JSC Recommendations Flashcards
High Quality Rating
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
High Quality Rating
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
Moderate Quality Rating
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
Lowe Quality Rating
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.
Grade A
Strong Recommendation
There is high certainty based on evidence that the net benefita is substantial.
Grade B
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.
Grade C
Weak Recommendation
There is at least moderate certainty based on evidence that there is a small net benefit.
Grade D
Recommendation against
There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh
benefits.
Grade E
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.
Grade N
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.
Recommendation 1
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
corollary recommendation
In the general population aged60years, if pharmacologic treatment for
high BP results in lower achieved SBP (eg,
recommendation2
In the general population 90mmHg and treat to a goalDBP
Recommendation 3
In the general population 140mmHg and treat to a goal SBP
Recommendation 4
In the population aged 18 years with chronic kidney disease (CKD), initiate
pharmacologic treatment to lowerBPatSBP140mmHgorDBP90
mmHgandtreat to goalSBP
Recommendation 5
In the populationaged18years with diabetes, initiate pharmacologic treatmenttolowerBPatSBP
140mmHgorDBP90mmHgandtreat toagoal
SBP
Recommendation 6
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)
Recommendation 7
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)
Recommendation 8
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)
Recommendation 9
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)
Strategy A
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
Strategy B
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
Strategy C
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.
2014 Hypertenstion guideline
General ≥60 y
Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB
2014 Hypertenstion guideline
General
Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB
2014 Hypertenstion guideline
Diabetes
Nonblack: thiazide-type diuretic, ACEI,
ARB, or CCB; black: thiazide-type diuretic
or CCB
2014 Hypertenstion guideline
CKD
ACEI or ARB