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3/5/2019
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ACC/AHA Hypertension Guidelineand How it Might Change Your Practice
Michael Ernst, PharmD, BCPS, BCGPAHSCP‐CHC: American Hypertension Specialist Program –
Certified Hypertension Clinician&
Clinical ProfessorDepartment of Pharmacy Practice & Science, College of Pharmacy, and
Department of Family Medicine, Carver College of Medicine
Disclosures
• Dr. Ernst reports no actual or potential conflicts of interest associated with this presentation.
Case Vignette• A 68‐year‐old Caucasian female presents for general follow‐up after a
recent wrist fracture which occurred from a fall while participating in a hot yoga class. She walks on a treadmill three times/week for 45 minutes and follows a vegan diet. She is a lifetime nonsmoker.
• Meds: lisinopril‐HCT 10/12.5 mg/d; simvastatin 10 mg/d
• BP = 142/78 mmHg (repeated to verify) and other vital signs are normal. She reports her home BP taken every once in awhile usually range in the 130s/70s.
• Her cardiovascular and eye exam are unremarkable. Her BMI is 30. She is not orthostatic and has no complaints.
• Labs: normal CBC, SCr=1.2 mg/dL (no proteinuria on urinalysis), Potassium=3.5 mEq/L, Tchol=175 mg/dL, LDL=98 mg/dL, HDL = 64 mg/dL fasting glucose=103 mg/dL.
• Her 10‐year ASCVD risk calculates out to 11.4%.
• SHOULD HER ANTIHYPERTENSIVE REGIMEN BE ADJUSTED?
• WHAT IF SHE WAS NOT PREVIOUSLY TREATED? SHOULD WE START TREATMENT?
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Objectives
At the end of this presentation, the awake participant should be able to:• Define hypertension based on the 2017 AHA/ACC Hypertension
Guideline.• Describe the clinical trial evidence underpinning the new blood
pressure goal recommendations.• Recognize potential problems with uniform adoption of a singular
blood pressure goal in all individuals.• Recommend effective non‐pharmacologic management strategies.• Advise patients how to obtain helpful home/out‐of‐office blood
pressure readings.• Individualize blood pressure goals based on age, comorbidities, and
other CV‐and related risk factors.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood
Pressure in Adults
Paul K. Whelton, MB, MD, MSc, FAHA, Chair
Robert M. Carey, MD, FAHA, Vice Chair
Wilbert S. Aronow, MD, FACC, FAHA*
Donald E. Casey, Jr, MD, MPH, MBA, FAHA†
Karen J. Collins, MBA‡
Bruce Ovbiagele, MD, MSc, MAS, MBA,FAHA†
Sidney C. Smith, Jr, MD, MACC, FAHA††
Crystal C. Spencer, JD‡
Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA§
Sondra M. DePalma, MHS, PA‐C, CLS, AACC║Samuel Gidding, MD, FACC, FAHA¶
Kenneth A. Jamerson, MD#
Daniel W. Jones, MD, FAHA†
Eric J. MacLaughlin, PharmD**
Paul Muntner, PhD, FAHA†
Randall S. Stafford, MD, PhD‡‡
Sandra J. Taler, MD, FAHA§§
Randal J. Thomas, MD, MS, FACC, FAHA║║Kim A. Williams, Sr, MD, MACC, FAHA†
Jeff D. Williamson, MD, MHS¶¶
Jackson T. Wright, Jr, MD, PhD, FAHA##
*American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ║American Academy of Physician Assistants Representative. ¶Task
Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of
Hypertension Representative. ║║Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative.
Published Nov 13, 2017Available at:https://www.ahajournals.org/lookup/doi/10.1161/HYP.0000000000000066
Evolution of U.S. BP Guidelines
JNC‐II 1980
JNC‐V 1992
JNC‐IV 1988
JNC‐III 1984
JNC‐VI1997
JNC 7 2003
JNC 8 2014
JNC‐I 1977
[JNC: Mostly expert opinion, but progressively more comprehensive based on expanding amount of observational and clinical trial evidence]
AHA/ACC2017
NHLBI exits guideline development, transfers responsibility to AHA/ACC
“Unofficial” guideline
JNC = Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure • A committee of experts appointed through the National Heart, Lung,
and Blood Institute (NHLBI), High Blood Pressure Education Program
2008: NHLBI appoints panel to update guidelines. New process employed: defined questions, systematic review of evidence, grading of evidence
<140/90 mmHgSBP: <150 mmHg if age ≥60
Diabetics: <135/85 mmHgSBP: <130 mmHg
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With the distribution of BP shifting downward in the population, the epidemiology of hypertension‐related CVD is changing.
AHA Guideline Summarized102‐pages (or 55 if exec summary!)
DIAGNOSIS– [New] classifications of BP (eliminated “prehypertension” category)– Emphasis on accurate measurements and use of out‐of‐office measurements
to confirm diagnosis and for titration of meds
INITIATING THERAPY– Non‐pharmacologic recommended for all persons with elevated BP or
hypertension– [New] incorporates use of ASCVD risk calculator for risk stratification
• Recommend meds in patients with clinical CVD or estimated 10‐year ASCVD risk of 10% or higher with SBP 130 mmHg or higher or DBP 80 mmHg or higher
• For 10‐year ASCVD risk of <10%, then recommended when SBP 140 mmHg or higher or DBP 90 mmHg or higher
MANAGEMENT– [New] BP target of <130/80 mmHg in nearly everyone– Thiazides, CCBs, ACEi or ARBs remain recommended first‐line– [New] Stage 2 hypertension (>140/90 mmHg): consider starting 2 first‐line
agents of different classes
2017 Updated Categories of BP in Adults*
*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as
detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm Hg
and <80 mm Hg
Hypertension
Stage 1 130–139 mm Hg
or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13‐e115.
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Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†
SBP/DBP ≥130/80 mm Hg or Self-Reported
Antihypertensive Medication†
SBP/DBP ≥140/90 mm Hg or Self-Reported Antihypertensive
Medication‡Overall, crude 46% 32%
Men(n=4717)
Women(n=4906)
Men(n=4717)
Women(n=4906)
Overall, age-sex adjusted
48% 43% 31% 32%
Age group, y20–44 30% 19% 11% 10%45–54 50% 44% 33% 27%55–64 70% 63% 53% 52%65–74 77% 75% 64% 63%75+ 79% 85% 71% 78%
Race-ethnicity§Non-Hispanic White 47% 41% 31% 30%Non-Hispanic Black 59% 56% 42% 46%Non-Hispanic Asian 45% 36% 29% 27%
Hispanic 44% 42% 27% 32%
The prevalence estimates have been rounded to the nearest full percentage.*130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.†BP cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition of hypertension in JNC 7.§Adjusted to the 2010 age‐sex distribution of the U.S. adult population.BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health
and Nutrition Examination Survey; and SBP, systolic blood pressure.
Paul Muntner et al. Circulation. 2018;137:109-118
EstimatedPrevalenceofHypertensionintheU.S.
Measurement of BP
2017 ACC/AHA Hypertension Guideline
Major point of emphasis in 2017 guideline
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Blood Pressure Is Highly Variable Over a 24‐Hour Period
18:00 22:00 02:00 06:00 10:00 14:00 18:00
Blood pressure (mmHg)
Time of awakeningSleep
180
160
140
120
100
80
200
Systolic BP
Diastolic BP
Adapted from: Millar‐Craig MW, et al. Lancet. 1978;15:795‐797.
Time of day
Checklist for Accurate Measurement of BP
Key Steps for Proper BP Measurements
Step 1: Properly prepare the patient. • Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min.
• Make sure patient avoids caffeine, exercise, and smoking for at least 30 min prior
Step 2: Use proper technique for BP measurements.
• Support the patient’s arm• Using the correct cuff, position the middle of
the cuff on the patient’s upper arm at the midpoint of the sternum
Step 3: Take the proper measurements needed for
diagnosis and treatment of elevated
BP/hypertension.
• At the first visit, record BP in both arms, and use
the arm with the higher reading
• Use a palpated estimate of radial pulse
obliteration pressure for systolic BP and inflate
the cuff 20‐30 mmHg above this level
• Deflate the cuff pressure 2 mmHg per second
Step 4: Properly document accurate BP readings. • Record systolic BP at the onset of first Korotkoff
sound and diastolic BP at the disappearance of all
Korotkoff sounds
Step 5: Average the readings. • Use an average based on ≥2 readings obtained on
≥2 occasions to estimate the individual’s level of
BP
Step 6: Provide BP readings to patient. • Provide patients the systolic/diastolic BP readings
both verbally and in writing
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“Only 1/159 medical students correctly performed all 11 elements in a BP check challenge with simulated patients!”
From: Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis
JAMA Intern Med. Published online February 04, 2019. doi:10.1001/jamainternmed.2018.6551
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From: Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures?
Ann Intern Med. 2011;154(12):781-788. doi:10.1059/0003-4819-154-12-201106210-00005
To accurately record BP at home, patients should take at least 2 readings 1 minute apart each morning and evening for 3‐7 days. This provides approximately 14‐28 readings.
Measurement of blood pressure in humans. A scientific statement from the American Heart Association. Hypertension 2019; epub ahead of print
Out‐of‐Office and Self‐Monitoring of BP
Recommendation for Out‐of‐Office and Self‐Monitoring of BP
Out‐of‐office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP‐lowering medication, in conjunction with telehealth counseling or clinical interventions.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
For Primary Prevention For Secondary Prevention
When 10‐year ASCVD risk ≥ 10% AND SBP ≥ 130 mmHg or DBP ≥ 80 mmHg
Clinical CVD AND SBP ≥ 130 mmHg or DBP ≥ 80 mmHg
OR
No history of CVD and 10‐year ASCVD risk <10% AND SBP ≥ 140 mmHg or DBP ≥ 90 mmHg
BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension
Drug therapy for hypertension is recommended:
*ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator/) to estimate 10-year risk of atherosclerotic CVD.
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Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13‐e115.
Note – once on meds, monthly follow‐up/med titration until BP goal is met!
Clinical Condition(s)BP Threshold
for Tx, mm Hg
BP Goal,
mm Hg
General
Clinical CVD or 10‐year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10‐year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized,
ambulatory, community‐living adults)
≥130 (SBP) <130 (SBP)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80
What About Older People and Those with Specific Comorbidities?
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13‐e115.
Interventions to Reduce BP
2017 ACC/AHA Hypertension Guideline
• Non‐pharmacologic (no real changes from before)
• Drug choices (essentially no changes from before)
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Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*
Nonpharmacological
Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim
for at least a 1‐kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1‐kg reduction in body weight.
‐5 mm Hg ‐2/3 mm Hg
Healthy diet DASH dietary pattern
Consume a diet rich in fruits,
vegetables, whole grains, and low‐fat
dairy products, with reduced content
of saturated and total fat.
‐11 mm Hg ‐3 mm Hg
Reduced intake
of dietary
sodium
Dietary sodium Optimal goal is <1500 mg/d, but aim
for at least a 1000‐mg/d reduction in
most adults.
‐5/6 mm Hg ‐2/3 mm Hg
Enhanced intake
of dietary
potassium
Dietary potassium
Aim for 3500–5000 mg/d, preferably by
consumption of a diet rich in
potassium.
‐4/5 mm Hg ‐2 mm Hg
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the
DASH? Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp‐dash‐how‐to.
Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)
Nonpharmacological
Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Physical
activity
Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
‐5/8 mm Hg ‐2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
‐4 mm Hg ‐2 mm Hg
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
‐5 mm Hg ‐4 mm Hg
Moderation
in alcohol
intake
Alcohol consumption In individuals who drink alcohol,
reduce alcohol† to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
‐4 mm Hg ‐3 mm
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually
about 5% alcohol), 5 oz of wine (usually about 12%alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
Choice of Initial Medication
Recommendation for Choice of Initial Medication
For initiation of antihypertensive drug therapy, first‐line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
All of the major classes of antihypertensives have been shown to reduce morbidity and mortality from hypertension
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Choice of Initial Monotherapy Versus Initial Combination Drug Therapy
Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy*
Initiation of antihypertensive drug therapy with 2 first‐line agents of different classes, either as separate agents or in a fixed‐dose combination, is recommended in adults with stage 2 hypertension andan average BP more than 20/10 mm Hg above their BP target.
Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
Synergistic 2 drug combos: ACEi (or ARB) + CCBACEi (or ARB) + thiazideCCB + thiazide
Special Patient Groups
2017 ACC/AHA Hypertension Guideline
Emphasis on elderly – major point of difference with JNC‐8
Age‐Related Issues
Recommendations for Treatment of Hypertension in Older Persons
Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community‐dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.
For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team‐based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; :e – e .
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The lower BP goal (especially in healthy elderly) is a major departure from JNC‐8 and past guidelines.
What evidence led to the change in the BP goals in the new AHA guideline?
SPRINT: Primary Outcome and Death from Any Cause.
The SPRINT Research Group. N Engl J Med 2015;373:2103-2116
Primary outcome first occurrence of:
• Myocardial infarction (MI)
• Acute coronary syndrome (non‐MI ACS)
• Stroke• Acute
decompensated heart failure (HF)
• Cardiovascular disease death
Inclusion Criteria• ≥50 years old• Systolic blood pressure : 130
– 180 mm Hg (treated or untreated)
• Additional cardiovascular disease (CVD) risk (at least one)
• Clinical or subclinical CVD (excluding stroke)
• Chronic kidney disease (CKD), defined as eGFR 20 –<60 ml/min/1.73m2
• Framingham Risk Score for 10‐year CVD risk ≥ 15%
• Age ≥ 75 years
Conditions of Interest for SPRINT Participants > 75 Years
Williamson JD, et al. for the SPRINT Research Group. JAMA 2016;315:2673-2682.
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Risk Reduction: Let’s Re‐Look at Some Numbers from SPRINT
• 25% relative risk reduction
• Subjects in the intensive treatment goal had a 25% lower risk of the primary endpoint
• Primary outcome occurred in 6.8% vs 5.2% over 3.2 years = absolute riskreduction of 1.6%
• NNT = 1/ARR = 62.5
• 63 people need to be treated to an intensive BP goal for 3.2 years to avoid 1 additional primary event
The SPRINT Research Group. N Engl J Med 2015;373:2103-2116
• Serious ADE (intervention‐related) occurred in 4.7% of intensive treated group vs 2.5% of conventional group
• NNH = 1/ARI = 45.5• For every 46 people treated to
an intensive BP goal for 3.2 years, 1 additional harm will occur
The SPRINT Research Group. N Engl J Med 2015;373:2103-2116
For 1000 persons:• Benefit: 1000/62.5 = 16• Harm: 1000/45.5 = 22
For 1000 persons treated over 3.2 years to systolic goal BP of <120 mmHg compared to <140 mmHg…an average of 16 persons will benefit, 22 persons will be seriously harmed… and 962 will not experience benefits or harms!
Although the treatment may be worthwhile for patients on average, it may not be worthwhile for the average patient!This is because the average patient is at less risk than the mean!
Vickers AJ, Kent DM. Ann Intern Med 2015;162:866‐867.
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AHA Guideline Controversies
• Heavy reliance on SPRINT (chair of AHA guideline was chair of SPRINT)– AAFP does not endorse the new guideline
• AAFP and ACP published their own guideline on hypertension in adults over age 60 in Jan 2017. They continue to recommend a goal SBP of <150 mmHg (Ann Intern Med 2017;166:430‐437)
– ADA (2019)• 10‐yr ASCVD risk >15% = <130/80 mmHg (LEVEL C;“may be appropriate”)
• 10‐yr ASCVD risk <15% = <140/90 mmHg (LEVEL A)
– (BTW, the 10‐yr CVD risk calculator often overestimates risk in lower risk individuals, and using it in a strategy to determine treatment has not been tested prospectively)
Changing the Definition of Hypertension: How Innocent a Numbers Game?
Applying the AHA Guideline,
• ~46% of US adults now have hypertension (vs 32%)
• Control rates in those treated that were approaching 70% in some cohorts are now significantly lower– What is the implication of this across health systems, payments, etc?
Haynes RB, et al. Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 1978;299:741‐44.
More importantly, labeling a person with a disease comes at a cost….
e.g., a landmark study following 208 Canadian steel workers for 1 year documented an increase in absenteeism by about 80% in the year after labelling with hypertension in a screening program compared to the previous year
Case Vignette• A 68‐year‐old caucasian female presents for general follow‐up after a
recent wrist fracture which occurred from a fall while participating in a hot yoga class. She walks on a treadmill three times/week for 45 minutes and follows a vegan diet. She is a lifetime nonsmoker.
• Meds: lisinopril‐HCT 10/12.5 mg/d; simvastatin 10 mg/d• BP = 142/78 mmHg (repeated to verify) and other vital signs are normal.
She reports her home BP taken every once in awhile usually range in the 130s/70s.
• Her cardiovascular and eye exam are unremarkable. Her BMI is 30. She is not orthostatic and has no complaints.
• Labs: normal CBC, SCr=1.2 mg/dL (no proteinuria on urinalysis), Potassium=3.5 mEq/L, Tchol=175 mg/dL, LDL=98 mg/dL, HDL = 64 mg/dL fasting glucose=103 mg/dL.
• Her 10‐year ASCVD risk calculates out to 11.4%.• SHOULD HER ANTIHYPERTENSIVE REGIMEN BE ADJUSTED?• WHAT IF SHE WAS NOT PREVIOUSLY TREATED? SHOULD WE START
TREATMENT?– Her 10‐year ASCVD risk is 8.5%!
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Take Home Points (1)
BP Targets: A “Ceiling” or “Floor?”• Treatment benefit is not black and
white. Not all patients need to be reduced down to the lowest levels (i.e. “normal BP”) to achieve benefit.
• The magnitude of CVD risk reduction is generally proportional to the height of the pre‐treatment BP.
– Getting below 130 mmHg with multiple drugs is not the same as being there naturally!
• Management of BP is only one part of the recipe to reduce CV risk!
– Do not forget to concurrently manage other CV risk factors!
Over‐Diagnosed. Making People Sick in the Pursuit of Health. Welch HG, Schwartz LM, Woloshin S. Beacon Press. 1/3/2012. ISBN: 978‐080702199‐6.
Take Home Points (2)• The 2017 ACC/AHA guideline updates the classification of blood pressure;
in doing so, nearly 50% of Americans now have a chronic disease.– The importance of proper measurement is stressed.– Thresholds for treatment and BP goals are updated, with some controversy
• Incorporation of ASCVD risk calculator to help individualize decision to treat• More evidence informing the approach to elderly (i.e., community‐dwelling, ambulatory)
• SPRINT data drive the change in guidelines…absolute benefit is small, and not all will benefit from intensified BP goals
• My opinion: for most patients, focus on 140 mmHg as a ‘ceiling’, 130 mmHg as a ‘floor’, and control other concurrent CV risk factors in all!
– If you have significant residual CV risk you can’t control, then consider more aggressive BP goal (i.e., 130 mmHg as ‘ceiling’)
• Remember that guidelines are just that… not mandates
• Don’t forget the importance of using your clinical reasoning to individualize BP targets!!
THANK YOU.michael‐ernst@uiowa.eduTel. 319/384‐7756
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