The Hypertension Guidelines JNC 8

JNC-8 New Guidelines…Finally

Let the controversies begin

Eric D Peterson, MD, MPH

Director of DCRI

Feb, 2014 http://www.dcri.duke.edu/research/coi.jsp

All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2

• Affects 1 billion people worldwide

• US – about 1 in 3 adults

– 73 million have hypertension (SBP >140/90)

• A 55yo normotensive person has up to a 90% lifetime risk of developing hypertension (Vasan 2001)

• Number one reason listed for office visits

• Causes/contributes to 457,000 admissions per year

• A leading cause/contributor to death (MI, stroke, vascular disease)


• “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.”- J.H. Hay, 1931.

• “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” Paul Dudley White, 1937.

How Aggressive to Treat Hypertension Some Early Views on the Controversy


Stroke and IHD Mortality vs Systolic BP by Age

Mort

alit

y

(Flo

ating a

bsolu

te r

isk a

nd 9

5%

CI)

Usual Systolic BP (mm Hg)

50-59 years

60-69 years

70-79 years

80-89 years

Stroke

Age at risk

256

128

64

32

16

8

4

2

1

0

120 140 160 180

Ischemic Heart Disease

Usual Systolic BP (mm Hg)

50-59 years

60-69 years

70-79 years

80-89 years

Age at risk:

40-49 years

256

128

64

32

16

8

4

2

1

0

120 140 160 180

Lancet. 2002;360:1903-1913


BP Reductions as Small as 2 mmHg Reduce the Risk of CV Events by Up to 10%

▶ Meta-analysis of 61 prospective, observational studies

▶ 1 million adults

▶ 12.7 million person-years

Prospective Studies Collaboration. Lancet. 2002;360:1903-1913

2 mmHg

increase in

mean SBP 10% increase in

risk of stroke

mortality

7% increase in

risk of ischemic

heart disease

mortality


Benefits of Treating Hypertension: RCT

-100-90-80-70-60-50-40-30-20-10

0

Heart failure Stroke Cardiovascular

death

Ris

k r

eduction (

%)

↓ 50% ↓ 40%

↓ 20%

Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996


Lifestyle Modifications

Goal blood pressure <140/90 mm Hg

<130/80 mm Hg with diabetes or chronic kidney disease*

Initial drug choices

Without Compelling indications

Stage 1 Hypertension

(SBP 140-159 DBP 90-99 )

Diuretics for most; may consider ACE inhibitor,

ARB, beta blocker, CCB or combination

Stage 2 hypertension

(SBP ≥ 160 or DBP ≥ 100)

2-drug combination for most (Diuretic +ACE, ARB,

beta blocker, or CCB)

With compelling indications

Drug(s) for compelling indications

Diuretics, ACE inhibitor, ARB, beta blocker, CCB as

needed

* Released in 2003


NHLBI Drops Out of

Guidelines Business JNC-8 Significantly

Delayed


James et al JAMA December 13 2014





JNC-8 Hypertension Treatment Choices




The Evidence for Targets: JATOS Study

• 2200 pts per arm

• Baseline BP 170/90

• Target

<150 mild vs. <140 strict

• Drugs:

– Ca++blocker 50-60%

– Ace 30-40%

– Alpha blocker 15%

– Diuretic 15%

• Follow-up 2 yrs

Hypertens Res. 2008;31(12):2115-2127


JATOS Results

Hypertens Res. 2008;31(12):2115-2127


The Evidence for Targets: VALISH Trial

Hypertension. 2010;56(2):196-202

• 1630 pts per arm

• Baseline BP 170/80

• Target

Mild <150, strict <140

• Drugs:

– Valsartan 100%

– Ca++ blacker 30%

– Diuretic 10-15%

• Median Follow-up 3 yrs


Hypertension. 2010;56(2):196-202

VALISH Trial


RCTs Evaluating SBP Targets

in those Aged < 60

“Does the absence of evidence lead to

the conclusion of evidence of absence?”

JNC-8 authors concluded:

- Yes for those >60

- No for those <60



Guidelines, Performance Measures and Policy

• Guideline:

– In past: practical advice on a course of action

– Have become: RCT-based, rigorous

• Performance Measures:

– Distillation of guidelines:

• Use strict criteria to define what should and must

be done to avoid a quality concern

– Often applied to public reporting or financial

incentives


BP Treatment Targets Have Risks Both Ways

• If one votes to keep all at 140/90

– PM’s and incentives may encourage over-treatment

• Worse symptoms, falls, costs in elderly

• If one votes to move to 150/90 in elderly

– Risk of under-treatment

• Despite existing guideline goals/PM’s, <50%

of public reaches goal!


JNC-8 Implications for US

All US Adults Ages 18-59 Ages 60+

JNC 7: HTN 66.6 32.8 33.8

Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%)

JNC 8: HTN 60.8 30.8 30.0

Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)


Major Findings

• Currently: 66.7 million in US have hypertension,

– of which 39.9% met guideline targets.

• Using JNC 8: 60.8 million in US have hypertension,

– of which 56.4% have controlled blood pressure.

• In 60+, switching to JNC-8

– improves BP control rates from 34.3% to 60.8%

– reclassifying 13.6 million with previously

uncontrolled BP now seen as under control


Conclusions

• Hypertension: common, costly and modifiable

• Interpretation of existing evidence is challenging

– Determining the optimal threshold will require

more RCTs.

• In interim: My view:

– Aim for 140/90 but allow for individualization

– What’s your take?

Health & Medicine

The Hypertension Guidelines JNC 8