JSC Recommendations

Question 1

High Quality Rating

Answer 1

Well-designed, well-executed RCTs that adequately represent populations to which the results are applied and directly
assess effects on health outcomes
Well-conducted meta-analyses of such studies
Highly certain about the estimate of effect; further research is unlikely to change our confidence in the estimate of effect

Question 2

High Quality Rating

Answer 2

Well-designed, well-executed RCTs that adequately represent populations to which the results are applied and directly
assess effects on health outcomes
Well-conducted meta-analyses of such studies
Highly certain about the estimate of effect; further research is unlikely to change our confidence in the estimate of effect

Question 3

Moderate Quality Rating

Answer 3

RCTs with minor limitations affecting confidence in, or applicability of, the results
Well-designed, well-executed non–randomized controlled studies and well-designed, well-executed observational studies
Well-conducted meta-analyses of such studies
Moderately certain about the estimate of effect; further research may have an impact on our confidence in the estimate
of effect and may change the estimate

Question 4

Lowe Quality Rating

Answer 4

RCTs with major limitations
Non–randomized controlled studies and observational studies with major limitations affecting confidence in,
or applicability of, the results
Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports)
Physiological studies in humans
Meta-analyses of such studies
Low certainty about the estimate of effect; further research is likely to have an impact on our confidence in the estimate
of effect and is likely to change the estimate.

Question 5

Grade A

Answer 5

Strong Recommendation

There is high certainty based on evidence that the net benefita is substantial.

Question 6

Grade B

Answer 6

Moderate Recommendation
There is moderate certainty based on evidence that the net benefit is moderate to substantial or there is high
certainty that the net benefit is moderate.

Question 7

Grade C

Answer 7

Weak Recommendation

There is at least moderate certainty based on evidence that there is a small net benefit.

Question 8

Grade D

Answer 8

Recommendation against
There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh
benefits.

Question 9

Grade E

Answer 9

Expert Opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the
committee recommends.”)
Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, but the committee thought it was important to
provide clinical guidance and make a recommendation. Further research is recommended in this area.

Question 10

Grade N

Answer 10

No Recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)
Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, and the committee thought no recommendation
should be made. Further research is recommended in this area.

Question 11

Recommendation 1

Answer 11

In the general population aged 60 years, initiate pharmacologic treatment
to lower blood pressure (BP) at systolic blood pressure (SBP)150
mmHg or diastolic blood pressure (DBP)90mmHg and treat to a goal
SBP

Question 12

corollary recommendation

Answer 12

In the general population aged60years, if pharmacologic treatment for
high BP results in lower achieved SBP (eg,

Question 13

recommendation2

Answer 13

In the general population 90mmHg and treat to a goalDBP

Question 14

Recommendation 3

Answer 14

In the general population 140mmHg and treat to a goal SBP

Question 15

Recommendation 4

Answer 15

In the population aged 18 years with chronic kidney disease (CKD), initiate
pharmacologic treatment to lowerBPatSBP140mmHgorDBP90
mmHgandtreat to goalSBP

Question 16

Recommendation 5

Answer 16

In the populationaged18years with diabetes, initiate pharmacologic treatmenttolowerBPatSBP
140mmHgorDBP90mmHgandtreat toagoal
SBP

Question 17

Recommendation 6

Answer 17

In the general nonblack population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic, calcium
channel blocker (CCB), angiotensin-converting enzyme inhibitor
(ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation
– Grade B)

Question 18

Recommendation 7

Answer 18

In the general black population, including those with diabetes, initial antihypertensive
treatment should include a thiazide-type diuretic or CCB. (For
general black population: ModerateRecommendation –Grade B; for black
patients with diabetes:Weak Recommendation – Grade C)

Question 19

Recommendation 8

Answer 19

In the population aged18 years with CKD, initial (or add-on) antihypertensive
treatment should include an ACEI or ARB to improve kidney outcomes.
This applies toallCKDpatients with hypertension regardless of race
or diabetes status. (Moderate Recommendation – Grade B)

Question 20

Recommendation 9

Answer 20

The main objectiveofhypertension treatment is to attain and maintain goal
BP. If goalBPis not reached within amonthof treatment, increase the dose
of the initial drug or add a second drug from one of the classes in recommendation6(
thiazide-type diuretic,CCB,ACEI, or ARB).Theclinician should
continue to assess BP and adjust the treatment regimen until goal BP is
reached. If goal BP cannot be reached with 2 drugs, add and titrate a third
drug from the list provided.Donot use anACEI and anARBtogether in the
same patient. If goal BP cannot be reached using only 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. Referral to a hypertension specialistmay be indicated for patients in
whomgoal BP cannot be attained using the above strategy or for the management
of complicated patients for whom additional clinical consultation
is needed. (Expert Opinion – Grade E)

Question 21

Strategy A

Answer 21

Start one drug, titrate to maximum
dose, and then add a second drug

If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum
recommended dose to achieve goal BP
If goal BP is not achieved with the use of one drug despite titration to the maximum recommended
dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the
maximum recommended dose of the second drug to achieve goal BP
If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB,
ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum
recommended dose to achieve goal BP

Question 22

Strategy B

Answer 22

Start one drug and then add a second
drug before achieving maximum dose
of the initial drug
Start with one drug then add a second drug before achieving the maximum recommended dose of the
initial drug, then titrate both drugs up to the maximum recommended doses of both to achieve goal BP
If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB,
ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum
recommended dose to achieve goal BP

Question 23

Strategy C

Answer 23

Begin with 2 drugs at the same time,
either as 2 separate pills or as a single
pill combination
Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination.
Some committee members recommend starting therapy with ≥2 drugs when SBP is >160 mm Hg
and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If
goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB,
ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum
recommended dose.

Question 24

2014 Hypertenstion guideline

General ≥60 y

Answer 24

Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB

Question 25

2014 Hypertenstion guideline

General

Answer 25

Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB

Question 26

2014 Hypertenstion guideline

Diabetes

Answer 26

Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB

Question 27

2014 Hypertenstion guideline

CKD

Answer 27

ACEI or ARB