Hypertension Guidelines 2014

Jason A. Smith, DO
Associated Cardiovascular Consultants at
Lourdes Cardiology Services

Disclosures
No disclosures

Hypertension
Hypertension is the most common
condition in primary care.
1 in 3 patients have hypertension
according to NHLBI

Risk factor for MI, CVA, ARF, death

Hypertension

Case
A 58 year old African-American woman
with diabetes and dyslipidemia has a
BP of 158/94 confirmed on several
office visits. Other than obesity, the
exam is normal. Labs show normal
renal function, well-controlled lipids on
atorvastatin and well-controlled
diabetes on metformin. Urine microalbumin is mildly elevated.

Case Question 1
What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.

<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg

Case Question 2
What is the drug of choice to start?
1.
2.
3.
4.
5.
6.

HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
Combination therapy

Classification of BP JNC 7
Category

Systolic
(mmHg)

Diastolic
(mmHg)

Normal

< 120

and

< 80

Pre-HTN

120-139

or

80-89

Stage I

140-159

or

90-99

Stage II

> 160

or

> 100

Hypertension

2013 ESH/ESC Guidelines for the management of arterial hypertension

Denitions and classication of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg DBP >90 mmHg
Category

Systolic

Diastolic

Optimal

<120

and

<80

Normal

120129

and/or

8084

High normal

130139

and/or

8589

Grade 1 hypertension

140159

and/or

9099

Grade 2 hypertension

160179

and/or

100109

Grade 3 hypertension

180

and/or

110

Isolated systolic hypertension

140

and

<90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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JNC 8
2014 Evidence-Based Guidelines for
the Management of High Blood
Pressure in Adults
JAMA. 2014;311(5):507-520
December 18, 2013

JNC 8: Hypertension Management

Questions Guiding Review
In adults with HTN:
1. Does initiating antihypertensive
pharmacologic therapy at specific BP
thresholds improve health outcomes?
2. Does treatment with antihypertensive
pharmacologic therapy to a specified goal
lead to improvements in health outcomes?
3. Do various antihypertensive drugs or drug
classes differ in comparative benefits and
harms on specific health outcomes?

JNC 8: Hypertension Management

Evidence Review
Limited to RCTs
Hypertensive adults > 18 years old
Sample size > 100
Follow-up > 1 year
Reported effect of treatment on important
health outcomes (mortality, MI, HF, CVA,
ESRD)

January 1966 to December 2009

Separate criteria used of RCTs published
after December 2009

JNC 8: Hypertension Management

Evidence Review
RCTs December 2009 August 2013
1. Major study in hypertension

ACCORD, NEJM 2010

2. > 2,000 participants

3. Multicentered
4. Met all other inclusion/exclusion criteria

JNC 8: Graded Recommendations

A Strong evidence
B Moderate evidence
C Weak evidence
D Against
E Expert Opinion
N No recommendation

JNC 8: Drug Treatment

Thresholds and Goals
Age > 60 yo
Systolic:
Threshold > 150 mmHg
Goal < 150 mmHg
LOE: Grade A

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A

JNC 8: Drug Treatment

Thresholds and Goals
Age < 60 yo
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages 1839

JNC 8: Drug Treatment

Thresholds and Goals
Age > 18 yo with CKD or DM
JNC 7: < 130/80 (MDRD NEJM 1994)
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade E

JNC 8: Initial Drug Choice

Nonblack, including DM
Thiazide diuretic, CCB, ACEI, ARB
LOE: Grade B

Black, including DM
Thiazide diuretic, CCB
LOE: Grade B (Grade C for diabetics)

JNC 8: Initial Drug Choice

Age > 18 yo with CKD and HTN
(regardless of race or diabetes)
Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
LOE: Grade B

Blacks w/ or w/o proteinuria

ACEI or ARB as initial therapy (LOE: Grade E)

No evidence for RAS-blockers > 75 yo

Diuretic is an option for initial therapy

JNC 8: Subsequent Management

Reassess treatment monthly
Avoid ACEI/ARB combination
Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
Goal BP not reached with 3 drugs, use
drugs from other classes
Consider referral to HTN specialist
LOE: Grade E

Dissenting Editorial
Ann Intern Med. January 14, 2014
5/17 authors (29%)
Insufficient evidence to increase
target SBP to 150 mmHg.
Expertise vs. Scientific Evidence

Recent HTN Guideline Statements

2013 ESH/ESC Guidelines for the
management of arterial hypertension.
J Hypertnsion 2013;31:1281-1357.

An Effective Approach to High Blood

Pressure Control: A Science Advisory
From the AHA, ACC, and CDC.
Hypertension online November 15, 2013.

Clinical Practice Guidelines for the

Management of HTN in the Community
A Statements by the ASH/ISH.
J Hypertension 2014;32:3-15

2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for most
Patients at lowmoderate CV risk
Patients with diabetes
Consider with previous stroke or TIA
Consider with CHD
Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly

Ages <80 years
Initial SBP 160 mmHg

140-150 mmHg

SBP goal for fit elderly

Aged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP

160 mmHg

140-150 mmHg

DBP goal for most

<90 mmHg

DB goal for patients with diabetes

<85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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BP goal in the elderly

2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations

Additonal considerations

Mandatory: initiate drug treatment in patients

with SBP 160 mmHg

Strongly recommended: start drug treatment

when SBP 140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes

RAS blockers may be preferred

Especially in presence of preoteinuria or
microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Avoid in patients with diabetes

Coadministration of RAS blockers not

recommended

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with nephropathy

Recommendations

Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria

Monitor changes in eGFR

RAS blockers more effective to reduce

albuminuria than other agents

Indicated in presence of microalbuminuria or

overt proteinuria

Combination therapy usually required to reach BP

goals

Combine RAS blockers with other agents

Combination of two RAS blockers

Not recommended

Aldosterone antagonist not recommended in CKD

Especially in combination with a RAS blocker

Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, reninangiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over the World
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What is the goal BP?

Comparison of Recent
Guideline Statements
JNC 8

ESH/ESC

AHA/ACC

ASH/ISH

>140/90

>140/90 <80 yr
>150/90 >80 yr

>140/90
Threshold
for Drug Rx

>140/90 < 60 yr Eldery SBP >160

>150/90 >60 yr Consider SBP
140-150 if <80 yr

B-blocker
First line Rx

No

Yes

No

No

Initiate Therapy
w/ 2 drugs

>160/100

"Markedly
elevated BP"

>160/100

>160/100

Goal BP
Group

BP Goal (mm Hg)

General
DM*

CKD**

JNC 8:

<60 yr: <140/90

>60 yr: <150/90

< 140/90

< 140/90

ESH/ESC:

< 140/90

< 140/85

< 140/90

Elderly

140-150/90
(<80 yr: SBP<140)

ASH/ISH

< 140/90
>80 yr: <150/90

AHA/ACC

< 140/90

*ADA: < 140/80 or lower

(SBP < 130 if proteinuria)

< 140/90

< 140/90

(Consider < 130/80 if proteinuria)

< 140/90

< 140/90

**KDIGO: <140/90 w/o albuminuria

<130/80 if >30 mg/24hr

2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake

Restrict 5-6 g/day

Moderate alcohol intake

Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

25 kg/m2

BMI goal

Waist circumference goal

Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*
30 min/day, 5-7 days/week
(moderate, dynamic exercise)

Exercise goals
Quit smoking
* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over the World
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Thank you for your attention!

smithj@lourdesnet.org