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JNC-8 New GuidelinesFinally Let the controversies begin
Eric D Peterson, MD, MPH
Director of DCRI
Feb, 2014 http://www.dcri.duke.edu/research/coi.jsp
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2
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)
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 3
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.
How Aggressive to Treat Hypertension Some Early Views on the Controversy
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 4
Stroke and IHD Mortality vs Systolic BP by Age
Mort
alit
y
(Flo
ating a
bsolu
te r
isk a
nd 9
5%
CI)
Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Stroke
Age at risk
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Ischemic Heart Disease
Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Age at risk:
40-49 years
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Lancet. 2002;360:1903-1913
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 5
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
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
2 mmHg
increase in
mean SBP 10% increase in
risk of stroke
mortality
7% increase in
risk of ischemic
heart disease
mortality
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 6
Benefits of Treating Hypertension: RCT
-100-90-80-70-60-50-40-30-20-10
0
Heart failure Stroke Cardiovascular
death
Ris
k r
ed
uc
tio
n (
%)
50% 40%
20%
Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 7
Lifestyle Modifications
Goal blood pressure
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 8
NHLBI Drops Out of
Guidelines Business JNC-8 Significantly
Delayed
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 9
James et al JAMA December 13 2014
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 10
James et al JAMA December 13 2014
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 11
James et al JAMA December 13 2014
JNC-8 Hypertension Treatment Choices
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 12
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 13
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 14
The Evidence for Targets: JATOS Study
2200 pts per arm
Baseline BP 170/90
Target
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 15
JATOS Results
Hypertens Res. 2008;31(12):2115-2127
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 16
The Evidence for Targets: VALISH Trial
Hypertension. 2010;56(2):196-202
1630 pts per arm
Baseline BP 170/80
Target
Mild
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 17
Hypertension. 2010;56(2):196-202
VALISH Trial
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 18
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
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 19
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 20
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
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 21
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,
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 22
JNC-8 Implications for US
All US Adults Ages 18-59 Ages 60+
JNC 7: HTN 66.6 32.8 33.8
Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%)
JNC 8: HTN 60.8 30.8 30.0
Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 23
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
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 24
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?