JNC 2013: Simplified BP Goal in Sight

The upcoming JNC 2013 update is likely to go with a hypertension treatment target of 140/90 mm Hg for all but older adults, a panel of experts on the guidelines committee suggested.

A “one-size-fits-most” goal seems to work well, although the higher target is defensible for patients over age 60, particularly those past 80, Raymond Townsend, MD, of the University of Pennsylvania in Philadelphia, told attendees here at the American Society of Hypertension meeting.

He unofficially reviewed the available evidence base for the latest Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, formerly known as JNC-8 and now renamed JNC 2013.

Although the presentation indicates a commitment to getting the new guidelines out within the year, it’s still not clear when the National Heart, Lung, and Blood Institute will release the document, William Cushman, MD, of the VA Medical Center in Memphis, Tenn., told MedPage Today. He was involved with the guidelines but did not speak at the session.

The major question facing the committee this time around was the treatment target, ASH president-elect Domenic Sica, MD, commented in an interview.

The JNC-7 recommended less than 140/90 mm Hg overall and 130/80 mm Hg in the presence of diabetes, heart failure, or chronic kidney disease. Townsend suggested simplification to a single target in JNC 2013.

“At the end of the day when you boil all this down, you look at the general population, you look at the patients with diabetes, you look at the patients with chronic kidney disease, it turns out the wisdom we’ve used in the past, which we’ve been arguing about for the past decade, turns out to have been fairly wise,” Townsend said.

When asked how to reconcile the stricter American Heart Association and American College of Cardiology guidelines targeting 130/80 mm Hg for blood pressure control, Suzanne Oparil, MD, of the University of Alabama at Birmingham, noted that an update to those guidelines is due out within the next few months as well.

“Without being specific, they’ve pushed back, or pushed up, thresholds and goals for treatment,” she commented. Oparil is a member of both committees.

“Cardiologists are very aggressive, but when we looked back at the evidence, the evidence wasn’t there and … careful analyses of large trials in high-risk people showed that you can do harm from lowering blood pressure too much,” Oparil told the audience.

“JNC is strictly evidence based with some necessity for expert opinion where there is no evidence. We don’t feel obliged to reconcile our recommendations with anybody else’s,” she added.

That’s part of the reason the guidelines won’t dive too deeply into pharmacology, “such as beta-alpha versus beta alone, simply because there’s just not a lot of data to let us do that,” Townsend noted. “So we tended to be a little more generic rather than specific and we tried to provide recommendations that are both defensible as well as actionable.”

However, most of the comments at the session centered on the relative ranking of beta-blockers in therapy lines.

“Based on recent guidelines, but not necessarily JNC-8, the degree of blood pressure reduction achieved, and not the initial anti-hypertensive class of agents chosen, is more important for improving cardiovascular outcome in those with hypertension,” Barry Carter, PharmD, of the University of Iowa in Iowa City, concluded in his talk on pharmacology elements of JNC 2013.

He and all the other committee members at the conference were diligent in stating the opinions expressed were their own.

Nevertheless, reading between the lines probably isn’t too hard when all the component evidence is already known, Cushman acknowledged.

Although written and awaiting the final go-ahead, he suggested the paper isn’t likely to publish before June.

Henry Black, MD, of NYU Langone Medical Center in New York City, who wasn’t on the current committee, blamed the Institute of Medicine for prompting a much more intensive evidence review. “It took us 3 months on JNC-7; it has taken 3 years for JNC 2013,” he said

(Fuente: www.medpagetoday.com) [Actualizado: 21 de mayo 2013]

En esta sección les exponemos algunos artículos publicados sobre la hipertensión arterial

Articulos de la Revista JAMA

Aortic Stiffness, Blood Pressure Progression, and Incident Hypertension

Por: Bernhard M. Kaess, MD; Jian Rong, PhD; Martin G. Larson, ScD; Naomi M. Hamburg, MD; Joseph A. Vita, MD; Daniel Levy, MD; Emelia J. Benjamin, MD, ScM; Ramachandran S. Vasan, MD; Gary F. Mitchell, MD.  JAMA. 2012;308(9):875-881

Effect of Continuous Positive Airway Pressure on the Incidence of Hypertension and Cardiovascular Events in Nonsleepy Patients With Obstructive Sleep ApneaA Randomized Controlled Trial

Por: Ferran Barbé, MD; Joaquín Durán-Cantolla, MD; Manuel Sánchez-de-la-Torre, PhD; Montserrat Martínez-Alonso, BSc(Stat); Carmen Carmona, MD; Antonia Barceló, MD; Eusebi Chiner, MD; Juan F. Masa, MD; Mónica Gonzalez, MD; Jose M. Marín, MD; Francisco Garcia-Rio, MD; Josefa Diaz de Atauri, MD; Joaquín Terán, MD; Mercedes Mayos, MD; Mónica de la Peña, MD; Carmen Monasterio, MD; Felix del Campo, MD; Josep M. Montserrat, MD; for the Spanish Sleep and Breathing Network. JAMA. 2012;307(20):2161-2168.

Association Between Treated and Untreated Obstructive Sleep Apnea and Risk of Hypertension

Por: José M. Marin, MD; Alvar Agusti, MD; Isabel Villar, PhD; Marta Forner, PhD; David Nieto, MD; Santiago J. Carrizo, MD; Ferran Barbé, MD; Eugenio Vicente, MD; Ying Wei, PhD; F. Javier Nieto, MD, PhD; Sanja Jelic, MD.  JAMA. 2012;307(20):2169-2176.

Fatal and Nonfatal Outcomes, Incidence of Hypertension, and Blood Pressure Changes in Relation to Urinary Sodium Excretion

Por: Katarzyna Stolarz-Skrzypek, MD, PhD; Tatiana Kuznetsova, MD, PhD; Lutgarde Thijs, MSc; Valérie Tikhonoff, MD, PhD; Jitka Seidlerová, MD, PhD; Tom Richart, MD; Yu Jin, MD; Agnieszka Olszanecka, MD, PhD; Sofia Malyutina, MD, PhD; Edoardo Casiglia, MD, PhD; Jan Filipovský, MD, PhD; Kalina Kawecka-Jaszcz, MD, PhD; Yuri Nikitin, MD, PhD; Jan A. Staessen, MD, PhD; for the European Project on Genes in Hypertension (EPOGH) Investigators.  JAMA. 2011;305(17):1777-1785.

[Actualizado: 22 de mayo de 2013]

Editorial. Estudios importantes sobre hipertension arterial de Cuba y el mundo

Hypertensive emergencies are associated with elevated markers of inflammation, coagulation, platelet activation and fibrinolysis

Por: U Derhaschnig, C Testori, E Riedmueller, S Aschauer, M Wolzt y B Jilma.   Journal of Human Hypertension (2013) 27, 368–373.

Hypertensive crises are frequently observed medical events. They comprise critical elevation of blood pressure (BP) complicated by target organ dysfunction, defined as hypertensive emergency (HE) or without target organ deterioration, that is, hypertensive urgency (HU). Data from in vitro and animal experiments suggest that progressive endothelial damage with subsequent activation of coagulation and inflammation have a key role in hypertensive crisis. However, clinical investigations are scarce. We hypothesized that hypertensive emergencies are associated with enhanced inflammation, endothelial- and coagulation activation. Thus, we enrolled 60 patients admitted to an emergency department in a prospective, cross-sectional study.  [Actualizado: 28 de mayo 2013]