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      Management of Hypertension: JNC 8 and Beyond

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          Abstract

          Hypertension is a leading risk factor for cardiovascular disease, the leading cause of death and morbidity in our society and on a global scale. Major components of cardiovascular disease include stroke, coronary artery disease, heart failure, and chronic kidney disease, in all of which hypertension plays a major role. The risk of these complications increases directly and linearly with systolic blood pressure starting at 115 mmHg. Although usually asymptomatic, hypertension is readily detectable on physical examination and is amenable to both lifestyle modification and pharmacologic treatment in most patients. However, large proportions of the hypertensive population remain undetected and undertreated. Numerous guidelines have been issued during the past few decades to promote detection and optimal therapy. Despite the increase in risk with systolic blood pressure greater than 115 mmHg, the generally accepted threshold for diagnosis and treatment has been systolic blood pressure greater than 139 mmHg and diastolic blood pressure greater than 80 mmHg because until recently treatment to lower levels has been associated with an unfavorable relation between clinical benefit and harm. In the past several years, new guidelines, advisories, commentaries, and clinical trials have provided evidence for a potential change in current recommendations for the management of hypertension. In this regard, the long-awaited eighth report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended patients older than 60 years be treated to a systolic blood pressure of less than 150 mmHg, which has generated considerable controversy and caution. The striking findings of the Systolic Blood Pressure Intervention Trial (SPRINT) have received considerable attention because of the demonstration that intensive therapy to a target systolic blood pressure below 120 mmHg decreases cardiovascular mortality and morbidity more than less intensive treatment to a target systolic blood pressure below 140 mmHg, but this approach is not fully generalizable because the trial excluded patients younger than 50 years and those with diabetes and prior stroke. This article addresses major issues in the management of hypertension, including those in the seventh and eight reports of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and subsequent studies, considering maintenance of prior standards as well as the potential application of important new findings.

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          Most cited references13

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          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).

          Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.
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            Let's Not SPRINT to Judgment About New Blood Pressure Goals.

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              Level of blood pressure control and cardiovascular events: SPRINT criteria versus the 2014 hypertension recommendations

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                Author and article information

                Journal
                CVIA
                Cardiovascular Innovations and Applications
                CVIA
                Compuscript (Ireland )
                2009-8782
                2009-8618
                September 2016
                October 2016
                : 1
                : 4
                : 409-416
                Affiliations
                [1] 1Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, CA 95817, USA
                Author notes
                Correspondence: Ezra A. Amsterdam, MD, University of California, Davis, School of Medicine, Ellison Building, 4860 Y Street, Sacramento, CA 95817, USA, Tel.: +1-916-7345191, E-mail: eaamsterdam@ 123456ucdavis.edu
                Article
                cvia20160030
                10.15212/CVIA.2016.0030
                c742ef4b-93d9-44f0-ae39-c7c6b8659a75
                Copyright © 2016 Cardiovascular Innovations and Applications

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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                Self URI (journal page): http://www.ingentaconnect.com/content/cscript/cvia
                Categories
                REVIEWS

                General medicine,Medicine,Geriatric medicine,Transplantation,Cardiovascular Medicine,Anesthesiology & Pain management
                hypertension,JNC 7,SPRINT,JNC 8,cardiovascular risk factors

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