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JNC-8 New GuidelinesFinally

Let the controversies begin

Eric D Peterson, MD, MPH


Director of DCRI
http://www.dcri.duke.edu/research/coi.jsp

Feb, 2014

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)

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How Aggressive to Treat Hypertension


Some Early Views on the Controversy
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.

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Stroke and IHD Mortality vs Systolic BP by Age


Mortality
(Floating absolute risk and 95% CI)

Age at risk
256

Age at risk:
80-89 years

128

70-79 years

60-69 years

64

60-69 years

50-59 years

32

50-59 years

256

80-89 years

128

70-79 years

64
32

16

16

Stroke

0
120

140

160

0
180

Usual Systolic BP (mm Hg)

40-49 years

Ischemic Heart Disease


120 140 160 180
Usual Systolic BP (mm Hg)

Lancet. 2002;360:1903-1913
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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


2 mmHg
increase in
mean SBP

7% increase in
risk of ischemic
heart disease
mortality
10% increase in
risk of stroke
mortality

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


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Risk reduction (%)

Benefits of Treating Hypertension: RCT


0
-10
-20
-30
-40
-50
-60
-70
-80
-90
-100

20%
50%
Heart failure

40%

Stroke

Cardiovascular
death

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


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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

With compelling indications

Stage 1 Hypertension
(SBP 140-159 DBP 90-99 )

Stage 2 hypertension
(SBP 160 or DBP 100)

Drug(s) for compelling


indications

Diuretics for most; may


consider ACE inhibitor,
ARB, beta blocker, CCB or
combination

2-drug combination for


most (Diuretic +ACE, ARB,
beta blocker, or CCB)

Diuretics, ACE inhibitor,


ARB, beta blocker, CCB as
needed

* Released in 2003
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JNC-8 Significantly
Delayed

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NHLBI Drops Out of


Guidelines Business

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James et al JAMA December 13 2014


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James et al JAMA December 13 2014


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JNC-8 Hypertension Treatment Choices

James et al JAMA December 13 2014


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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
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JATOS Results

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


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The Evidence for Targets: VALISH Trial


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
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VALISH Trial

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

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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

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BP Treatment Targets Have Risks Both Ways


If one votes to keep all at 140/90
PMs 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/PMs, <50%
of public reaches goal!

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JNC-8 Implications for US

JNC 7: HTN
Controlled
JNC 8: HTN
Controlled

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All US Adults
66.6
26.6 (39.9%)
60.8
34.3 (56.4%)

Ages 18-59
32.8
13.3 (40.5%)
30.8
14.6 (47.4%%)

Ages 60+
33.8
13.3 (39.3%)
30.0
19.7 (65.7%)

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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

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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
Whats your take?

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