Hypertension:
what is
new…and old
GREG FOTIEO, MD
Objectives

Background

Review JNC 8 Recommendations
through clinical cases

Discuss concerns about JNC 8

Figure out how to apply JNC 8 to
your practice (hopefully)
Prevalence

1/3 of adults

About 60 million hypertensives in
the US

Most common chronic condition
seen in primary care

Most common risk factor for heart
attack and stroke

Prevalence increases with
increasing age
Why worry?

There is a strong relationship between
blood pressure and the risk of CV events,
strokes and kidney disease

The risk is lowest at 115/75 and for each
increase of 20 mm in SBP or 10 mm in DBP
the risk of major CV event or stoke
doubles

Treatment of hypertension has been
shown to reduce risk of adverse CV
outcomes by 20-25% and stroke by 3040%
How are we doing?

Not so good

2005-8 NHANES survey found only
46-51% of persons with HTN had
their blood pressure controlled
<140/90.
JNC HISTORY

JNC 1: published 1976

JNC 2: published 1980

JNC 3: published 1984

JNC 4: published 1988

JNC 5: published 1992

JNC 6: published 1997

JNC 7: published 2003

JNC LATE
Questions Addressed by
the JNC 8 Panel
1. In adults with hypertension, does initiating
antihypertensive pharmacologic therapy at specific
BP thresholds improve health outcomes? Thresholds
2. In adults with hypertension, does treatment with
antihypertensive pharmacologic therapy to a
specified BP goal lead to improvement in health
outcomes? Targets
3. In adults with hypertension, do various
antihypertensive drugs or drug classes differ in
comparative benefits and harms on specific health
outcomes? Impact of drugs
The 9 Recommendations

Recommendations 1-5 address thresholds
and goals for BP treatment.

Recommendations 6-8 address selection of
antihypertensive drugs.

Recommendation 9 is a summary of
strategies based on expert opinion for
starting and adding antihypertensive drugs.
Case #1

A 72 yo Caucasian man with HTN, COPD,
BPH and a history of prostate cancer s/p
radical prostatectomy presents for
routine f/u. He feels well except for SOB
with heavy exertion that responds to his
albuterol inhaler. His BP is 118/78. He is
currently on albuterol MDI prn, Lisinopril 10
mg qday, and HCTZ 12.5 mg qday. His
labs are unremarkable. What should you
do with his hypertensive regimen?
RECOMMENDATION 1

In the general population aged ≥60 years,
initiate pharmacological treatment to lower
BP at SBP of ≥150 mm Hg or DBP of ≥
90mm Hg and treat to a goal SBP < 150
mm Hg and DBP <90 mmHg.

Strong recommendation – Grade A.
Basis

Treating to goal SBP of 150 decreases stroke, heart failure,
and CV events

Decreasing goal SBP to 140 provides no additional benefit

Trials used

HYVET

Syst-Eur (The Systolic Hypertension in Europe Trial)

SHEP (Systolic Hypertension in the Elderly Program)

JATOS (Japanese Trial to assess Optimal Systolic blood pressure in elderly
hypertensive patients)

VALISH (VALsartan in elderly Isolated Systolic Hypertension Study)

CARDIO-SIS
Corollary Recommendation

In the general population aged ≥ 60 years, if
pharmacological treatment for high BP results in
lower achieved SBP (for example <140 mm Hg)
and treatment is not associated with adverse
effects on health or quality of life, treatment does
not need to be adjusted.

Expert opinion – Grade E.
Case #2

A 44 yo Asian man with asthma, obesity,
and OSA presents for new patient visit.
He has no complaints but is concerned
about his blood pressure. His last doctor
told him that he did not need any
medications but needed to exercise and
lose weight. He brings in a log of home BP
readings for the last 6 months in the
range of 120-140/ 86-104. He has a BMI of
32. His BP is 132/98 and 138/100 on
repeat. He is currently on fluticasone
MDI, albuterol MDI prn, and uses his CPAP
nightly. His labs are unremarkable. How
would you approach his BP?
RECOMMENDATION 2

In the general population < 60 years, initiate
pharmacological treatment to lower BP at DBP of
≥90 mmHg and treat to a goal DBP of lower than
90 mmHg.

For ages 30-59 years, Strong recommendation Grade A.

For ages 18-29 years. Expert opinion –grade E.
Basis

Treating to goal DBP of 90 decreases stroke, heart failure,
and overall mortality

Setting goal DBP <90 provides no additional benefit

Trials used

HDFP (Hypertension Detection and Follow uP)

Hypertension – Stroke Cooperative

MRC

ANBP

VA Cooperative

HOT
What if he had a BP of
154/80?
RECOMMENDATION 3

In the general population younger than 60 years,
initiate pharmacological treatment to lower BP
at SBP of ≥140 mm Hg and treat to a goal SBP of
< 140 mm Hg.

Expert opinion – Grade E
Basis

In the absence of any RCTs that compared the current
SBP standard of 140 mm Hg with another higher or
lower standard in this age group, there was no
compelling reason to change current
recommendations.

In the DBP trials, many of the study participants who
achieved target DBP were also likely to have achieved
SBP <140 mmHg with Rx. It was not possible to
determine the outcome benefits were due to lowering
of DBP, SBP or both.
RECOMMENDATION 6

In the general nonblack population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type diuretic,
calcium channel blocker (CCB), angiotensin-
converting enzyme inhibitor (ACEI),or
angiotensin receptor blocker(ARB).

Moderate recommendation –Grade B.
Basis

Only used RCT comparing one class of
antihypertensives to another

Each of the 4 drug classes yielded comparable effects
on overall mortality and CV, cerebrovascular and
kidney outcomes.

Do not recommend β blockers because of increased
risk of CVA in one study.
Case #3

A 22 yo Hispanic man with a history
of HTN and CKD presents for routine
f/u. He feels well and has been
adherent to his regimen of
furosemide 20 mg and amlodipine
10 mg. His BP is 148/78. His labs are
significant for a K+ 4.6, creatinine
1.74 and GFR of 39. What should
you do with his hypertensive
regimen?
RECOMMENDATION 4

In the population aged 18 years or older with
CKD, initiate pharmacological treatment to lower
BP at SBP of ≥ 140 mm Hg or DBP of ≥ 90
mmHg and treat to goal SBP of < 140 mm Hg and
DBP < 90 mm Hg.

Expert opinion – grade E.
(Younger <70 yrs. with eGFR or measured GFR <60 ml/min/1.73m2
People of any age with albuminuria >30mgalb/g of creatinine)
Basis

In patients with CKD, no trials showed benefit in CV
or cerebrovascular outcomes, mortality, or progression
of renal disease by lowering BP below 140/90

There is no evidence to make a recommendation about
BP goal in patients over 70 with GFR <60.
RECOMMENDATION 8

In the population aged 18 years or older with
CKD and hypertension, initial (or add-on)
antihypertensive treatment should include ACEI
or ARB to improve kidney outcomes.

This applies to all CKD patients with hypertension
regardless of race or diabetes status.

Moderate Recommendation – Grade B.
Basis

This recommendation is based mainly on kidney
outcomes because there is less evidence for CV
outcomes in patients with CKD.

AASK study showed the benefit of an ACEI on
kidney outcomes in black patients with CKD and
provides additional evidence that supports ACEI
use in that population.
Case #4

A 52 yo Hispanic man with a history
of DM schedules an appointment
with you because his friends told
him that he should be on a BP
medication since he has DM. His
current meds are metformin, ASA,
atorvastatin, and glargine. BP
reading is 138/88. Labs show GFR
78, no microalbumin, and HgA1c
6.8%. Do his friends know what they
are talking about?
RECOMMENDATION 5

In the population aged 18 years or older with
diabetes, initiate pharmacological treatment to
lower BP at SBP of ≥ 140 mm Hg or DBP of ≥90
mm Hg and treat to a goal SBP < 140 mm Hg
goal DBP < 90 mm Hg

Expert opinion Grade E.
Basis

Evidence that treating to a SBP <150 improves
CV and cerebrovascular outcomes in patients with
DM.

No RCT compared goal of 140 to 150 in patients
with DM.

Recommend goal <140/90 to be consistent with
BP goal in general population younger than 60.
What if he had a BP of
154/80?
RECOMMENDATION 6

In the general nonblack population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type diuretic,
calcium channel blocker (CCB), angiotensin-
converting enzyme inhibitor (ACEI),or
angiotensin receptor blocker(ARB).

Moderate recommendation –Grade B.
Case #5

A 62 yo African-American man with
DM presents for routine f/u. His DM
is poorly controlled on glipizide and
metformin. His home BP readings
have been in the 150-160/80-95
range. His BP is 170/92. His HgA1c is
9.2 and his GFR is 78. How will you
deal with his BP?
RECOMMENDATION 7

In the general black population, including those
with diabetes, initial antihypertensive treatment
should include a thiazide – type diuretic or CCB.

For general black population: Moderate Recommendation
–Grade B.

For black patients with diabetes: Weak recommendation –
Grade C.
Basis

ALLHAT

A thiazide type diuretic was shown to be more
effective in improving vascular outcomes
compared to an ACEI in the black subpatient
group(diabetic and non diabetics).

Thiazide type diuretics and CCB were found to
have no difference in vascular outcomes.

51% higher rate of stroke in black patients on ACEI
vs CCB.

ACEI are less effective than CCB in lowering BP
What if his GFR was 40?
RECOMMENDATION 8

In the population aged 18 years or older with
CKD and hypertension, initial (or add-on)
antihypertensive treatment should include ACEI
or ARB to improve kidney outcomes.

This applies to all CKD patients with hypertension
regardless of race or diabetes status.

Moderate Recommendation – Grade B.
Case #5 continued

You start the patient on
chlorthalidone 12.5 mg. When
should you follow up with him?
RECOMMENDATION 9

If goal BP is not reached within a month of treatment,
increase the dose of the initial drug or add a second drug
from one of the classes in recommendation 6 (thiazide- type
diuretic, CCB, ACEI, ARB).

If goal BP cannot be reached with 2 drugs, add and titrate a
third drug from the list provided.

Do not use an ACEI and ARB together in the same patient.

If goal BP cannot be reached using the drugs in
recommendations, because of a contraindication or the need
of > 3 drugs to reach goal BP, antihypertensive drugs from
other classes can be used.

Referral to a hypertension specialist if not controlled with
this strategy.

Expert opinion –Grade E.
To Summarize….
Not everyone agrees
Dissention within JNC 8
5 members voiced exception to the
recommendation to increase the target SBP
from 140 to 150 mm Hg in patients over age
60
 "The majority [of the JNC 8 panel] embraced
the view that in the absence of definitive
evidence, increasing the SBP goal was the
optimum approach [in patients 60 or older].
We, the panel minority, believed that
evidence was insufficient to increase the SBP
goal from its current level of less than 140 mm
Hg because of concern that increasing the
goal may cause harm by increasing the risk
for CVD and partially undoing the
remarkable progress in reducing
cardiovascular mortality in Americans older
than 60 years.“

Other concerns

No cohort data, systematic reviews or meta-analysis
included in review

Used trial data up to 2009 and a bridge search to 2013

Despite the goal to be evidence based

Only 2 recommendations were Grade A

4 recommendations were based on expert opinion

Recent European, Canadian, UK, ACC/AHA, and ASH/ISH
guidelines favor SBP goal of 140 up to age 80

Mixed Messages


New cholesterol guidelines:

treat more people

abandon targets
New HTN guidelines:

treat less people

specify treatment targets
Cochrane Review: The
other side of the coin
What do you
think about
JNC 8?