Transcript Ways to Reduce Nervousness

Clinical Update on the JNC 7/8
Hypertension Guidelines
CDR Dean T. Goroski, PharmD, BCPS
Advanced Practice Clinical Pharmacist
Congestive Heart Failure Clinic Manager
Yakama Indian Health Clinic
USPHS COA Symposium
June 21, 2011
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Disclosures
• I have hypertension
• I work with people who have hypertension
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Overview
• Discuss potential changes to the JNC
hypertension guidelines and the rationale behind
these changes.
• Describe strategies to help implement
antihypertensive regimens with greatest
chances of success in meeting patient specific
BP goals
• Identify opportunities for pharmacists to
proactively collaborate with providers and
patients to develop antihypertensive strategies
best suited for individual patients
3
Why do we treat hypertension?
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Objective measurement we can modify….but
Reduce cardiovascular risk
Reduce all cause morbidity and mortality
Reduce the incidence and progression of left
ventricular hypertrophy
• Prevention of atherosclerosis, retinopathy, renal
failure, etc.
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Cardiovascular Mortality Risk
*
Increases as Blood
Pressure
Rises
8x
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Cardiovascular
Mortality Risk
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6
5
4x
4
3
2x
2
1
0
115/75
135/85
155/95
175/105
Systolic/Diastolic Blood Pressure (mm Hg)
*Measurements
taken in individuals aged 40–69 years, beginning with a blood
pressure of 115/75 mm Hg.
Lewington S, et al. Lancet. 2002;360:1903-1913;
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
LVH, CHD, CHF
Peripheral
Vascular
Disease
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Renal Failure,
Proteinuria
Overview
• Discuss potential changes to the JNC
hypertension guidelines and the rationale behind
these changes
• Describe strategies to help implement
antihypertensive regimens with greatest
chances of success in meeting patient specific
BP goals
• Identify opportunities for pharmacists to
proactively collaborate with providers and
patients to develop antihypertensive strategies
best suited for individual patients
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JNC Hypertension Guidelines
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Developed by NHLBI since 1976
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Guidelines, not requirements
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Originally updated every 4 years
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JNC Guidelines
JNC 1
1976
JNC 2
1980
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JNC 3
1984
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JNC 4
1988
4
JNC 5
1992
4
JNC 6
1997
5
JNC 7
2003
6
JNC 8
2012
9+
JNC 9
2021-2025 ???
9-13 ???
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Dependence on Guidelines?
• Review primary literature, studies, other
professional guidelines
• Develop your own patient population specific
guidelines
• Use professional training to decipher the trials
and implement changes proactively
• Evaluate other guideline and recommendations
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HTN Trials since JNC7
• ACCORD
• ASCOT-BPLA
• HYVET
• ANBP-2
• ONTARGET
• ACCOMPLISH
• LIFE
• ALLHAT(reviewed)
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ACCORD
• We have upper limit BP recommendations, what
about the lower end?
• Results—trial did not support aggressive BP
lowering therapy <120/80
• Does this change the <130/80 recommendation
in DM and CKD?
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HYVET
• Addresses questions of beneficence of
antihypertensive therapy in the very elderly
(80+) aka risk vs. benefit
• Significantly decreased death from stroke and all
cause death
• Treat HTN in very elderly to goal <150/80
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ONTARGET
• ACEI vs. ARB vs. Combination therapy
• ARBs no better than ACEIs for reducing fatal
and nonfatal cardiovascular events
• Combination therapy no better than ACEI,
significantly increased risk of renal dysfunction
• DO NOT use ACEI and ARB together
• VALIANT trial also supports this conclusion in
post-MI and heart failure
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LIFE
• Losartan vs. atenolol for endpoint reduction,
HCTZ as add on therapy
• Combination therapy needed
• Again---ARBs (and ACEIs) significantly reduce
incidence of new onset DM
• Losartan significantly reduced CV outcomes vs.
atenolol
• ?? White vs. black populations ??
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Other HTN Guidelines
• Canadian Hypertension Guidelines
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CHEP—annually updated since 2000
• European Society of Hypertension/ESC
• Japanese Society for Hypertension
• World Health Organization
• International Society of Hypertension
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NOW—on Thiazides…..
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ACCOMPLISH
ALLHAT
ANBP-2
ASCOT
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ACCOMPLISH
• 11290 patients with HTN and high risk CV
• Benazepril 20mg/amlodipine 5mg or benazepril
20mg/HCTZ 12.5mg
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Benazepril force titrated to 40mg
Amlodipine or HCTZ titrated per provider
Goal <140/90(<130/80 recommended for diabetes or
renal insufficiency)
• Primary outcomes—death from CV, non-fatal MI,
non-fatal stroke, hosp for angina, resuscitation
after SCD, and coronary revascularization
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ACCOMPLISH-take home points
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ACEI-CCB vs ACEI-HCTZ—19.6 RRR (HR
0.80, P<0.001) for CV morbidity/mortality
BP goal <140/90 at 3 yr follow up—ACEI-CCB
81.7% vs ACEI-HCTZ 78.5%
HCTZ not chlorthalidone
Mean dose of HCTZ 19.3mg daily
High percentage of high risk pts
Combination therapy successful to meet goals
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ALLHAT
• 42418 patients 55yrs and older with HTN and 1
other risk factor for CHD
• Randomized and titrated on chlorthalizone,
amlodipine, lisinopril or doxazosin (Step 1)
• Adding open label atenolol, clonidine, or reserpine
(Step 2)
• Adding hydralazine (Step 3)
• Assessed metabolic syndrome and race
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ALLHAT-take home points
• Doxazosin stopped early for high CV risk
• Amlodipine vs chlorthalidone
• HF RR 1.38 (p<0.001)
• Lisinopril vs chlorthalidone
• Significantly increased risk for stroke, combined
CVD, and HF in lisinopril group
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ALLHAT-take home points
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Largely basis for JNC 7
Used chlorthalidone, not HCTZ
Step 2 and 3 meds not optimal
Critics of ALLHAT reject JNC 7
• Salt vs plasma renin activity
• Hypothesis generating in secondary outcomes
• Considered first step therapy, but no washout,
no initial BP to judge response
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ANBP-2
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Enalapril vs. HCTZ in 6083 patients aged 65-84
11% reduction in CV events in enalapril
Results contradict ALLHAT
HCTZ used versus chlorthalidone in ALLHAT
Limitations
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Population 95% white, ALLHAT 35% black
Changes in defined outcomes
Relative benefit limited to men?
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ASCOT-BPLA
• 19257 patients aged 40-79 with 3+ CV risks
• Amlodipine +/- perindopril vs. atenolol +/bendroflumethiazide and potassium
• Terminated early despite primary endpoints
failing to reach significance
• Secondary and tertiary endpoints did have
significance
• Not directly comparing two drugs……
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Thiazide summary
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Choice of medication
Dose of medication
First line? Compelling indications?
Excellent in combinations
Watch hypokalemia
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Overview
• Discuss potential changes to the JNC
hypertension guidelines and the rationale behind
these changes.
• Describe strategies to help implement
antihypertensive regimens with greatest
chances of success in meeting patient specific
BP goals
• Identify opportunities for pharmacists to
proactively collaborate with providers and
patients to develop antihypertensive strategies
best suited for individual patients
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Strategies for success
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Review local statistics on HTN treatment
Formulary maintenance and critical review
Develop adherence strategies
Assess and address lifestyle modifications
Self monitored blood pressures
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Review local statistics
• Run reports to review:
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Current prescribing patterns
Percentage of clinic patients at goal
Percentage of provider patients at goal
• Regular review and report to reinforce
• Review morbidity and mortality reports
• Develop performance measures/incentives
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Review local formulary
• Keep formulary choices up to date with current
literature/studies/guidelines
• Supply well validated medication choices
• Remove less favorable drugs when possible
• Incorporate formulary into local guidelines
• Recognize total benefit of medications, not just
medication costs
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Develop adherence strategies
• Well defined follow up
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Appts, phone calls, nutrition consults, labs
• Healthcare team approach
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Provider, nurse, pharmacist
• Lifestyle changes
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Physiologic, psychologic, pharmacologic in
addition to nutritional
Patient involvement in all aspects
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Address compliance issues
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Medication issues
Lifestyle issues
Social nutritional habits
Medication/provider access issues
Continuity of care
Implement changes to help with compliance
Customer service
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Overview
• Discuss potential changes to the JNC
hypertension guidelines and the rationale behind
these changes.
• Describe strategies to help implement
antihypertensive regimens with greatest
chances of success in meeting patient specific
BP goals
• Identify opportunities for pharmacists to
proactively collaborate with providers and
patients to develop antihypertensive strategies
best suited for individual patients
32
Opportunities to collaborate
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Know your guidelines and local populations
Offer clinical services and input regularly
Offer clinical inservices on hypertension
BP checks—pharmacy or nursing
Laboratory monitoring
Pharmaceutical knowledge on side effects,
beneficial effects
• Develop clinical resources for providers
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Opportunities to collaborate
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Clinical consultation services
Ask patients about follow up labs/BP checks
Impromptu clinical consultation with patient
A fib and BP assessment at coag visits
Medication synchronization visits
Have nutrition and lifestyle handouts at the
pharmacy
• Know some clinical pearls on HTN meds
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Overview
• Discuss potential changes to the JNC
hypertension guidelines and the rationale behind
these changes.
• Describe strategies to help implement
antihypertensive regimens with greatest
chances of success in meeting patient specific
BP goals
• Identify opportunities for pharmacists to
proactively collaborate with providers and
patients to develop antihypertensive strategies
best suited for individual patients
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Questions??
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Contact information
• [email protected]
• 509-865-2102 x201
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