Download - JNC 8
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JNC 8Evidence to the fore?
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PROCESS
>400 nominees
Members selected
Guidelines first draft - January 2013
Reviewed by 20 reviewers + 16 federal agencies - February 2013
Revised document - June 2013
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QUESTIONS
In adults with HTN:-
•Starting Pharmac Rx @ specific BP threshold = benefit?
•Treating to specific BP goal = benefit?
•Diff anti-HTN drugs/classes = Diff benefit or harm in specific health outcomes?
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EVIDENCE SELECTION
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POPULATION CRITERIA
• Adults ≥ 18 years with HTN• Subgroups
• DM• CAD• PAD• HF• Prev Stroke• CKD• Proteinuria• Older adults• Men/Women• Racial/ethnic groups,
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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
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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
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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
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RESULTANT 9 recommendations
Strength of recommendation for each
Recomm 1 – 5 Threshold and goals
Recomm 6 – 8 Selection of antiHTN drugs
Recomm 9 Summary of strategies (expert opinion)
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RECOMMENDATIONS
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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
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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)
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RECOMMENDATION 3
Gen pop < 60 years
Start at SBP ≥ 140
Goal SBP < 140
Exp Op – Grade E
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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
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RECOMMENDATION 5
DM ≥ 18 years
Start at SBP ≥ 140 OR DBP ≥ 90
Goal SBP < 140 AND DBP < 90
Exp Op – Grade E
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RECOMMENDATION 6
Gen pop non-black (+/- DM)
Initial drug:- Thiazide diuretic CCB ACEi ARB
Mod Recomm – Grade B
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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
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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
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RECOMMENDATION 8
Adults CKD (any race, +/- DM)
ACEi/ARB as initial/add-on
Mod Recomm – Grade B
PS – Only improves kidney outcomes
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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
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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
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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
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THANK YOU ALL
For Your Kind Attention