106210-00005

To accurately record BP at home, patients should take at least 2 readings 1 minute apart each morning and evening for 3‐7 days. This provides approximately 14‐28 readings.

Measurement of blood pressure in humans. A scientific statement from the American Heart Association. Hypertension 2019; epub ahead of print

Out‐of‐Office and Self‐Monitoring of BP

Recommendation for Out‐of‐Office and Self‐Monitoring of BP

Out‐of‐office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP‐lowering medication, in conjunction with telehealth counseling or clinical interventions.

Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .

For Primary Prevention For Secondary Prevention

When 10‐year ASCVD risk ≥ 10% AND SBP ≥ 130 mmHg or DBP ≥ 80 mmHg

Clinical CVD AND SBP ≥ 130 mmHg or DBP ≥ 80 mmHg

OR

No history of CVD and 10‐year ASCVD risk <10% AND SBP ≥ 140 mmHg or DBP ≥ 90 mmHg

BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension

Drug therapy for hypertension is recommended:

*ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator/) to estimate 10-year risk of atherosclerotic CVD.

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Note – once on meds, monthly follow‐up/med titration until BP goal is met!

Clinical Condition(s)BP Threshold

for Tx, mm Hg

BP Goal,

mm Hg

General

Clinical CVD or 10‐year ASCVD risk ≥10% ≥130/80 <130/80

No clinical CVD and 10‐year ASCVD risk <10% ≥140/90 <130/80

Older persons (≥65 years of age; noninstitutionalized,

ambulatory, community‐living adults)

≥130 (SBP) <130 (SBP)

Specific comorbidities

Diabetes mellitus ≥130/80 <130/80

Chronic kidney disease ≥130/80 <130/80

Chronic kidney disease after renal transplantation ≥130/80 <130/80

Heart failure ≥130/80 <130/80

Stable ischemic heart disease ≥130/80 <130/80

Secondary stroke prevention ≥140/90 <130/80

Secondary stroke prevention (lacunar) ≥130/80 <130/80

Peripheral arterial disease ≥130/80 <130/80

What About Older People and Those with Specific Comorbidities?


Interventions to Reduce BP


• Non‐pharmacologic (no real changes from before)

• Drug choices (essentially no changes from before)

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Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*

Nonpharmacological

Intervention

Dose Approximate Impact on SBP

Hypertension Normotension

Weight loss Weight/body fat Best goal is ideal body weight, but aim

for at least a 1‐kg reduction in body

weight for most adults who are

overweight. Expect about 1 mm Hg for

every 1‐kg reduction in body weight.

‐5 mm Hg ‐2/3 mm Hg

Healthy diet DASH dietary pattern

Consume a diet rich in fruits,

vegetables, whole grains, and low‐fat

dairy products, with reduced content

of saturated and total fat.

‐11 mm Hg ‐3 mm Hg

Reduced intake

of dietary

sodium

Dietary sodium Optimal goal is <1500 mg/d, but aim

for at least a 1000‐mg/d reduction in

most adults.

‐5/6 mm Hg ‐2/3 mm Hg

Enhanced intake

of dietary

potassium

Dietary potassium

Aim for 3500–5000 mg/d, preferably by

consumption of a diet rich in

potassium.

‐4/5 mm Hg ‐2 mm Hg

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the

DASH? Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp‐dash‐how‐to.

Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp


Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)

Nonpharmacological

Intervention

Dose Approximate Impact on SBP

Hypertension Normotension

Physical

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

‐5/8 mm Hg ‐2/4 mm Hg

Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10

repetitions/set


Isometric resistance ● 4 × 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction, 3

sessions/wk

● 8–10 wk


Moderation

in alcohol

intake

Alcohol consumption In individuals who drink alcohol,

reduce alcohol† to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

‐4 mm Hg ‐3 mm

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually

about 5% alcohol), 5 oz of wine (usually about 12%alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).


Choice of Initial Medication

Recommendation for Choice of Initial Medication

For initiation of antihypertensive drug therapy, first‐line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs.


All of the major classes of antihypertensives have been shown to reduce morbidity and mortality from hypertension

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Choice of Initial Monotherapy Versus Initial Combination Drug Therapy

Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy*

Initiation of antihypertensive drug therapy with 2 first‐line agents of different classes, either as separate agents or in a fixed‐dose combination, is recommended in adults with stage 2 hypertension andan average BP more than 20/10 mm Hg above their BP target.

Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.


Synergistic 2 drug combos: ACEi (or ARB) + CCBACEi (or ARB) + thiazideCCB + thiazide

Special Patient Groups


Emphasis on elderly – major point of difference with JNC‐8

Age‐Related Issues

Recommendations for Treatment of Hypertension in Older Persons

Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community‐dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.

For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team‐based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.


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The lower BP goal (especially in healthy elderly) is a major departure from JNC‐8 and past guidelines.

What evidence led to the change in the BP goals in the new AHA guideline?

SPRINT: Primary Outcome and Death from Any Cause.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

Primary outcome first occurrence of:

• Myocardial infarction (MI)

• Acute coronary syndrome (non‐MI ACS)

• Stroke• Acute

decompensated heart failure (HF)

• Cardiovascular disease death

Inclusion Criteria• ≥50 years old• Systolic blood pressure : 130

– 180 mm Hg (treated or untreated)

• Additional cardiovascular disease (CVD) risk (at least one)

• Clinical or subclinical CVD (excluding stroke)

• Chronic kidney disease (CKD), defined as eGFR 20 –<60 ml/min/1.73m2

• Framingham Risk Score for 10‐year CVD risk ≥ 15%

• Age ≥ 75 years

Conditions of Interest for SPRINT Participants > 75 Years

Williamson JD, et al. for the SPRINT Research Group. JAMA 2016;315:2673-2682.

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Risk Reduction: Let’s Re‐Look at Some Numbers from SPRINT

• 25% relative risk reduction

• Subjects in the intensive treatment goal had a 25% lower risk of the primary endpoint

• Primary outcome occurred in 6.8% vs 5.2% over 3.2 years = absolute riskreduction of 1.6%

• NNT = 1/ARR = 62.5

• 63 people need to be treated to an intensive BP goal for 3.2 years to avoid 1 additional primary event


• Serious ADE (intervention‐related) occurred in 4.7% of intensive treated group vs 2.5% of conventional group

• NNH = 1/ARI = 45.5• For every 46 people treated to

an intensive BP goal for 3.2 years, 1 additional harm will occur


For 1000 persons:• Benefit: 1000/62.5 = 16• Harm: 1000/45.5 = 22

For 1000 persons treated over 3.2 years to systolic goal BP of <120 mmHg compared to <140 mmHg…an average of 16 persons will benefit, 22 persons will be seriously harmed… and 962 will not experience benefits or harms!

Although the treatment may be worthwhile for patients on average, it may not be worthwhile for the average patient!This is because the average patient is at less risk than the mean!

Vickers AJ, Kent DM. Ann Intern Med 2015;162:866‐867.

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AHA Guideline Controversies

• Heavy reliance on SPRINT (chair of AHA guideline was chair of SPRINT)– AAFP does not endorse the new guideline

• AAFP and ACP published their own guideline on hypertension in adults over age 60 in Jan 2017. They continue to recommend a goal SBP of <150 mmHg (Ann Intern Med 2017;166:430‐437)

– ADA (2019)• 10‐yr ASCVD risk >15% = <130/80 mmHg (LEVEL C;“may be appropriate”)

• 10‐yr ASCVD risk <15% = <140/90 mmHg (LEVEL A)

– (BTW, the 10‐yr CVD risk calculator often overestimates risk in lower risk individuals, and using it in a strategy to determine treatment has not been tested prospectively)

Changing the Definition of Hypertension: How Innocent a Numbers Game?

Applying the AHA Guideline,

• ~46% of US adults now have hypertension (vs 32%)

• Control rates in those treated that were approaching 70% in some cohorts are now significantly lower– What is the implication of this across health systems, payments, etc?

Haynes RB, et al. Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 1978;299:741‐44.

More importantly, labeling a person with a disease comes at a cost….

e.g., a landmark study following 208 Canadian steel workers for 1 year documented an increase in absenteeism by about 80% in the year after labelling with hypertension in a screening program compared to the previous year

Case Vignette• A 68‐year‐old caucasian female presents for general follow‐up after a

recent wrist fracture which occurred from a fall while participating in a hot yoga class. She walks on a treadmill three times/week for 45 minutes and follows a vegan diet. She is a lifetime nonsmoker.

• Meds: lisinopril‐HCT 10/12.5 mg/d; simvastatin 10 mg/d• BP = 142/78 mmHg (repeated to verify) and other vital signs are normal.

She reports her home BP taken every once in awhile usually range in the 130s/70s.

• Her cardiovascular and eye exam are unremarkable. Her BMI is 30. She is not orthostatic and has no complaints.

• Labs: normal CBC, SCr=1.2 mg/dL (no proteinuria on urinalysis), Potassium=3.5 mEq/L, Tchol=175 mg/dL, LDL=98 mg/dL, HDL = 64 mg/dL fasting glucose=103 mg/dL.

• Her 10‐year ASCVD risk calculates out to 11.4%.• SHOULD HER ANTIHYPERTENSIVE REGIMEN BE ADJUSTED?• WHAT IF SHE WAS NOT PREVIOUSLY TREATED? SHOULD WE START

TREATMENT?– Her 10‐year ASCVD risk is 8.5%!

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Take Home Points (1)

BP Targets: A “Ceiling” or “Floor?”• Treatment benefit is not black and

white. Not all patients need to be reduced down to the lowest levels (i.e. “normal BP”) to achieve benefit.

• The magnitude of CVD risk reduction is generally proportional to the height of the pre‐treatment BP.

– Getting below 130 mmHg with multiple drugs is not the same as being there naturally!

• Management of BP is only one part of the recipe to reduce CV risk!

– Do not forget to concurrently manage other CV risk factors!

Over‐Diagnosed. Making People Sick in the Pursuit of Health. Welch HG, Schwartz LM, Woloshin S. Beacon Press. 1/3/2012. ISBN: 978‐080702199‐6.

Take Home Points (2)• The 2017 ACC/AHA guideline updates the classification of blood pressure;

in doing so, nearly 50% of Americans now have a chronic disease.– The importance of proper measurement is stressed.– Thresholds for treatment and BP goals are updated, with some controversy

• Incorporation of ASCVD risk calculator to help individualize decision to treat• More evidence informing the approach to elderly (i.e., community‐dwelling, ambulatory)

• SPRINT data drive the change in guidelines…absolute benefit is small, and not all will benefit from intensified BP goals

• My opinion: for most patients, focus on 140 mmHg as a ‘ceiling’, 130 mmHg as a ‘floor’, and control other concurrent CV risk factors in all!

– If you have significant residual CV risk you can’t control, then consider more aggressive BP goal (i.e., 130 mmHg as ‘ceiling’)

• Remember that guidelines are just that… not mandates

• Don’t forget the importance of using your clinical reasoning to individualize BP targets!!

THANK YOU.michael‐[email protected]. 319/384‐7756

Documents

Ernst, Michael - ACC AHA Hypertension Guideline and How it ... · JNC‐II 1980 JNC‐V 1992 JNC‐IV 1988 JNC‐III 1984 JNC‐VI 1997 JNC 7 2003 JNC 8 2014 JNC‐I 1977 [JNC: Mostly