Hypertension Guidelines 2015Barry D. Bertolet, MD

Cardiology Associates of North Mississippi

Tupelo – Columbus – Starkville - Oxford

Disclosures

No disclosures

Hypertension

• Hypertension is the most common condition in primary care.

• 68 million Americans > 18 years old (31%) have hypertension – that’s 1:3

• Incidence increases with age

• Risk factor for MI, CVA, ARF, death

HTN Increases with Age

Progression to HTN Increases with Age

Hypertension Prevalence and Control in US Adults (%)

2098 Franklin #7

BP and Ischemic Heart Disease Mortality

160 180140

Usual SBP (mm Hg)

90 100 110

IHD

Mo

rtal

ity

(Flo

atin

g A

bso

lute

Ris

k an

d 9

5% C

I)

1200

4

32

256

70 80

Usual DBP (mm Hg)

50-59

60-69

70-79

80-89

40-49

Age at Risk (y)

50-59

60-69

70-79

80-89

40-49

Age at Risk (y)

0

4

32

256

Adapted from Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.

2098 Franklin #8

CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment*

*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressureLewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

CVmortalityrisk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105

Additive Effects

Benefits of Anti-hypertensive Tx

Benefits of Anti-Hypertensive Tx

How Well Do We Do?

Barriers to Success

• Asymptomatic (silent killer)

• Non-compliance

• Therapeutic inertia– Not knowing the definition– Not knowing the goals– Not knowing the meds– Accepting less than ideal reductions

Case

• A 58 year old African-American woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine micro-albumin is mildly elevated.

Case Question 1

• What goal BP is most appropriate for this patient?

1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Case Question 2

• What is the drug of choice to start?

1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

JNC -7 Blood Pressure Guidelines

JNC-7 Treatment Algorithm

JNC-7 Compelling Indications

Development of JNC-8

• 3 critical questions for adults with hypertension– Does initiating antihypertensive pharmacologic

therapy at specific blood pressure thresholds improve health outcomes? [When to start therapy?]

– Does treatment with antihypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes? [How low should I go?]

– Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? [What drug do I use?]

JNC 8

• 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults– JAMA. 2014;311(5):507-520– December 18, 2013

JNC 8: Hypertension ManagementEvidence Review

• Limited to RCT’s– Hypertensive adults > 18 years old– Sample size > 100– Follow-up > 1 year– Reported effect of treatment on important

health outcomes (mortality, MI, HF, CVA, ESRD)

• January 1966 to December 2009– Separate criteria used of RCT’s published

after December 2009

JNC 8: Hypertension ManagementEvidence Review

• RCT’s December 2009 – August 20131. Major study in hypertension

• ACCORD, NEJM 2010

2. > 2,000 participants

3. Multicentered

4. Met all other inclusion/exclusion criteria

What is the goal BP?

JNC 8: Drug TreatmentThresholds and Goals

• Age > 60 yo– Systolic:

• Threshold > 150 mmHg• Goal < 150 mmHg

– LOE: Grade A

– Diastolic:• Threshold > 90 mmHg• Goal < 90 mmHg

– LOE: Grade A

JNC 8: Drug TreatmentThresholds and Goals

• Age < 60 yo– Systolic:

• Threshold > 140 mmHg• Goal < 140 mmHg

– LOE: Grade E

– Diastolic:• Threshold > 90 mmHg• Goal < 90 mmHg

– LOE: Grade A for ages 40-59; Grade E for ages 18-39

JNC 8: Drug TreatmentThresholds and Goals

• Age > 18 yo with CKD or DM– JNC 7: < 130/80 (MDRD NEJM 1994)– Systolic:

• Threshold > 140 mmHg

• Goal < 140 mmHg– LOE: Grade E

– Diastolic:• Threshold > 90 mmHg

• Goal < 90 mmHg– LOE: Grade E

Initial Treatment Considerations

• Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

What Are Effective Lifestyle Modifications for HTN?

• Weight Reduction

• DASH diet

• Dietary sodium reduction

• Physical Activity

• Decrease alcohol consumption

Hypertension

Select a Drug Titration Pathway

• CKD – all races– Initiate ACEI or ARB, alone or in

combination with other drug clsses

• Non CKD – black (Hispanic)– Initiate thiazide-type diuretic or CCB, alone

or in combination

• Non CKD – nonblack– Initiate thiazide-type diuretic or ACEI/ARB

or CCB, alone or in combination

JNC 8: Subsequent Management

• Reassess treatment monthly

• Avoid ACEI/ARB combination

• Consider 2-drug initial therapy for Stage 2 HTN (> 160/100)

• Goal BP not reached with 3 drugs, use drugs from other classes– Consider referral to HTN specialist

A Word about ACE-I / ARB Combinations It is Dead!

• Based on the results of the Renal Outcomes With Telmisartan, Ramipril, or Both, in People at High Vascular Risk (ONTARGET) study, the ARB telmisartan to be noninferior to the ACE inhibitor ramipril but the combination of the two together to be associated with more adverse events and no increased benefit.

• A separate, prespecified analysis looking at renal outcomes in ONTARGET showed that the ARB/ACE-inhibitor combination was associated with an increased risk of dialysis, doubling of serum creatinine, and death, compared with using either agent alone.

34

Subsequent Therapies

Black Non-Black

Step One Thiazide &/or Thiazide &/or

CCB ACE / ARB &/or

CCB

Step Two Add ACE / ARB Use combo

Step Three Add beta-blocker &/or Add beta-blocker &/or

aldactone aldactone

Step Four Others Others

Reinforce compliance and lifestyle modifications!

Dissenting Editorial

• Ann Intern Med. January 14, 2014

• 5/17 authors (29%)

• “Insufficient evidence” to increase target SBP to 150 mmHg.

• Expertise vs. Scientific Evidence

Recent HTN Guideline Statements

• 2013 ESH/ESC Guidelines for the management of arterial hypertension.

• J Hypertnsion 2013;31:1281-1357.

• An Effective Approach to High Blood Pressure Control: A Science Advisory From the AHA, ACC, and CDC.

• Hypertension online November 15, 2013.

• Clinical Practice Guidelines for the Management of HTN in the Community A Statements by the ASH/ISH.

• J Hypertension 2014;32:3-15

What to do?

Comparison of RecentGuideline Statements

JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90

Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr

for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr140-150 if <80 yr

B-blocker No Yes No NoFirst line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100w/ 2 drugs elevated BP"

Goal BP

Group BP Goal (mm Hg)General DM* CKD**

JNC 8: <60 yr: <140/90 < 140/90 < 140/90>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)

ASH/ISH < 140/90 < 140/90 < 140/90

>80 yr: <150/90 (Consider < 130/80 if proteinuria)

AHA/ACC < 140/90 < 140/90 < 140/90

*ADA: < 140/80 or lower**KDIGO: <140/90 w/o albuminuria

<130/80 if >30 mg/24hr

BP goal in the elderly

Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

2013 ESH/ESC Guidelines for the management of arterial hypertension

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357

Blood pressure goals in hypertensive patients

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

Recommendations

SBP goal for “most”•Patients at low–moderate CV risk•Patients with diabetes•Consider with previous stroke or TIA•Consider with CHD•Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly•Ages <80 years•Initial SBP ≥160 mmHg

140-150 mmHg

SBP goal for fit elderlyAged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP•≥160 mmHg

140-150 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

Reinforce Lifestyle Changes!

Case

• A 58 year old African-American woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine micro-albumin is mildly elevated.

Case

• A 58 year old African-American woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine micro-albumin is mildly elevated.

Case Question 1

• What goal BP is most appropriate for this patient?

1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Case Question 1

• What goal BP is most appropriate for this patient?

1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Initial Treatment Considerations

• Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

Case Question 2

• What is the drug of choice to start?

1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

Case Question 2

• What is the drug of choice to start?

1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

Case Question 3

• Despite amlodipine 5 mg and HCTZ 25 mg daily, she has a BP of 145/87. What is the next drug of choice to start?1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

Case Question 3

• Despite amlodipine 5 mg and HCTZ 25 mg daily, she has a BP of 145/87. What is the next drug of choice to start?1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

Subsequent Therapies

Black Non-Black

Step One Thiazide &/or Thiazide &/or

CCB ACE / ARB &/or

CCB

Step Two Add ACE / ARB Use combo

Step Three Add beta-blocker &/or Add beta-blocker &/or

aldactone aldactone

Step Four Others Others

Reinforce compliance and lifestyle modifications!

Physiological Effects of DiureticsPhysiological Effects of Diuretics

Diuretics

↓ Plasma volume

↓ Cardiac Output

Initially

Long-term

Counter-regulatoryMechanisms

↓ Blood Pressure

↓ Arterial Resistance

↓ Renal Perfusion

↑ Renin/Angiotensin Activity

↑ Arterial Resistance

↑ Blood Pressure

Adapted from Moser and Setaro, Med Clin N Am 2004;88:167-187.

True or False

• 65 year old “healthy” man presents for evaluation. Serial BPs show an average of 148/88 with no improvement after a 3 month period of diet and exercise. There is no history of CAD, diabetes, or renal disease.

• Based on the new HTN guidelines, medical therapy should be initiated.

True or False

• 65 year old “healthy” man presents for evaluation. Serial BPs show an average of 148/88 with no improvement after a 3 month period of diet and exercise. There is no history of CAD, diabetes, or renal disease.

• Based on the new HTN guidelines, medical therapy should be initiated.

False

Initial Treatment Considerations

• Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

Case

• A 78 year old Caucasian man with history of CABG is seen with a BP of 160/104 and confirmed this range on several office visits.

• He has been placed on a DASH diet for three months.

• Other than mild dementia, the exam is normal. Lab is remarkable for a Cr 2.4 and LDL 120 mg/dl.

Case Question 1

• What goal BP is most appropriate for this patient?

1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Case Question 1

• What goal BP is most appropriate for this patient?

1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Case

• A 78 year old Caucasian man with history of CABG is seen with a BP of 160/104 and confirmed this range on several office visits.

• He has been placed on a DASH diet for three months.

• Other than mild dementia, the exam is normal. Lab is remarkable for a Cr 2.4 and LDL 120 mg/dl.

Initial Treatment Considerations

• Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

Case Question 2

• Appropriate initial (and minimum) therapy would include:1. Aspirin, ACEI, beta-blocker, and

atorvastatin 10 mg

2. Aspirin, ACEI, thiazide, and pravastatin 20 mg

3. Aspirin, ACEI, and atorvastatin 40 mg

4. Aspirin and ACEI

Case Question 2

• Appropriate initial (and minimum) therapy would include:1. Aspirin, ACEI, beta-blocker, and

atorvastatin 10 mg

2. Aspirin, ACEI, thiazide, and pravastatin 20 mg

3. Aspirin, ACEI, and atorvastatin 40 mg

4. Aspirin and ACEI

Intensity of Statin Therapy

Case Question 2

• Appropriate initial (and minimum) therapy would include:1. Aspirin, ACEI, beta-blocker, and

atorvastatin 10 mg

2. Aspirin, ACEI, thiazide, and pravastatin 20 mg

3. Aspirin, ACEI, and atorvastatin 40 mg

4. Aspirin and ACEI

Thank you for your attention!