Update in hypertension management

Update In Hypertension Management

Dr.Tarek Khalil, M.D., FESC, EAPCIProf. of Cardiology, Menoufiya University

Interventional Cardiology Consultant, Arrawdha general hospital

Dammam23/03/2016

I am a gentle killer All over the world, I am called HYPERTENSION

World Hypertension Day, annually celebrated on May 17th

Statement of Need

“My greatest challenge as a doctor in the management

of patients with hypertension is……………”

Please write down your answer to the following:

1-When to begin treatment?2-How low should I go? and 3-What drug do I use?To Improve CV Outcomes

Scope of the Problem

Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide1

Number of people with HTN

worldwide in 20001

972 million

Increase in the number of adults with HTN globally by 20251

60%

Percent of all global healthcare spending

attributable to high blood pressure2

10%

Annual worldwide cost of hypertension2

$370 billion

1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.

1.6 Billion HTN patients estimated

by 2025

Residual Lifetime Risk for Developing Hypertension

• a cohort from the Framingham data, 1298 participants free of hypertension in 1975, and aged either 55 or 65 at baseline.

• Lifetime risk for hypertension for these subjects, defined as BP > 140/90 mm Hg or the use of antihypertensive medications, based on data gathered between 1976 and 1998.

Vasan et al. JAMA 2002;287(8):1003-10

Scope of the problem

Residual lifetime risk of hypertension for men and women, aged 55 and 65 at baseline

Results

By age group By sex0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%90% 90%90% 90%

Life

time

Ris

k fo

r H

yper

tens

ion

Vasan et al. JAMA 2002;287(8):1003-10


These high numbers mean strategies to prevent, detect, and treat Hypertension become even more critical.

BP Control RatesTrends in awareness, treatment, and control of high

blood pressure in adults ages 18–74National Health and Nutrition Examination Survey, Percent

NHANESII

1976–80

NHANES III

1988–91

NHANES III

1991–94

NHANES

1999–2000

NHANES

2007-2008

NHANES

2011-2012

Awareness 51 73 68 70 81 82

Treatment 31 55 54 59 72 75

Control* 10 29 27 34 50 51

Sources: Unpublished data for 2011–2012 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 8.

*SBP <140 mmHg, DBP <90 mmHg


USA53.1

Canada41.0

Mexico21.8

Germany33.6

Greece49.5

England29.2

Egypt8

South Africa*47.6

Japan*55.7

Taiwan18.0

China28.8

Turkey19.8

*Data for men only

Worldwide Blood Pressure Control in Treated Hypertensive Patients

Updated from Kearney et al. J Hypertens 2004; 22: 11–19

The blood pressure of treated patients is far from being normotensive.

Factors of Suboptimal Hypertension Control

1. Inadequate access to health care2. Cost of therapy3. Poor compliance and persistence with medications4. Drug adverse effects5. Clinician inertia6. Disregard of treatment guidelines7. Inadequate education of clinicians and patients8. Unhealthy lifestyles.

Chobanian AV; JAMA 2010;303(20):2082-2083

HTN leads to an increased risk of death from stroke and heart diseaseC

V m

orta

lity

risk

SBP/DBP (mm Hg)

0123456

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

*Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure

Lewington S et al. Lancet 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572

78 8x

4x

2x

CV mortality risk doubles for every 20/10 mmHg increase in systolic and diastolic blood pressure.

Time to take some serious action

Benefits of Lowering BP

Series1

-60

-40

-20

0

>50

35-40

20-25

CHF MIStroke Incidence

All reductions are statistically significant

Average reduction in events

(%)

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Evidence-Based Cardiology Consult

Hypertension Guidelines

•2013ESH/ESCASH/ISH

•2014JNC 8

•2015CHEP

Blood Pressure Classification JNC-VII

Normal <120 and <80

Prehypertension 120–139 or 80–89Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160 or >100

BP Classification SBP mmHg DBP mmHg

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) JAMA 21; 289(19):2560-71. 2003

JNC 8 (2014 Hypertension Guideline)

• Definitions of hypertension and prehypertension not addressed

• But thresholds for pharmacologic treatment were defined

When to begin treatment?

What drug do I use?

How low should I go?

Questions Guiding The JNC 8 Review

The answers to these three questions are reflected in 9 recommendations

James PA et al. JAMA 2014;311:507-20.

When to begin treatment?How low should I go?

Questions guiding the JNC 8 review


JNC 8 Recommendations

Recommendation 1(Strong recommendation)

Recommendation 2(Strong recommendation)

Recommendation 3 (Expert opinion)

General population ≥60 years

SBP ≥150 mm Hgor DBP ≥90 mm Hg

SBP <150 mm Hgand DBP <90 mm Hg

General population <60 years

SBP ≥140 mm Hg SBP <140 mm Hg

GoalsBP thresholds

General population <60 years

DBP ≥90 mm Hg DBP <90 mm Hg

Consequence Recommendation: (Expert Opinion) If pharmacologic treatment achieves lower SBP (e.g. <140) & no adverse

events, treatment adjustment not required

Based on high-quality evidence from 5 DBP trials (HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative)

Based on results from JATOS Trial, and Valsartan Study group

Based on HYVET, Syst-Eur, SHEP, JATOS, VALISH, and CARDIO-SIS

JNC 8 Recommendations

GoalsBP thresholds

Which drug do I use ?

Population with CKD ≥18 years



Population with diabetes ≥18 years





Based on results of trials such as AASK, MDRD & REIN- 2 (<70 yrs with eGFR <60ml or any age with albuminuria >30mg albumin/g at any level of GFR)

Based on results from Trials such as SHEP, Syst-Eur, UKPDS, ACCORD-BP trial, ADVANCE trial, HOT trial

The A,B,C,D drug classes

Angiotensin-converting enzyme inhibitors

Angiotensin receptor blockers

Beta-blockers

Calcium channel blockers

Diuretics

JNC 8 Recommendations: Which Drug Do I Use ?

General nonblack population ( ± diabetes ) orA C Dor

Recommendation 6(Moderate recommendation) Initial treatments

What happened to the beta-blockers (BB)? Most evidence for BB is from atenolol

• Does not meet current FDA criteria for a once-daily drug

LIFE Study BB still recommended for many patients with comorbid

conditions (CHF, CAD, etc.)

•Losartan Intervention For Endpoint reduction in hypertension (n=9193)–Previously treated or untreated hypertension–Systolic BP 160-200 mmHg or diastolic BP 95-115 mmHg–ECG LVH when the blood pressure is lowered with an ARB to the same degree as it is with the comparative agent, the ARB will offer better protection against hypertension-related hard end points.

Primary composite endpoint of cardiovascular morbidity and mortality, defined as stroke, MI or cardiovascular death

Losartan vs atenolol2002

Insights Gained From Clinical Trials In Hypertension

20

4060

80100

120140

160180

LIFE Study Blood Pressure During Follow-up

Study Month

Systolic

Diastolic

Mean Arterial

mm

Hg

AtenololLosartan

6 5412 3018 24 36 42 480

Dahlof B, et al. Lancet. 2002;359:995-1003.Reprinted with permission from Elsevier Science.

Insights Gained From Clinical Trials In Hypertension

LIFE: Event rate

0%

2%

4%

6%

8%

10%

12%

14%

Composite Stroke MI Death

Losartan Atenolol

11%

13%

4% 4%5%

7%

4% 5%

Dahlof B, et al. Lancet. 2002;359:995-1003.Presented by B Dahlof at the American College of Cardiology Scientific Sessions Late-Breaking Clinical Trials III, 2002.

13% RR p=0.021

7% RR p=0.491

25% RR p=0.001 11% RR

p=0.206



Recommendation 6(Moderate recommendation) Initial treatments

What happened to the beta-blockers (BB)? Most evidence for BB is from atenolol

• Does not meet current FDA criteria for a once-daily drug

LIFE Study BB still recommended for many patients with comorbid

conditions (CHF, CAD, etc.)



Recommendation 6(Moderate recommendation)

Initial treatments

Initial or add-on treatments

General ( ± diabetes ) black population orC D

Population with CKD ≥18 years(irrespective

of race or diabetes)A


Initial treatments


In single large trial (ALLHAT) , a thiazide-type diuretic was shown to be more effective in improving stroke, HF, & combined CV outcomes compared to an ACEI in the black patient subgroup

based primarily on kidney outcomes because there is less evidence favouring ACEI or ARB for cardiovascular outcomes in patients with CKD

Use of renin-angiotensin system inhibitors in CKD population requires monitoring of electrolyte & serum creatinine levels

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

Start one drug and then add a second drug before achieving maximum dose of the initial drug

Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination

A

C

B

Recommendation 9: Strategies to Dose of Antihypertensive Drugs To Achieve Goal BP


Multiple Antihypertensive Agents Are Needed to Achieve Target BP

DBP = diastolic blood pressure; MAP = mean arterial pressure.Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.

Trial Target BP (mm Hg)

UKPDS DBP <85

ABCD DBP <75

MDRD MAP <92

HOT DBP <80

AASK MAP <92

No. of Antihypertensive Agents0 1 2 3 4

Possible combinations of classes of antihypertensive drugs

Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination.

D

A

A

C

B

DM CKD

C D A

B

A C DAlone or in combination

Alone or in combination with other drug class

Comparisons to Other Guidelines

BP Goal JNC-7 JNC-8 ASH/ISH ESC/ESH CHEP

Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90

Age 60-79

<140/90 <150/90 <140/90 <140/90 <140/90

Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90

Diabetes <130/80 <140/90 <140/90 <140/85 <130/80

CKD <130/80 <140/90 <140/90 <130/90 <140/90

Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

Comparisons to Other GuidelinesJNC-7 JNC-8 ASH/ISH ESC/ESH CHEP

Non-black (no DM or CKD)

Thiazide Thiazide, ACEI, ARB, CCB

<60:ACEI,ARB>60:CCB, thiazide

Thiazide, ACEI, ARB, CCB, BB

Thiazide, ACEI, ARB (BB if <60)

Black (no DM or CKD)

Thiazide Thiazide, CCB

Thiazide, CCB

Thiazide, ACEI, ARB, CCB, BB

Thiazide, ARB (BB if <60)

Diabetes ACEI, ARB, CCB, BB, thiazide

CCB, thiazide

ACEI, ARB, CCB, thiazide

ACEI, ARB ACEI, ARB, CCB, thiazide

CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB

Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

Major changes from JNC 7

Higher target SBP for patients over 60 y/o Limited data to support either 150 or 140 mmHg Removed special lower target BP for those

with CKD or DM Liberalized initial drug choicesA C D

Conclusion• HTN is a widespread and treatable condition, but

• BP control in the community continues to be suboptimal,

• leading to increased rates of MI, stroke and other serious comorbid conditions.

• JNC8 Guidelines are fairly simple to understand and use in general practice,

• But not a substitute for good clinical judgment.

It’s easy to get good players.

Getting’ `em to play together …

That’s the hard part.

Thank You

Healthcare

Update in hypertension management