Transcript Treatment Guidelines HTN, DM, Hyperlipidemia

Gregory Burns, MMS, PA-C
Past President-Florida Academy of Physician Assistants (FAPA)
Assistant Professor of Barry University PA Program-St. Petersburg
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Define the different types of HTN
Compare old JNC Guidelines to new JNC-8
Guidelines
Know the screening of HTN
Know the correct ways of BP measurements
Know how to evaluate a patient with HTN
Know the Goals of Therapy
Examine different Trials of HTN
Examine different classes of Therapy
Examine the 9 Recommendations of JNC-8
The treatment of hypertension is the most
common reason for office visits of nonpregnant adults to physicians in the United
States and for use of prescription drugs.
 The National Health and Nutrition
Examination Survey (NHANES) conducted
from 2005 through 2008 estimated that
approximately 29 to 31 percent of adults in
the United States have hypertension.
This means up to 65 Million US Adult
Hypertensives!
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1977: JNC-1 First Report of JNC
no specific recommendation on treating SBP;
Identified DHTN at 105; consider treatment
90-105
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2003: JNC-7 =Seventh Report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure
http://www.nhlbi.nih.gov/guidelines/hyperte
nsion/jncintro.htm
December 2013: JNC-8= Eight Report is
Blood Pressure Classification
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139
or
80–89
Stage 1 Hypertension
140–159
or
90–99
Stage 2 Hypertension
>160
or
>100
The pathogenesis of primary, or essential,
hypertension is poorly understood.
Factors that may implicate include:
1. Increased sympathetic neural activity, with
enhanced beta-adrenergic responsiveness
2. Increased angiotensin II activity and
mineralocorticoid excess
3. Genetic factors account for approximately
30 percent of the variation in blood pressure
in various populations
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Secondary or Identifiable
Causes of Hypertension
 Sleep apnea
 Pheochromocytoma
 Drug-induced or related
causes
 Coarctation of the aorta
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy
and Cushing’s syndrome
 Thyroid or parathyroid
disease
 *Oral contraceptives
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Isolated systolic hypertension: blood
pressure of ≥140/<90 mmHg
Isolated diastolic hypertension: blood
pressure <140/≥90 mmHg
Malignant hypertension: severe
hypertension with retinal hemorrhages,
exudates, or papilledema, with or without
hypertensive encephalopathy
Hypertensive urgency: severe hypertension
(diastolic pressure >120 mmHg) in
asymptomatic patients
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Resistant hypertension is defined in the 2008
American Heart Association (AHA) scientific
statement as blood pressure that remains
above goal in spite of concurrent use of three
antihypertensive agents of different classes
Thus, patients whose blood pressure is
controlled with four or more medications
should be considered to have resistant
hypertension
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All patients with resistant hypertension
should be evaluated for the possible presence
of primary aldosteronism, renal artery
stenosis, chronic kidney disease, and
obstructive sleep apnea (Most Common
Cause).
Less common identifiable causes of resistant
hypertension include pheochromocytoma,
Cushing's syndrome, and aortic coarctation.
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Resistant Hypertension that cannot be
controlled (up to 10% of this population) is
called Refractory Hypertension.
Neurologic mechanisms (eg, sympathetic
overactivity) may be the culprit of Refractory
Hypertension.
Potentially reversible factors that contribute
to resistant hypertension include
suboptimal therapy, lifestyle and diet,
medications and herbal preparations that
can raise the blood pressure, and secondary
causes of hypertension
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The 2007 United States Preventive Services
Task Force (USPSTF) guidelines on screening
for high blood pressure recommend
screening every two years for persons with
systolic and diastolic pressures below 120
mmHg and 80 mmHg, respectively (normal BP
in JNC 7), and yearly for persons with a
systolic pressure of 120 to 139 mmHg or a
diastolic pressure of 80 to 89 mmHg
(prehypertension in JNC 7)
Same for JNC 8!
BP Measurement Techniques
Method
Brief Description
In-office
Two readings, 5 minutes apart, sitting in
chair. Confirm elevated reading in
contralateral arm.
Indicated for evaluation of “white-coat” HTN.
Absence of 10–20% BP decrease during
sleep may indicate increased CVD risk.
Ambulatory BP monitoring
Self-measurement
Provides information on response to therapy.
May help improve adherence to therapy and
evaluate “white-coat” HTN.
Office BP Measurement
 Use auscultatory method with a properly calibrated and
validated instrument.
 Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at
heart level.
 Appropriate-sized cuff should be used to ensure accuracy.
 At least two measurements should be made.
 Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.
Self-Measurement of BP
 Provides information on:
1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN
 Home measurement of >135/85 mmHg is generally
considered to be hypertensive.
 Home measurement devices should be checked regularly.
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Suspected episodic hypertension (eg,
pheochromocytoma)
Hypertension resistant to increasing
medication
Hypotensive symptoms while taking
antihypertensive medications
Autonomic dysfunction
The Dublin Outcome Study in 2005
Results: Ambulatory measurement of blood
pressure is superior to clinic measurement in
predicting cardiovascular mortality, and
nighttime blood pressure is the most potent
predictor of outcome
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Patient Evaluation
Evaluation of patients with documented HTN has three
objectives:
1. Assess lifestyle and identify other CV risk factors or
concomitant disorders that affects prognosis and guides
treatment.
2. Reveal identifiable causes of high BP.
3. Assess the presence or absence of target organ damage
and CVD.
CVD Risk
 The BP relationship to risk of CVD is continuous, consistent,
and independent of other risk factors.
 Each increment of 20/10 mmHg doubles the risk of CVD
across the entire BP range starting from 115/75 mmHg.
 Prehypertension signals the need for increased education to
reduce BP in order to prevent hypertension.
CVD Risk Factors
 Hypertension*
 Cigarette smoking
 Obesity* (BMI >30 kg/m2)
 Physical inactivity
 Dyslipidemia*
 Diabetes mellitus*
 Microalbuminuria or estimated GFR <60 ml/min
 Age (older than 55 for men, 65 for women)
 Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
Target Organ Damage
 Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
 Reduce CVD and renal morbidity and mortality.
Benefits of Lowering BP
In stage 1 HTN and additional CVD risk factors, achieving
a sustained 12 mmHg reduction in SBP over 10 years will
prevent 1 death for every 11 patients treated.
Lifestyle Modification
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
JNC 7Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Followup and Monitoring
 Patients should return for followup and adjustment of
medications until the BP goal is reached.
 More frequent visits for stage 2 HTN or with complicating
comorbid conditions.
 Serum potassium and creatinine monitored 1–2 times per
year.
Followup and Monitoring
(continued)
 After BP at goal and stable, followup visits at 3- to 6-month
intervals.
 Comorbidities, such as heart failure, associated diseases,
such as diabetes, and the need for laboratory tests influence
the frequency of visits.
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The Antihypertensive and Lipid Lowering
Treatment to Prevent Heart Attack Trial
Trial from 1994 thru 2002 involving over
42,000 patients.
Results: The principal finding of ALLHAT is
that chlorthalidone, amlodipine, and lisinopril
provided similar protection from coronary
heart disease death and nonfatal myocardial
infarction among patients with hypertension
and risk factors for cardiovascular disease.
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Chlorthalidone at the same dose is
approximately 1.5 to 2.0 times as potent as
HCTZ. Thus, 12.5 mg/day of chlorthalidone is
equivalent to 19 to 25 mg/day of HCTZ.
Longer duration of action of chlorthalidone
(24 to 72 hours versus 6 to 12 hours with
HCTZ)
Chlorthalidone may be a better choice for
nighttime coverage than HCTZ. Watch out for
Hypokalemia. No difference-HCTZ.
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Avoiding Cardiovascular Events in
Combination Therapy in Patients Living with
Systolic Hypertension Trial
In the ACCOMPLISH trial, amlodipine plus
benazepril was associated with a 20 percent
lower rate of cardiovascular events compared
to hydrochlorothiazide plus benazepril,
despite slightly higher 24-hour blood
pressures in the amlodipine arm.
Hypertension in Older
Persons
 More than two-thirds of people over 65 have HTN.
 This population has the lowest rates of BP control.
 Treatment, including those who with isolated systolic HTN,
should follow same principles outlined for general care of
HTN.
 Lower initial drug doses may be indicated to avoid
symptoms; standard doses and multiple drugs will be
needed to reach BP targets.
Postural Hypotension
 Decrease in standing SBP >10 mmHg, when associated
with dizziness/fainting, more frequent in older SBP patients
with diabetes, taking diuretics, venodilators, and some
psychotropic drugs.
 BP in these individuals should be monitored in the upright
position.
 Avoid volume depletion and excessively rapid dose titration
of drugs.
Hypertension in Women
 Oral contraceptives may increase BP, and BP should be
checked regularly. In contrast, HRT does not raise BP.
 Development of HTN—consider other forms of contraception.
 Pregnant women with HTN should be followed carefully.
Methyldopa, BBs, and vasodilators, preferred for the safety of
the fetus. ACEI and ARBs contraindicated in pregnancy.
Hypertensive Urgencies
and Emergencies
 Patients with marked BP elevations and acute target organ
dysfunction (TOD) (e.g., encephalopathy, myocardial
infarction, unstable angina, pulmonary edema, eclampsia,
stroke, head trauma, life-threatening arterial bleeding, or
aortic dissection) require hospitalization and parenteral drug
therapy.
 Patients with markedly elevated BP but without acute TOD
usually do not require hospitalization, but should receive
immediate combination oral antihypertensive therapy.
Additional Considerations in
Antihypertensive Drug Choices
Potential favorable effects
 Thiazide-type diuretics useful in slowing demineralization in
osteoporosis.
 BBs useful in the treatment of atrial
tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (shortterm), essential tremor, or perioperative HTN.
 CCBs useful in Raynaud’s syndrome and certain arrhythmias.
 Alpha-blockers useful in prostatism such as BPH.
Additional Considerations in
Antihypertensive Drug Choices
Potential unfavorable effects
 Thiazide diuretics should be used cautiously in gout or a history of
significant hyponatremia.
 BBs should be generally avoided in patients with asthma, reactive
airways disease, or second- or third-degree heart block.
 ACEIs and ARBs are contraindicated in pregnant women or those likely
to become pregnant.
 ACEIs should not be used in individuals with a history of angioedema.
 Aldosterone antagonists and potassium-sparing diuretics can cause
hyperkalemia.
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Brand name is Tekturna
Direct Renin Inhibitor
Became available March 2007
Black box warning-fetus/pregnancy
AVOID Trial: this med combined with losartan
showed 20% greater reduction in proteinuria
than losartan alone but no real clinical effect.
ALTITUDE Trial: Patients with DM2 and kidney
disease were randomly assigned to this med
or placebo. Trial stopped early due to futility
or increase in non-stroke, hypotension and
hyperkalemia.
Clonidine and Methyldopa: Alpha2Adrenergic Agonists
--Stimulates the Alpha2 receptors in the brain
decreasing cardiac output and peripheral
vascular resistance.
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Hydralazine and Nitroprusside: Vasodilators
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
Comparison of Current Recommendations With JNC 7 Guidelines
Date of download: 2/9/2014
Copyright © 2014 American Medical
Association. All rights reserved.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
2014 Hypertension Guideline Management AlgorithmSBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.
aACEIs and ARBs should not be used in combination.
bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic
Copyright © 2014 American Medical
plan.
Date of download: 2/9/2014
Association. All rights reserved.
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There 9 Recommendations proposed from
JNC 8!
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The main objective of hypertension treatment
is to attain and maintain goal BP.
If goal BP is not reached within a month of
treatment, increase the dose of the initial
drug or add a second drug from one of the
classes in recommendation 6 (thiazide-type
diuretic, CCB, ACEI, or ARB).
The clinician should continue to assess BP
and adjust the treatment regimen until goal
BP is reached.
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If goal BP cannot be reached with 2 drugs, add and
titrate a third drug from the list provided.
Do not use an ACEI and an ARB together in the
same patient.
If goal BP cannot be reached using only the drugs
in recommendation 7 because of a contraindication
or the need to use more than 3 drugs to reach goal
BP, antihypertensive drugs from other classes can
be used. Referral to a hypertension specialist may
be indicated for patients in whom goal BP cannot
be attained using the above strategy or for the
management of complicated patients for whom
additional clinical consultation is needed.
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In the general population aged ≥60 years,
initiate pharmacologic treatment to lower
blood pressure (BP) at systolic blood pressure
(SBP) ≥150 mm Hg or diastolic blood
pressure (DBP) ≥90 mm Hg and treat to a
goal SBP <150 mm Hg and goal DBP <90 mm
Hg.
(Strong Recommendation – Grade A)
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In the general population <60 years, initiate
pharmacologic treatment to lower BP at DBP
≥90 mm Hg and treat to a goal DBP <90 mm
Hg.
(For ages 30-59 years, Strong
Recommendation – Grade A; For ages 18-29
years, Expert Opinion – Grade E)
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In the general population <60 years, initiate
pharmacologic treatment to lower BP at SBP
≥140 mm Hg and treat to a goal SBP <140
mm Hg.
(Expert Opinion – Grade E)
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The change to a more lenient systolic blood
pressure goal may be confusing to many
patients who are accustomed to the lower
goals of JNC 7, including the <140/90 mm
Hg goal for most patients and <130/80 mm
Hg goal for patients with hypertension and
major comorbidities.
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The guidelines were informed by results of 5
key trials: the Hypertension Detection and
Follow-up Program (HDFP), the HypertensionStroke Cooperative, the Medical Research
Council (MRC) trial, the Australian National
Blood Pressure (ANBP) trial, and the Veterans’
Administration (VA) Cooperative.
In these trials, patients between the ages of
30 and 69 years received medication to lower
DBP to a level <90 mm Hg. Results showed a
reduction in cerebrovascular events, heart
failure, and overall mortality in patients
treated to the DBP target level.
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In the population aged ≥18 years with
chronic kidney disease (CKD), initiate
pharmacologic treatment to lower BP at SBP
≥140 mm Hg or DBP ≥90 mm Hg and treat to
goal SBP <140 mm Hg and goal DBP <90 mm
Hg.
(Expert Opinion – Grade E)
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In the population aged ≥18 years with
diabetes, initiate pharmacologic treatment to
lower BP at SBP ≥140 mm Hg or DBP ≥90 mm
Hg and treat to a goal SBP <140 mm Hg and
goal DBP <90 mm Hg.
(Expert Opinion – Grade E)
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In the general nonblack population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor
(ACEI), or angiotensin receptor blocker (ARB).
(Moderate Recommendation – Grade B)
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In the general black population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic or CCB.
(For general black population: Moderate
Recommendation – Grade B; for black
patients with diabetes: Weak
Recommendation – Grade C)
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In ALLHAT Study, mentioned before, a
thiazide-type diuretic was shown to be more
effective in improving cerebrovascular, heart
failure, and combined cardiovascular
outcomes compared to an ACEI in the black
patient subgroup, which included large
numbers of diabetic and nondiabetic
participants
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In the population aged ≥18 years with CKD,
initial (or add-on) antihypertensive treatment
should include an ACEI or ARB to improve
kidney outcomes. This applies to all CKD
patients with hypertension regardless of race
or diabetes status.
(Moderate Recommendation – Grade B)
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First-line and later-line treatments should
now be limited to 4 classes of medications:
thiazide-type diuretics, calcium channel
blockers (CCBs), ACE inhibitors, and ARBs.
Second- and third-line alternatives included
higher doses or combinations of ACE
inhibitors, ARBs, thiazide-type diuretics, and
CCBs.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
Evidence-Based Dosing for Antihypertensive Drugs
Date of download: 2/9/2014
Copyright © 2014 American Medical
Association. All rights reserved.
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Several medications are now designated as
later-line alternatives, including the
following: beta-blockers, alpha-blockers,
alpha1/beta-blockers (eg, carvedilol),
vasodilating beta-blockers (eg, nebivolol),
central alpha2/-adrenergic agonists (eg,
clonidine), direct vasodilators (eg,
hydralazine), loop diuretics (eg, furosemide),
aldosterone antagoinsts (eg, spironolactone),
and peripherally acting adrenergic
antagonists (eg, reserpine).•
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CCBs and thiazide-type diuretics should be
used instead of ACE inhibitors and ARBs in
patients over the age of 75 years with
impaired kidney function due to the risk of
hyperkalemia, increased creatinine, and
further renal impairment.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension
Date of download: 2/9/2014
Copyright © 2014 American Medical
Association. All rights reserved.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
Strategies to Dose Antihypertensive Drugsa
Date of download: 2/9/2014
Copyright © 2014 American Medical
Association. All rights reserved.
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JNC 7 is posted on NHLBI website.
Most of these slides are from their program,
with starred ones from:
Kaplan NM, Domino FJ. 2012 UptoDate Topic
3852 Version 18.0
J Am Coll Cardiol, 2011; 57:2037-2114,
doi:10.1016/j.jacc.2011.01.008 (Published
online 25 April 2011).
http://guidance.nice.org.uk/CG127/NICEGui
dance/doc
http://jama.jamanetwork.com/article.aspx?ar
ticleid=1791497
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http://www.nhlbi.nih.gov/guidelines/cvd_adu
lt/background.htm
http://www.nejm.org/doi/full/10.1056/NEJM
oa0806182
Up-to-date.com
Medscape.com
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Thank you for your attention!