The document summarizes the key recommendations from the Eighth Joint National Committee (JNC 8) evidence-based guidelines for managing high blood pressure in adults. The guidelines recommend: 1) Treating hypertension for those over age 60 to a goal of <150/90 mmHg and for all others to a goal of <140/90 mmHg. 2) Initial treatment should include a thiazide-type diuretic, calcium channel blocker, ACE inhibitor, or ARB. For black patients, including those with diabetes, initial treatment should be a thiazide or calcium channel blocker. 3) For patients with chronic kidney disease, treatment should include an ACE inhibitor or ARB

1. Evidence-Based Guideline for Management
of High Blood Pressure in Adults
Report From the Panel Members Appointed to the
Eighth Joint National Committee (JNC 8)
Dr Arun kochar
MD;DM;DNB
Senior interventional cardiologist
Fortis Hospital, Mohali

2. JNC 8 is not just JNC 7 “Renovated”….
but 911ed and Reconstructed

3. Historical Comments about Hypertension
“The greatest danger to
a man with
high blood pressure
lies in its discovery…….
because then some fool is certain to try
his hand and reduce it.”
Hay, Brit Med J,

4. Let us take a early dinner…
 Treat to 150/90 mm Hg in patients over age 60 and
140/90 for everybody else.
 Any of 4 classes of drugs could be chosen.
 Destination is important and not the journey.
 No stages please.
 In blacks C and D.
THANK YOU

5. Introduction
 Hypertension remains one of the most important
preventable contributors to disease and death.
 Clinical guidelines are at the intersection between
research evidence and clinical actions that can
improve patient outcomes.
 This report highlights the Evidence-Based Guideline
for the Management of High Blood Pressure in
Adults.

6. Introduction
 The panel members appointed to the JNC 8 used
evidence-based methods, developing Evidence
Statements and recommendations for blood
pressure treatment.
 Recommendations are based on a systematic review
of the literature to meet needs of the primary care
clinician.
 This is an Executive summary of the evidence and is
provides clear recommendations for all clinicians.

7. Date of download: 12/21/2013
Copyright © 2012 American Medical
Association. All rights reserved.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
Comparison of Current Recommendations With JNC 7 Guidelines
Figure Legend:

8. Questions Guiding the Evidence Review
 Guideline focuses on the panel’s most debated
questions related to high BP management.
 These questions address:
 Thresholds and goals for treatment of hypertension.
 Whether particular antihypertensive drugs have a bearing
health outcomes.

9. 1. In adults with hypertension, does initiating
antihypertensive pharmacologic therapy at specific BP
thresholds improve health outcomes? Goals
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
Questions Guiding the Evidence Review

10. Recommendations

11. Concerning thresholds and goals.
Recommendations 1 -5

12.  General population aged 60 years or older
Recommendation 1
SBP ≥150 mmHg
Or
DBP ≥ 90mmHg
Goal of Treatment :
SBP <150 mmHg
OR
DBP of < 90mmHg.
Initiate Treatment at :

13.  General population < 60 years
Recommendation 2
Initiate Treatment at : DBP ≥ 90mmHg
Goal of Treatment : DBP of < 90mmHg.

14.  General population < 60 years
Recommendation 3
SBP ≥ 140 mmHg
Goal of Treatment : SBP of < 140 mmHg.
Initiate Treatment at :

15.  Population aged 18 years or older with CKD
Recommendation 4
Initiate Treatment at:
SBP ≥ 140 mmHg
Or
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHg
Or
DBP < 90 mmHg

16.  Population aged 18 years or older with
diabetes
Recommendation 5
Initiate Treatment at:
SBP ≥ 140 mmHg
Or
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHg
Or
DBP < 90 mmHg

17. Concerning selection of
antihypertensive drugs.
Recommendations6,7,8

18. Recommendation 6
 In General nonblack population, including those
with diabetes
 Initial antihypertensive treatment should include any
of the following:
 A thiazide-type diuretic
 Calcium channel blocker (CCB)
 Angiotensin-converting enzyme inhibitor (ACEI) or
 Angiotensin receptor blocker (ARB).

19. Recommendation 7
 In general black population, including those
with diabetes:
 Initial antihypertensive treatment should
include :
 Thiazide-type diuretic
 CCB.

20. Recommendation 8
 Population aged 18 years or older with CKD
and hypertension
 Initial (or add-on) antihypertensive treatment
should include an ACEI or ARB to improve
kidney outcomes.
 This applies to all CKD patients with
hypertension regardless of race or diabetes
status.

21. Recommendation 9
 The main objective of hypertension treatment is to
attain and maintain goal BP.
 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, or
ARB).
 The clinician should continue to assess BP and
adjust the treatment regimen until goal BP is
reached.

22. Opinion for starting & adding drugs
.
Recommendation 9

23. Recommendation 9
 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 an ARB together in the
same patient.
 If goal BP cannot be reached using the drugs in
recommendation 6 because of a contraindication or
the need to use more than 3 drugs to reach goal BP:
antihypertensive drugs from other classes can be
used.

24. Date of download: 12/21/2013
Copyright © 2012 American Medical
Association. All rights reserved.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
Strategies
to
Dose
Antihypertensive
Drugs
Figure Legend:

25.  For patients in whom goal BP cannot be attained
using the above strategy OR
 The management of complicated patients for
whom additional clinical consultation is needed.
 Referral to a hypertension specialist may be
indicated
Recommendation 9

26. JNC-8 ASH/ISH AHA/ACC
Published on 18th Dec 2013 19th Dec 2013 21st Nov 2013
Target goal
For general
patients
including
DM/CKD
<140/90 <140/90 <140/90
Lower targets may
be appropriate for
LVD, LVH, DM,
CKD
For Elderly
people
150/90(≥60 yrs) 150/90(≥80 yrs)
Lower targets for
the Elderly
Treatment preference
General <60 yrs
Initiate Thiazide-
type Diuretic or
ACEI or ARB or
CCB
For uptitration,
any possible
combination from
above (avoid
ACEI+ARB)
Stage 1 HT:
ACEI or ARB
(If needed, add
CCB or Thiazide-
type Diuretic)
Stage 1 HT:
Thiazide for most
patients or
ACEI, ARB, CCB,
(or combination, if
uncontrolled)
Stage 2 HT:
ACEI or ARB
+
CCB or Thiazide-
type Diuretic
Stage 2 HT:
Thiazide with
ACEI / ARB/ CCB,
or
ACEI with CCB
General ≥60 yrs Same as above
Stage 1: CCB or
Thiazide (If
needed, add ACEI
or ARB)
Same as Above
Hypertension
with Diabetes
Same as above
ACEI or ARB
If needed add CCB
or thiazide-type
diuretic
ACEI or ARB,
thiazide, BB,
calcium channel
blocker
Hypertension
with CKD
ACEI or ARB alone
Or in combination
with other
ACEI or ARB
If needed add CCB
or thiazide-type
diuretic
ACEI or ARB

27. Comparison..(cont.)
Hypertension
with CAD
---
β-Blocker plus ARB
or ACE inhibitor
If needed add CCB
or thiazide-type
diuretic
β-Blocker, ACEI
Hypertension
with stroke
---
ACE inhibitor or
ARB
If needed add CCB
or thiazide-type
diuretic
Thiazide, ACEI.
Hypertension
with HF
---
ARB or ACE
inhibitor+ β -
blocker+ diuretic+
spironolactone
regardless of blood
pressure
ACEI or
angiotensin-
receptor blocker
(ARB), BB,
aldosterone
antagonist,
thiazide;

28. Conclusion
 Guidelines Offer clinicians an analysis of what is known
and not known about BP treatment thresholds, goals, and
drug treatment strategies
 Provides evidence-based recommendations for the
management of high BP
 Should meet the clinical needs of most patients.
 However, these recommendations are not a substitute for
clinical judgment, and decisions must carefully consider
and incorporate the clinical characteristics of each
individual.

29. Thank you for your patience