Transcript What is the goal BP? - Mississippi Nurses` Association

Hypertension Guidelines 2015
Barry 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 (%)
BP and Ischemic Heart Disease Mortality
Age at Risk (y)
IHD Mortality
(Floating Absolute Risk and 95% CI)
Age at Risk (y)
80-89
256
256
80-89
70-79
70-79
60-69
50-59
32
60-69
32
50-59
40-49
40-49
4
4
0
0
120
140
160
180
Usual SBP (mm Hg)
70
80
90
100
110
Usual DBP (mm Hg)
Adapted from Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.
2098 Franklin #7
CV Mortality Risk Doubles with
Each 20/10 mm Hg BP Increment*
8
7
6
5
CV
mortality 4
risk
3
2
1
0
115/75
135/85
155/95
175/105
SBP/DBP (mm Hg)
*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.
2098 Franklin #8
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 microalbumin is mildly elevated.
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg
Case Question 2
• What is the drug of choice to start?
1.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
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 Management
Evidence 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 Management
Evidence Review
• RCT’s December 2009 – August 2013
1. 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 Treatment
Thresholds 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 Treatment
Thresholds 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 1839
JNC 8: Drug Treatment
Thresholds 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/ACEinhibitor combination was associated with an
increased risk of dialysis, doubling of serum
creatinine, and death, compared with using either
agent alone.
34
Subsequent Therapies
Reinforce compliance and lifestyle modifications!
Step One
Black
Non-Black
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
Others
Others
Step Four
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 Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
>140/90 <80 yr
>150/90 >80 yr
>140/90
Threshold
for Drug Rx
>140/90 < 60 yr Eldery SBP >160
>150/90 >60 yr Consider SBP
140-150 if <80 yr
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
w/ 2 drugs
>160/100
"Markedly
elevated BP"
>160/100
>160/100
Goal BP
Group
BP Goal (mm Hg)
General
DM*
CKD**
JNC 8:
<60 yr: <140/90
>60 yr: <150/90
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
*ADA: < 140/80 or lower
(SBP < 130 if proteinuria)
< 140/90
< 140/90
(Consider < 130/80 if proteinuria)
< 140/90
< 140/90
**KDIGO: <140/90 w/o albuminuria
<130/80 if >30 mg/24hr
BP goal in the elderly
2013 ESH/ESC Guidelines for the management of arterial hypertension
Blood pressure goals in hypertensive patients
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 elderly
Aged <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
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
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
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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 microalbumin 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 microalbumin is mildly elevated.
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<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.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
Combination therapy
Case Question 2
• What is the drug of choice to start?
1.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
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.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
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.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
Combination therapy
Subsequent Therapies
Reinforce compliance and lifestyle modifications!
Step One
Black
Non-Black
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
Others
Others
Step Four
Physiological Effects of Diuretics
Diuretics
Initially
↓ Plasma volume
↓ Cardiac Output
Long-term
↓ Blood Pressure
↓ Arterial Resistance
Counter-regulatory
Mechanisms
↓ 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.
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.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<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!