Hypertension Today: JNC-8 Evidence-Based Guidelines

Event Type
Live Online

Expiration Date
7/16/2016

Credits
1 Contact Hour

Target Audience
Nurses, Pharmacists, Pharmacy Technicians


Program Overview
Hypertension (HTN) is a prevalent disease state throughout the United States and is one of the
risk factors for developing cardiovascular disease. Cardiovascular disease is the leading cause
of death in the United States. The optimal way to treat hypertension has been the focus of
many studies and has led to many conflicting opinions and guidelines over the past
decade. Most recently, in December 2013, the Eighth Joint National Committee (JNC8)
released their newest guidelines to address when to initiate therapy, what the optimal BP goal
is for patients, and what drug therapies we should be using to control hypertension.

Nurse/Pharmacist Educational Objectives
Review the historical goals and treatment of patients with hypertension
Determine optimal threshold for initiating treatment in patients with hypertension
Establish evidence based treatment goals for patients with hypertension
Select optimal treatment for patients with hypertension focusing on key evidence regarding
diuretics, combination therapy, and beta blockers

Pharmacy Technician Educational Objectives
List signs and symptoms of hypertension
List medications used to treat hypertension

Activity Type
Knowledge





Accreditation
Nurse
Pharmacist
Pharmacy Technician
N-875
0798-0000-14-275-L01-P
0798-0000-13-275-L01-T


PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education.


PharmCon, Inc. has been approved as a provider of continuing education for nurses by the
Maryland Nurses Association which is accredited as an approver of continuing education in
nursing by the American Nurses Credentialing Centers Commission on Accreditation.

Faculty




Kate Moore, PharmD
Associate Professor, Presbyterian College School of Pharmacy

Financial Support Received From
Pharmaceutical Education Consultants, Inc.

Disclaimer
PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the
value of the material is decreased. The content of the activity was planned to be balanced and
objective. Occasionally, authors may express opinions that represent their own viewpoint.
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in this
activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions
drawn by participants should be derived from objective analysis of scientific data presented
from this activity and other unrelated sources.
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 1
Hypertension Today:
JNC-8 Evidence-Based Guidelines
Accreditation
Pharmacists: 0798-0000-14-275-L01-P
Pharmacy Technicians: 0798-0000-14-275-L01-T
Nurses: N-875
Faculty
Kate Moore, PharmD
Presbyterian School of Pharmacy
CE Credit(s)
1.0 contact hour(s)
Faculty Disclosure
Dr. Moore has no actual or potential conflicts of interest in
relation to this program.
Learning Objectives
Review the historical goals and treatment of patients with hypertension
Determine optimal threshold for initiating treatment in patients with hypertension
Establish evidence based treatment goals for patients with hypertension
Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination
therapy, and beta blockers
Legal Disclaimer
The material presented here does not necessarily reflect the views of Pharmaceutical EducationConsultants (PharmCon) or the companies that
support educational programming. Aqualifiedhealthcareprofessional shouldalways beconsultedbefore using any therapeutic product discussed.
Participants shouldverify all informationanddata before treating patients or employing any therapies describedin this educational activity.
Objectives
Review the historical goals and treatment of patients
with hypertension
Determine optimal threshold for initiating treatment
in patients with hypertension
Establish evidence based treatment goals for patients
with hypertension
Select optimal treatment for patients with
hypertension focusing on key evidence regarding
diuretics, combination therapy, and beta blockers
Disclosures
I have no financial disclosures
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 2
Defining the Burden:
Cardiovascular Disease
Leading cause of death in US
Responsible for 17% of national health expenditures
2 million heart attacks annually
Projected:
By 2030, 40.5% of US will have CVD
Will account for $1 trillion/year
Risk Factors for Cardiovascular Disease
Cigarette smoking
Hypertension
Elevated LDL Cholesterol
Family history of premature CHD (<55 years in male,
<65 years in female)
Age >45 men, >55 women
Diabetes
Obesity
Physical inactivity
Excessive alcohol use
MMWR 2011;60(36):124851
Defining the Burden:
Risk Factor-Hypertension (2011)
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm, accessed 1/30/2013
Hypertension and Cardiovascular Disease
Risk factor for heart disease and stroke
BP >140/90 mmHg
DBP more potent predictor <50 yrs old
SBP more important >50 yrs old
Two-fold increase in risk of CVD with BP 130-
139/85-89 vs <120/80
Primary or contributing cause of death for 348,000
Americans in 2008
N Engl J Med 2001;345:1291-7
Circulation 2001;103:1245-9
Circulation. 2012;125(1):e2220.
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 3
Historical Review: BP Goals
Discrepancy across guidelines
JNC-7 vs AHA
Lower not always better
Mortality may increase with lower DBP
Co-morbid Condition JNC-7 AHA
None <140/90 <140/90
Diabetes <130/80 <130/80
Chronic kidney disease <130/80 <130/80
Known CAD ---- <130/80
Non-coronary atherosclerotic vascular disease ---- <130/80
Framingham risk assessment >10% ---- <130/80
Left ventricular dysfunction (heart failure) ---- 120/80
NHLBI, JNC 7, Aug 2004;
Circulation 2007;115:2761-88
Historical Review: Compelling Indications
Compelling Indication Antihypertensive
Diabetes ACEI, ARB, BB, CCB, diuretic
Post Myocardial Infarction BB, ACEI, Aldo Ant
Heart Failure ACEI, ARB, diuretic, BB, Aldo Ant
Chronic Kidney Disease ACEI, ARB
Stroke ACEI, diuretic
High Coronary Risk ACEI, BB, CCB, diuretic
NHLBI, JNC 7, Aug 2004
Historical Review: Treatment Algorithm
NHLBI, JNC 7, Aug 2004
Lifestyle Modifications
Not at goal blood pressure
(<140/90 or <130/80)
Initial Drug Choices
Without Compelling Indications With Compelling Indications
Stage 1 (140-
159/90-99):
Thiazide-type
diuretic for
most, May
consider ACEI,
ARB, BB,CCB or
combination
Stage 2
(160/100):
Two-drug
combination for
most (usually
thiazide-type
diuretic and
ACEI, ARB,
BB,CCB or
combination
Use therapies for
the compelling
indications and
other
antihypertensive
drugs as needed
Where are we now?
JNC-8
Systematic review based process
Critical Questions:
Does initiating antihypertensive pharmacological therapy at specific
BP thresholds improve health outcomes? When should you initiate
treatment?
Does treatment with an antihypertensive pharmacological therapy to
a specified BP goal lead to improvements in health outcomes? How
low should you go?
Do various antihypertensive drugs or drug classes differ in
comparative benefits and harms on specific health outcomes? How do
you get there?
JAMA 2013. doi:10.1001/jama.2013.284427
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 4
Patient Case-Harry T. Nabb
Pt is 49 years old Caucasian male with no significant
past medical history. He presents today for his
routine yearly physical.
Vitals
BP 136/88 (first reading), 134/84 (second reading)
Height 510
Weight 198 lbs (BMI 28.4)
When should we
initiate treatment?
Treat Pre-hypertension?
The TROPHY Study
Objective:
to determine whether patients with pre-hypertension treated
for two years with candesartan reduces the incidence of
hypertension for up to two years after the discontinuation of
active treatment.
Comparison
Candesartan vs placebo
Patients
age 30-65
BP 130-139/89 mmHg or <139/85-89 mmHg
Not treated
Endpoint
Development of hypertension (SBP >140 or DBP >90)
NEJM2006;354:1685-97
Treat Pre-hypertension?
The TROPHY Study
Adverse effects
Similar between groups
Conclusion
Treating pre-hypertension can decrease the development of
hypertension
No information on cost effectiveness
No information on outcome impact (death, hospitalizations,
stroke, MI)
Outcome Candesartan
N=391
Placebo
N=381
P-value Relative Risk (95%
CI)
Developed Hypertension 208 240
Hypertension at 2 years, % 13.6 40.4 <0.001 0.34 (0.25-0.44)
Hypertension at 4 years, % 53.2 63 0.007 0.84 (0.75-0.95)
NEJM2006;354:1685-97
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 5
Cochrane Review of Mild Hypertension
Effect of treatment vs no treatment in patients with
no history of CV events and BP 140-159/90-
99mmHg on CV events, stroke, mortality
Withdrawals due to adverse effects of therapy
Trials included
VA-NHLBI 1997 (chlorthalidone vs placebo)
ANBP 1984 (chlorthiazide vs placebo)
MRC 1981 (Bendrofluazide, propranolol vs placebo)
SHEP 2000 (chlorthalidone vs placebo)
Cochrane Database of Systematic Reviews 2012, Issue 8.
Cochrane Review of Mild Hypertension
Outcome
No. of
Trials
included
Number
of
Subjects
Relative Risk
(95% CI)
Mortality
4 8912 0.85 (0.65-1.15)
Stroke
3 7080 0.51 (0.24-1.08)
Coronary Heart Disease
3 7080 1.12 (0.8-1.57)
Total CV Events
3 7080 0.97 (0.72-1.32)
Withdrawal due to Adverse Events
1 17354 4.80 (4.14-5.57)
Cochrane Database of Systematic Reviews 2012, Issue 8.
Cochrane Review of Mild Hypertension
Conclusion
Treatment of mild hypertension for 5 years does not
reduce mortality, stroke, CHD, or CV events
Thoughts to ponder
Therapies included do not match current practice
Many other trials show outcomes benefit with similar
baseline BP
ALLHAT-baseline BP 146/86
ACCOMPLISH-baseline BP 145/80
Negative impact of hypertension may take >5 years to
develop
Does not apply to those with history of CV disease!
Cochrane Database of Systematic Reviews 2012, Issue 8.
JNC-8: When should we initiate treatment?
Age 60 years
SBP 150mmHg
DBP 90 mmHg
Age < 60 years
SBP 140mmHg
DBP 90 mmHg
Strong recommendations to reduce risk of stroke, heart
failure, coronary heart disease
JAMA 2013. doi:10.1001/jama.2013.284427
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 6
What is our optimal
blood pressure goal?
Patient Case-Harry T. Nabb
1 year has passed and Mr. Nabb returns for another
physical. He did not make any lifestyle changes as
recommended before and is currently not taking any
medications
Vitals
BP 144/88 (first reading), 142/84 (second reading)
Height 510
Weight 215 lbs (BMI 30.8)
Labs
A1c 7.8, fasting BG 142
TC 201, LDL 140, HDL 32, TG 142
Hypertension Optimal Treatment (HOT) Trial
Comparison
Target DBP <90 vs <85 vs <80
Patients all >100mmHg at baseline
Treatment
Step 1: felodipine 5mg
Step 2: ACE inhibitor or Beta Blocker
Steps 3-5: dose titrations
Endpoint
Incidence of major CV event
Fatal & non-fatal MI, stroke, CV death
Lancet 1998;351:1755-62
HOT Trial
Patient Characteristics
<90mmHg
n=6264
<85mmHg
n=6264
<80mmHg
n=6262
Age (years) 61.5 61.5 61.5
Males (%) 53 53 53
BMI (kg/m
2
) 28.4 28.5 28.4
Blood Pressure (mmHg) 170/105 170/105 170/105
Total Cholesterol
Previous BP treatment (%) 52.3 52.7 52.6
History of MI (%) 1.6 1.5 1.5
History of Stroke (%) 1.2 1.2 1.2
Diabetes (%) 8 8 8
Lancet 1998;351:1755-62
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 7
HOT Trial
Results-Overall Population
<90mmHg
n=6264
<85mmHg
n=6264
<80mmHg
n=6262
P-value for
trend
SBP achieved
143.7 (11.3)
141.4
(11.7)
139.7 (11.7)
DBP achieved 85.2 (5.1) 83.2 (4.8) 81.1 (5.3)
Major CV events* 9.9 10 9.3 0.50
Myocardial
Infarction*
3.6 2.7 2.6 0.05
Stroke* 4 4.7 3.8 0.74
CV Mortality* 3.7 3.8 4.1 0.49
Total Mortality* 7.9 8.2 8.8 0.32
*events per 1000 patient years
Lancet 1998;351:1755-62
HOT Trial
Results-Diabetes Population
Lancet 1998;351:1755-62
<90mmHg
n=6264
<85mmHg
n=6264
<80mmHg
n=6262
p-value for
trend
SBP achieved 143.7
(11.3)
141.4
(11.7)
139.7 (11.7)
DBP achieved 85.2 (5.1) 83.2 (4.8) 81.1 (5.3)
Major CV events* 24.4 18.6 11.9 0.005
Myocardial
Infarction*
7.5 4.3 3.7 0.11
Stroke* 9.1 7 6.4 0.34
CV Mortality* 11.1 11.2 3.7 0.016
Total Mortality* 15.9 15.5 9 0.068
*events per 1000 patient years
ACCORD-BP
Comparison
Intensive therapy (SBP <120mmHg) vs standard therapy
(SBP <140mmHg)
Patients
Type 2 Diabetes (A1c >7.5%)
>40 years with CV disease or >55 with risk factors
Endpoint
First occurrence of major cardiovascular event
Nonfatal MI, nonfatal stroke, CV death
NEJM2010;362:1575-85
ACCORD-BP
Patient Baseline Characteristics
Characteristic
Overall
N=4733
Age (yr) 62.2 (6.9)
Female (%) 47.7
History of CV event (%) 33.7
Weight (kg) 92 (18.6)
Systolic blood pressure (mmHg) 139.2 (15.8)
Diastolic blood pressure (mmHg) 76 (10.4)
HbA1c (%) 8.3
LDL (mg/dL) 110 (36.7)
Estimated GFR (ml/min/1.73m
2
) 91.6 (28.8)
NEJM2010;362:1575-85
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 8
ACCORD-BP
Results-Primary Outcome
HR= 0.88 (0.73-1.06)
NEJM2010;362:1575-85
Mean SBP Achieved:
Intensive group-
119mmHg
Control group-
133mmHg
ACCORD-BP
Results-Primary & Secondary Outcomes
Outcome
Intensive
Therapy
# events (%/yr)
Standard
Therapy
# events (%/yr)
Hazard Ratio
(95% CI)
p-value
Primary Outcome 208 (1.87) 237 (2.09) 0.88 (0.73-1.06) 0.2
Nonfatal MI 126 (1.13) 146 (1.28) 0.87 (0.68-1.10) 0.25
Stroke 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01
Death-all cause 150 (1.28) 144 (1.19) 1.07 (0.85-1.35) 0.55
Death-CV cause 60 (0.52) 58 (0.49) 1.06 (0.74-1.52) 0.74
NEJM2010;362:1575-85
ACCORD-BP
Results-Adverse Events
Event
Intensive
Therapy
# events (%)
Standard
Therapy
# events (%)
p-value
Event attributed to BP medication 77 (3.3) 30 (1.27) <0.001
Hypotension 17 (0.7) 1 (0.04) <0.001
Syncope 12 (0.5) 5 (0.02) 0.1
Bradycardia, arrythmia 12 (0.5) 3 (0.13) 0.02
Hyperkalemia 9 (0.4) 1 (0.04) 0.01
Angiodemia 6 (0.3) 4 (0.17) 0.55
Renal failure 5 (0.2) 1 (0.04) 0.12
NEJM2010;362:1575-85
Summary of trials in Diabetes
Journal of Hypertension 2009; 27: 929.
Difference found
Difference in subgroups only
No difference found
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 9
JNC-8: What is our Optimal BP Goal?
Age 60 years
Goal <150/90mmHg
Optional <140 systolic if treatment well tolerated
Age < 60 years
Goal <140/90mmHg
Age 18 years with diabetes
Goal <140/90mmHg
Age 18 years with CKD
Goal <140/90mmHg
JAMA 2013. doi:10.1001/jama.2013.284427
Is one agent or combination
of agents better than
another?
Anti-Hypertensive Therapies
Thiazide and Thiazide-Type Diuretics
Angiotensin Converting Enzyme Inhibitors (ACE)
Angiotensin Receptor Blockers (ARB)
Beta Blocker (BB)
Calcium Channel Blocker (CCB)
Alpha agonists
Vasodilators
Aldosterone Receptor Antagonists
Loop Diuretics
Direct Renin Inhibitors
Thiazide-type Diuretics
JNC-8: Similar benefit on overall mortality and coronary
heart disease outcomes compared to ACE, CCB, BB or
alpha 1-blocker
ALLHAT
Lower 6 year rate of stroke (p=0.02)
No difference in combined fatal or nonfatal MI (p=0.81)
No difference in overall mortality vs ACE (p=0.9) or CCB
(p=0.2)
Greater reduction in stroke in black population vs ACE
ANBP2
No difference in coronary events vs ACE inhibitor (p=0.16)
JAMA. 2002;288:29812997; NEJM2003;348:583-92
JAMA 2013. doi:10.1001/jama.2013.284427
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 10
Chlorthalidone (CTD)
Trial Comparator Result
HDFP PCP choice CTD care better
MRFIT-
10yr f/u
Usual care CTD better
SHEP Placebo CTD better
TOMHS acebutolol
doxazosin
amlodipine
enalapril
No difference
ALLHAT amlodipine
lisinopril
CTD better
Hydrochlorothiazide (HCTZ)
Trial Comparator Result
VA II placebo HCTZ better
EWPHBPE Placebo No difference
HAPPHY Beta-blockers No difference
MAPPHY metoprolol Metoprolol
better
MRC-E Placebo
Atenolol
Atenolol
better
MIDAS CCB No difference
INSIGHT Nifedipine No difference
PATS Placebo HCTZ better
ANBP Enalapril Enalapril
better
Thiazide-type Diuretics
Clinical Trial Overview
Chlorthalidone vs Hydrochlorothiazide
Mean Change from Week 0 to Week 8 in Mean Hourly Ambulatory SBP
Hypertension2006;47:352-358.
Thiazide-type Diuretics Clinical Pearls
Chlorthalidone has a longer half-life & duration of
action and is ~2x as potent
Doses >25mg of chlorthalidone & HCTZ do not offer
significant benefit
No difference in hypokalemia
Dose related side effect
Are not beneficial in renal dysfunction
Beta Blockers and Hypertension
2004 Meta-analysis
Atenolol vs placebo
Decreased BP
No difference in all-cause or CV mortality, MI
Non-significant decrease in stroke
Atenolol vs other antihypertensives
No difference in BP lowering
Higher mortality with atenolol
Lancet 2004;364:1684-89
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 11
Beta Blockers and Hypertension
Outcome Comparator # of studies (pts) Risk Ratio (95% CI)
Total mortality Placebo
Diuretic
CCB
RAS agent
4 (23613)
5 (18241)
4 (44825)
3 (10828)
0.99 (0.88-1.11)
1.04 (0.82-1.54)
1.07 (1.00-1.14)
1.10 (0.98-1.24)
Stroke Placebo
Diuretic
CCB
RAS agent
4 (23613)
4 (18135)
3 (44167)
2 (9951)
0.8 (0.66-0.96)
1.17 (0.65-2.09)
1.24 (1.11-1.40)
1.30 (1.11-1.53)
Coronary Heart Disease Placebo
Diuretic
CCB
RAS agent
4 (23613)
4 (18135)
3 (44167)
2 (9951)
0.93 (0.81-1.07)
1.12 (0.82-1.54)
1.05 (0.96-1.15)
0.90 (0.76-1.06)
Withdrawal due to AE Placebo
Diuretic
CCB
RAS agent
2 (16372)
3 (11566)
2 (21591)
2 (9951)
6.35 (3.94-10.22)
1.69 (0.95-3.00)
1.20 (0.71-2.04)
1.41 (1.29-1.54)
Cochrane Database of Systematic Reviews 2012, Issue 11
Decline of Beta Blockers
Limited role for first line therapy unless compelling
indication
HF (with ACE)
Post MI
Duration recently questioned
Less tolerated than other agents
Fatigue, exercise intolerance
Bradycardia
Sexual dysfunction
Bronchospasm
Beta Blocker Clinical Pearls
Not created equal
Selectivity
Route of elimination
Indications
Monitor HR carefully
Caution initiation/titration in symptomatic heart failure
Selectivity lost at higher doses
Taper off slowly
Risk of rebound hypertension, angina, sudden cardiac death
1-2 weeks minimum
ACE Inhibitors
JNC-8: ACE reduce incidence of heart failure, but
similar effect on other cardiovascular,
cerebrovascular, kidney outcomes and mortality
compared to CCB
ACE lead to higher incidence of stroke in general black
population compared to CCB
ACE improves kidney outcomes compared to CCB or BB,
however does not improve cardiovascular outcomes
JAMA 2013. doi:10.1001/jama.2013.284427
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 12
Angiotensin Receptor Blockers
JNC-8: No trials of sufficient quality to determine
whether initial therapy with ARB improves
outcomes compared to other therapies in general
population
ARB improves kidney outcomes in those with
proteinuria and hypertension compared to CCB,
however does not improve cardiovascular outcomes
JAMA 2013. doi:10.1001/jama.2013.284427
Renin-Angiotensin Agent Clinical Pearls
Combination therapy (ACE + ARB/DRI)
Increased hyperkalemia
No difference in clinical outcomes for hypertension
Avoid ACE or ARB + DRI in patients with DM & renal
insufficiency
Angioedema
ACE > ARB, DRI
Can happen with all 3 classes
Discontinue if increase in SCr >30%
Avoid in pregnancy or childbearing years
JNC-8: What Initial Agent should
be Started?
General Non-black population (including diabetes)
Thiazide-type diuretic, CCB, ACE or ARB
General black population (including diabetes)
Thiazide-type diuretic or CCB
Age 18 years with CKD
ACE or ARB
Main objective is to reach and maintain goal BP
JAMA 2013. doi:10.1001/jama.2013.284427
What Combination Therapy is Best?
The ACCOMPLISH Trial
High risk patients: SBP 160 or on therapy, >60 with 1 risk factor,
or 55-59 with 2 risk factors
Benazepril 20mg +
HCTZ 12.5mg
Benazepril 20mg+
Amlodipine 5mg
Benazepril 40mg +
HCTZ 12.5mg
Benazepril 40mg+
Amlodipine 5mg
Benazepril 40mg+
Amlodipine 10mg
Benazepril 40mg +
HCTZ 25mg
Add on from any
other class
Add on from any
other class
Primary endpoint:
CV event or death from CV cause NEJM2008;359:2417-28.
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 13
What Combination Therapy is Best to Initiate?
NEJM2008;359:2417-28.
P<0.001
HR 0.80 (0.72-0.9), p<0.001
NNT: 46
A Constant: Lifestyle Modifications
DASH Diet
Fresh fruit, vegetables
Low-fat dairy
Whole grains, poultry, fish, nuts
Low in fat, red meat, sweets
8-14 mmHg decrease
Limit alcohol
2-8 mmHg
Exercise
Cardiovascular exercise ~30 minutes most days of the week
4-9 mmHg
Weight reduction
5-20 mmHg decrease per 10kg loss
NHLBI, JNC 7, Aug 2004
JNC-8 Algorithm
Lifestyle modifications
Age 60 Age < 60
Diabetes,
no CKD
CKD +/-
Diabetes
18 years with HTN
Goal
<150/90
Goal
<140/90
Goal
<140/90
Goal
<140/90
Initiate thiazide-
type diuretic, ACE,
ARB, CCB alone or
combination
Initiate thiazide-
type diuretic or
CCB alone or
combination
Initiate ACE or ARB
alone or in
combination with
other class
JAMA 2013. doi:10.1001/jama.2013.284427
Black Non-black
Summary
Initiate therapy when BP is above 140/90mmHg
Goal BP for most patients is <140/90mmHg
Initial treatment depends on race and
comorbidities, however for most it is
recommended to select thiazide-type diuretic, ACE,
ARB or CCB
JAMA 2013. doi:10.1001/jama.2013.284427
Hypertension Today: JNC-8 Evidence-Based Guidelines
2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 14
NOTES:
JAMA 2013. doi:10.1001/jama.2013.284427
NOTES:
JAMA 2013. doi:10.1001/jama.2013.284427