Transcript Nurse in Adv Pract Meeting 4-9

Hypertension Update: Review of the
2014 HTN Guidelines
Do Recent Guidelines Really Change
Patient Management?
Angela L. Brown, MD
Associate Professor of Medicine
Department of Medicine
Cardiovascular Division
Disclosure: Angela L. Brown, M.D.
Angela L. Brown, M.D. has financial interests to disclose.
Potential conflicts of interest have been resolved.
Research Support / Grants
NIH. Medtronic
Speakers Bureau / Honoraria
Arbor Pharmaceuticals
2
Department of Medicine
Cardiovascular Division
Objectives
• Understand the current hypertension treatment guidelines
• Understand implications of current guidelines
• Discuss current prescribing trends of antihypertensive
medications
Department of Medicine
Cardiovascular Division
Why Are We Still Talking About Hypertension?
• It’s prevalent: NHANES 2010:
• Over 77.9 million adults in US
• 80 million adults have pre-hypertension
• Increasing prevalence with aging of
population and epidemic of
overweight/obesity
• Lowering BP leads to a reduction in events
• Approximately 50% reduction in heart
failure
Approximately 40% reduction in stroke
•
• Approximately 20-25% reduction in MI
Go et al. Circ. 2013
Hebert PR et al. Arch Inten Med. 1993;153:578-81.
Kannel WB. JAMA. 1996;275:1571-6. Moser M and Hebert P. J Am Coll Cardiol. 1996;27:1214-8.
Department of Medicine
Cardiovascular Division
Prevalence of Hypertension
Department of Medicine
Cardiovascular Division
High Blood Pressure Remains One of the
Most Important Multipliers for CV Risk
•
BP >140/90 mm Hg
associated with:
• 69% of first MIs
• 74% of cases of HF
• 77% of first strokes
• HBP is associated with a 2x
to 3x higher risk for
developing HF
Rosamond W et al. Circulation. 2007;115:e69-171.
Department of Medicine
Cardiovascular Division 6
Mortality From High Blood Pressure
Higher in African Americans
Overall Mortality Rates From Causes Related to Hypertension, 2003*
Mortality Rate, %
60
50
40
49.7
40.8
30
14.9
20
14.5
10
0
Male
Female
African American
Male
Female
White
In hypertensive African Americans, 30% and 20% of all deaths in
men and women, respectively, may be due to high blood pressure.
*High blood pressure listed as a primary or contributing cause of death.
High blood pressure=systolic ≥140 mmHg or diastolic ≥90 mmHg, taking antihypertensive
medicine,
being
told
by a physician
that you have high blood pressure.
Adapted from
Thom
T et≥2al.times
Circulation.
2006;113:e85–e151.
Department of Medicine
Cardiovascular Division
Development of Hypertension Guidelines: the
JNCs and Drug Therapy
JNC I
Earliest
Guidelines
JNC III
JNC II
JNC V
JNC IV
1972 1973 1976 1980 1984 1988 1993
34 drugs
Diuretics
NHBPEP
STARTS
28 drugs
DBP 105
Diuretics
HR Black, 2003.
50 drugs
ACEI, CAs
added
43 drugs
68 drugs
Low-dose
Diuretics/
diuretics,
b-blockers
b-blockers
JNC 7
JNC VI
1997
JNC 8
2003
2013
84 drugs
7 options
>125 drugs
Diuretics
RAS blockers
CAs
> 125 drugs
Diuretics
Added
Department of Medicine
Cardiovascular Division
JNC BP Classifications: SBP
SBP
(mm Hg)
220
210
200
190
180
170
160
150
140
130
120
110
Stage 4
Stage 3
ISH
Border
- line
No recommendations
for SBP in JNC I
or JNC II
JNC I
JNC II
JNC I. JAMA. 1977;237:255-261.
JNC II. Arch Intern Med. 1980;140:1280-1285.
JNC III. Arch Intern Med. 1984;144:1045-1057.
JNC III
Stage 3
ISH
Stage 2
Stage 2
Stage 2
Border
- line
Stage 1
Stage 1
Stage 1
Normal
Highnormal
Normal
Highnormal
Normal
Prehypertension
Optimal
Optimal
Normal
JNC V
JNC VI
JNC 7
JNC IV
JNC IV. Arch Intern Med. 1988;148:1023-1038.
JNC V. Arch Intern Med. 1993;153:154-183.
JNC VI. Arch Intern Med. 1997;157:2413-2446.
JNC VII. JAMA. 2003;289:2560-2572.
JNC 7 Treatment Goals
Condition
Uncomplicated hypertension
Diabetes mellitus
Chronic renal disease
Goal BP, mmHg
<140/90
<130/80
<130/80
Chobanian AV et al. Hypertension. 2003;42:1206-1252;
Department of Medicine
Cardiovascular Division
NHLBI Approach: Adult CVD Guideline
Reports
• Advisory group recommendations
• Update risk factor guidelines
• Develop an integrated guideline (including JNC 8)
• Use evidence-based approach
• Development process
• Increase rigor and minimize bias
• Utilize new IOM standards (decision making based
on evidence)
 Strictly evidence based
• Only RCTs assessing important health outcomes
• No use of intermediate or surrogate measures
Department of Medicine
Cardiovascular Division
NHLBI Systematic Review and Guideline
Development Process
Topic Area
Identified
Expert Panel
Selected
Critical Questions
&Study Eligibility
Criteria Identified
Evidence Tables
Developed;
Body of Evidence
Summarized
Studies Quality Rated;
Data Abstracted
Literature Searched;
Eligible Studies
Identified
Graded Evidence
Statements &
Recommendations
Developed
External Review
of Recommendation
Drafts; Revised
as Needed
Guidelines
Disseminated &
Implemented
Department of Medicine
Cardiovascular Division
NHLBI Evidence Quality Rating and
Recommendation Strength
Evidence Quality
• High
• Well-designed and
conducted RCTs
• Moderate
• RCTs with minor limitations
• Well-conducted
observational studies
• Low
• RCTs with major limitations
• Observational studies with
major limitations
Recommendation
Strength
A – Strong
B – Moderate
C – Weak
D – Against
E – Expert Opinion
N – No Recommendation
Department of Medicine
Cardiovascular Division
Levels of Evidence
Mathematics
1A
Physics
1B
Chemistry
2A
Biology
2B
Social Sciences (Psychology/Sociology)
2C
Philosophy
2D
Department of Medicine
Cardiovascular Division
JNC 8:
Questions to Address
• Among adults with hypertension, does initiating
antihypertensive pharmacological therapy at
specific BP thresholds improve health outcomes?
(When to initiate drug treatment?)
• Among adults, does treatment with
antihypertensive pharmacological therapy to a
specific BP goal lead to improvements in health
outcomes? (How low should you go?)
• In adults with hypertension, do various
antihypertensive drugs or drug classes differ in
comparative benefits and harms on specific
health outcomes? (How do we get there?)
Department of Medicine
Cardiovascular Division
Inclusion/Exclusion Criteria for Studies
•
•
•
•
Randomized Controlled trials
1966-present
Minimum one year follow-up
Studies with samples size <100 excluded
Department of Medicine
Cardiovascular Division
Among adults with HTN, does initiating drug
therapy at a particular level lead to improvement in
health outcomes?
Articles screened = 1496
Included = 44
Good = 8
Fair = 18
Excluded = 1452
Poor = 18
Total abstracted = 26
Department of Medicine
Cardiovascular Division
Among adults with HTN, does treating to a
specific goal lead to improvements in health
outcomes?
Articles screened = 1978
Included = 92
Good = 17
Fair = 39
Excluded = 1886
Poor = 36
Total abstracted = 56
Department of Medicine
Cardiovascular Division
Among adults with HTN, do various anti-hypertensive
drugs or drug classes differ in comparative benefits and
harms on specific health outcomes?
Articles screened = 2662
Included = 101
Good = 15
Fair = 51
Excluded = 2561
Poor = 35
Total abstracted = 66
Department of Medicine
Cardiovascular Division
JNC 8-RECOMMENDATIONS
 In the general population 60 years of age or older,
initiate pharmacologic treatment to lower blood
pressure at SBP >150 mmHg or DBP > 90 mmHg and
treat to a goal of <150/90 mmHg
(Strong Recommendation-Grade A)
 In the general population less than 60 years of age,
initiate Pharmacological treatment to lower BP at SBP
> 140 mmHg and treat to goal < 140/90 mmHg
(Expert Opinion-Grade E)
 In the population with nondiabetic chronic kidney
disease initiate pharmacological treatment at BP
>140/90 mmHg and treat to <140/90 mmHg
(Expert Opinion-Grade E)
Department of Medicine
Cardiovascular Division
JNC 8-RECOMMENDATIONS
 In the population with diabetic chronic kidney
disease initiate pharmacological treatment at BP
>140/90 mmHg and treat to <140/90 mmHg
(Expert Opinion-Grade E)
 In the general, non-black population initial
antihypertensive treatment should include a
thiazide-type diuretic, CCB, ACEI or ARB
(Moderate recommendation-Grade B)
 In the general, non-black population with diabetes
initial antihypertensive treatment should include a
thiazide-type diuretic, CCB, ACEI or ARB
(Moderate recommendation-Grade B)
Department of Medicine
Cardiovascular Division
JNC 8-RECOMMENDATIONS
 In the general black population initial
antihypertensive treatment should include a thiazidetype diuretic or CCB
(Moderate recommendation-Grade B)
 In the general black population with diabetes initial
antihypertensive treatment should include a thiazidetype diuretic or CCB
(Weak recommendation-Grade C)
 In the population 18-80 years of age with chronic
kidney disease and hypertension initial (or add-on)
antihypertensive treatment should include and ACE
inhibitor or ARB to improve kidney outcomes
(Moderate Recommendation-Grade B)
Department of Medicine
Cardiovascular Division
JNC 8 Hypertension Guideline Management Algorithm
James PA, Oparil S, Carter BL et al. JAMA 2014: 311 (5):507-520, Feb 5, 2014.
Department of Medicine
Cardiovascular Division
Annals of Internal Medicine
Evidence Supporting a Systolic Blood
Pressure Goal of Less Than 150 mm Hg
in Patients Aged 60 Years or Older: The
Minority View
Jackson T. Wright Jr., MD, PhD; Lawrence J. Fine, MD, DrPH; Daniel T.
Lackland, DrPH; Gbenga Ogedegbe, MD, MPH, MS; and Cheryl R.
Dennison Himmelfarb, PhD, RN, ANP
Conclusion: These five dissenters believe that the threshold
and goal BP should be < 140 mm Hg and not < 150 mm Hg in
those > 60 years of age
Annals of Internal Med January 2014
Department of Medicine
Cardiovascular Division
Benefit of Treatment of Stage 2 Isolated Systolic
HTN: Final BP <150 mmHg but not <140 mm Hg
Change in
BP v P
Change in CVE
Trial
Bp
BP
SHEP
170/77
143/68
12/4
0.67 (0.56–0.80)
Syst-Eur
174/86
152/78
10/5
0.69 (0.55–0.86)
Syst-China
170/86
150/81
8/3
0.61 (0.39–0.96)
HYVET
170/91
144/80
15/6
0.66 (0.53–0.82)
SHEP Cooperative Research Group. JAMA. 1991;265:3255.
Staessen JA et al. Lancet. 1997;350:757.
Liu L et al. J Hypertens. 1998;16:1823.
Beckett NS et al. N Engl J Med. 2008;358:1887.
Bp,=initial BP
BP=treatment BP
P=placebo
CVE=cardiovascular event
Department of Medicine
Cardiovascular Division
Major Randomized Trials Testing SBP
Goals in General (Older) Populations
SHEP
Syst-Eur
HYVET
>60
>60
>80
65-85
70-84
4,736
4,695
3,845
4,418
3,260
Entry SBP
160-219
160-219
160-199
>160
>160
Goal SBP
<148
<150
<150
<140
<140
Achieved
SBP
142
151
144
136
137
Stroke 
36%
42%
ns
ns
ns
CVD 
32%
31%
34%
ns
ns
ns
ns
21%
ns
ns
Age
Number
Mortality 
JATOS VALISH
SBP = systolic blood pressure; CVD = cardiovascular disease
Department of Medicine
Cardiovascular Division
Risk of Adverse Outcomes Among Elderly CAD Patients in
INVEST by Age and BP-“Is There a Sweet Spot for BP”
Denardo et al. Am J Med 123:719-726, 2010
Department of Medicine
Cardiovascular Division
Contrasts in Goal BP Recommendations
Source
>60 years
>80 years
CKD
ASH/ISH
<140/90
<150/90
130-140/80-90
ESH/ESC
<140/90
<150/90
130-140/90
2014 HTN
guidelines
<150/90
<150/90
<140/90
ADA 2015
-
—
American Diabetes Association. Diabetes Care. 2015;38(suppl 1):S49-57;
ASH-ISH Weber MA, et al. J Clin Hypertension. Dec. 17, 2013 [Epub ahead of print];
2014 HTN Guidelines James PA, et al. JAMA. 2014;311:507-520.
ESH/ESC Mancia G, et al. J Hypertens. 2013;.31: 1281-1357
Department of Medicine
Cardiovascular Division
What is the Goal BP and Initial Therapy in Kidney Disease or
Diabetes to Reduce CV Risk?
Group
Goal BP
(mmHg)
Initial Therapy
ADA (2013)
<140/80
ACE Inhibitor/ARB*
KDIGO/KDOQI (NKF) (2012)
<140/90
ACE Inhibitor/ARB
ESH (2007+ 2009)
<130/80
ACE Inhibitor/ARB*
KDOQI (NKF) (2004)
<130/80
ACE Inhibitor/ARB*
JNC 7 (2003)
<130/80
ACE Inhibitor/ARB*
Am. Diabetes Assoc (2003)
<130/80
ACE Inhibitor/ARB*
Canadian HTN Soc. (2002)
<130/80
ACE Inhibitor/ARB*
Am. Diabetes Assoc (2002)
<130/80
ACE Inhibitor/ARB*
Natl. Kidney Foundation (2000)
<130/80
ACE Inhibitor*
British HTN Soc. (1999)
<140/80
ACE Inhibitor
WHO/ISH (1999)
<130/85
ACE Inhibitor
<130/85
Department of Medicine
ACE Inhibitor
Cardiovascular Division
29
* IndicatesJNC
use VI
with
diuretic
(1997)
Categories
NICE*
2011
ESH/ESC
2013
ASH / ISH
2014
AHA/ACC/CDC
2013
JNC 8*
2014
Definition of
Hypertension
≥140/90 and
daytime ABPM (or
home BP) ≥135/85
≥140/90
≥140/90
≥140/90
Not
addressed
Drug therapy/
low risk patients
after non-pharm
treatment
≥160/100 or
day-time ABPM
≥ 150/95
≥140/90
≥140/90
≥140/90
< 60 y.
≥140/90 ≥ 60
y. ≥150/90
b-blockers first line drug
No
Yes
No
No
No
thiazides
thiazides
Chlorthalidone indapamide
thiazides
chlorthalidone,
indapamide
Initial single
pill combo Rx
Not mentioned
markedly
elevated BP
≥160/100
BP targets
< 140/90 ≥ 80 y.
< 150/90
<140/90 ; < 80,
SBP 140-150
SBP <140 in fit
patients Elderly ≥
80 y. SBP 140150
<140/90
≥ 80 y. <
150/90
BP target in
Diabetes
Not addressed
Diuretic
< 140/85
thiazides
chlorthalidone,
indapamide
<140/90
chlorthalidone,
indapamide
≥160/100
<140/90
Lower targets may
be appropriate in
some patients,
including the elderly
<140/90 –
Consider lower
≥160/100
< 60 y.
<140/90
≥ 60 y.
<150/90
<140 /90
Ischemic Heart Disease Mortality Rate
in Each Decade of Age
SBP
DBP
256
256
128
128
64
64
32
IHD
mortality 16
(absolute risk 8
and 95% CI)
4
32
16
2
2
1
1
70-79 y
60-69 y
50-59 y
40-49 y
8
4
120 140 160 180
Usual SBP (mm Hg)
Lancet. 2002;360:1903-1913.
Age at risk:
80-89 y
70 80 90 100 110
Usual DBP (mm Hg)
ACCORD Results are Mixed
Intensive
Events (%/yr)
Standard
Events (%/yr)
HR (95% CI)
P
CVD (Primary)
208 (1.87)
237 (2.09)
0.88 (0.73-1.06)
0.20
Cardiovascular
Deaths
60 (0.52)
58 (0.49)
1.06 (0.74-1.52)
0.74
Total Stroke
36 (0.32)
62 (0.53)
0.59 (0.39-0.89)
0.01
Outcome
Department of Medicine
Cardiovascular Division
ACCORD Adverse Events
Intensive
N (%)
77 (3.3)
Standard
N (%)
30 (1.3)
<0.0001
Hypotension
17 (0.7)
1 (0.04)
<0.0001
Syncope
12 (0.5)
5 (0.2)
0.10
Bradycardia or Arrhythmia
12 (0.5)
3 (0.1)
0.02
Hyperkalemia
9 (0.4)
1 (0.04)
0.01
Renal Failure
5 (0.2)
1 (0.04)
0.12
eGFR ever <30 mL/min/1.73m2
99 (4.2)
52 (2.2)
<0.001
Any Dialysis or ESRD
59 (2.5)
58 (2.4)
0.93
Dizziness on Standing†
217 (44)
188 (40)
0.36
Adverse Events
Serious AE
P value
N Engl J Med. 2010;362:1575-85
Department of Medicine
Cardiovascular Division
Systolic Blood Pressure
Intervention Trial: SPRINT
• RCT to test whether a treatment strategy aimed
at reducing systolic blood pressure to
lower goal (SBP < 120 mmHg)
compared with
currently recommended (SBP < 140 mmHg)
will reduce the occurrence of cardiovascular
disease (CVD)
• N = 9250, age 50 and over
• 28% > age 75 years
Department of Medicine
Cardiovascular Division
Primary Outcome Composite (CVD)
•
•
•
•
•
CVD mortality
Myocardial infarction
Non-MI acute coronary syndrome
Stroke
Heart Failure
Department of Medicine
Cardiovascular Division
Key Secondary Objectives
•
•
•
•
•
Total mortality
Progression of CKD
Probable dementia
Cognitive impairment
White matter lesions detected by MRI
Department of Medicine
Cardiovascular Division
SPRINT: Results
• Planned completion 2017
• Stopped early September 2015
• “Lower blood pressure target greatly reduces CV
complications and deaths in older adults” – NIH
Cardiovascular events
⅓
Death
¼
NIH Press Release, Sept 11, 2015
Department of Medicine
Cardiovascular Division
Other Planned Analyses
•
•
•
•
•
Achieved blood pressure
Adverse events
Health related quality of life
Cost
Various laboratory assays
• Chemistry profile, fasting glucose, lipid
profile
Department of Medicine
Cardiovascular Division
Op-Ed: European Society of Hypertension
Clyde Yancy, MD, Northwestern University
• “The management of hypertension now falls within the
camp of primary care physicians, internists, and a
dedicated community of hypertension clinician scientists.”
• Unanswered questions?
 Clear targets of blood pressure lowering
 Risk algorithms to guide decision-making regarding
risk/benefit of antihypertensive therapy
 Clear algorithm to inform stepwise progression of care
 Old adage of simply lowering BP - May matter how we
lower BP and to what thresholds
Department of Medicine
Cardiovascular Division
PATHWAY Clinical Trials (ESH)
• 335 subjects with resistant hypertension
• Standard therapy plus spironolactone 25-50mg,
doxazosin 4-8mg, bisoprolol 5-10mg, or placebo
• BP reduction: 8.7 mmHg vs 4.03 mmHg vs 4.48 mmHg
• BP control: 58% vs 43.7% (p<0.001)
•
•
•
•
440 subjects with 1 other component of MetS
Role of potassium in glucose intolerance
Amiloride 10-20mg, HCTZ 25-50mg, ½ dose both
Amiloride vs HCTZ 55 mmol/L change from baseline;
½ dose - neutral change in glucose (0.42 mmol/L) but
greatest BP reduction 17mmHg
Department of Medicine
Cardiovascular Division
Spironolactone Induced Reduction in Systolic Blood Pressure
(BP) Diastolic BP at 6-weeks, 3- and 6-months Follow-up in
Subjects with Resistant Hypertension (N=76)
BP Response (mm Hg)
0
6wk
3mo
-10
-10
6mo
-10
-20
-12
-30
-21
-23
-25
BP reduction was significant at all time points compared to baseline
Nishizaka MK, et al. American Journal of Hypertension 2003;16(11):925-930.
Department of Medicine
Cardiovascular Division
Additional BP Reduction with
Spironolactone in Resistant Hypertension
Pimenta, Calhoun, Oparil. Arq Bras Cardiol 2007; 88(6) : 604-613
Department of Medicine
Cardiovascular Division
BP Control using Multiple or Fixed-Dose
Combination Agents
RAS Blocker
(ACEI or ARB)
+
Thiazide Diuretic
or Amlodipine
Not at Goal
Amlodipine or Chlorthalidone
(using alternative not used above)
Not at Goal
Additional Agents
(consider Mineralocorticoid Receptor Blocker)
All Patients
Department of Medicine
Lifestyle Modification—Especially Diet and Exercise
Cardiovascular Division
PARAMETER Trial (ESH)
• Pulse pressure independent risk factor for vascular
events in the elderly
• Valsartan/sacubitril (LCZ696) 400mg vs olmesartan
40mg
• 454 subjects – SBP > 150 mmHG, PP > 60mmHg
• Central Ao SBP reduction: 12.6 mmHg vs 8.9 mmHg
• Pulse pressure reduction: 6.4 mmHg vs 4.0 mmHg
Department of Medicine
Cardiovascular Division
Effect of BP on CHD Mortality: MRFIT
81
CHD death rate
per 10,000
person-years
48
44
37
31
26
38
35
25
25
25
25
160+
17
14
140–159
13
13
12
12
120–139
10
9
9
9
<120
SBP (mm Hg)
90–99 80–89 75–79 70–74 <70
24
21
100+
DBP (mm Hg)
Adapted with permission from Neaton JD et al. Arch Intern Med. 1992;152:56
Age Differences in Treatment and Control
of HTN in US Physician Offices, 20032010 (NAMCS)
2003 - 2004
2009 - 2010
Prescriptions
69.2%
78.8%
p<0.001
BP Control
39.1%
48.8%
p<0.001
Beta-blockers in
older patients
25.4%
34.7%
p<0.001
ARBs
17%
22.1%
p=0.042
NAMCS - National Ambulatory Medical Care Survey
Gu A, Yue, et al. Am J Med. Aug 2015
Department of Medicine
Cardiovascular Division
Age Differences in Treatment and
Control of Hypertension in US Physician
Offices, 2003-2010
Gu A, Yue, et al. Am J Med. Aug 2015
Department of Medicine
Cardiovascular Division
Antihypertensive Prescribing Trends
2003-2010
• Diuretics most commonly prescribed and
consistent between groups
• HCTZ > chlorthalidone and indapamide
• ACE-I > in younger patients
• Beta-blocker use persisted in the elderly after
excluding compelling indications
National Ambulatory Medical Care Survey
(NAMCS),
Gu A, Yue, et al. Am J Med. Aug 2015
Department of Medicine
Cardiovascular Division
Chlorthalidone Lowers Ambulatory Systolic Blood
Pressure More than Hydrochlorothiazide at Week 8 (N=30)
Chl (25 mg)
HCTZ (50 mg)
 mm Hg
24 hr ABPM 
p = 0.054
p = 0.009
Nighttime
ABPM 
Office BP reductions in SBP trended greater for Chlorthalidone -17.1
vs. 10.8 mm Hg (P=NS)
Ernst ME, et al. Hypertension 2006;47:352-358.
Department of Medicine
Cardiovascular Division
β-blockers as 1st Line Therapy in HTN
β-blockers vs other drugs
stroke
all cause mortality
MI
RR
16%
3%
not significant
β-blockers vs placebo or no treatment
stroke
19%
all cause mortality
not significant
MI
not significant
Lindholm, Carlberg Samuelsson.
Lancet 2005
Department of Medicine
Cardiovascular Division
Implications of JNC-8 on HTN
Management for Aging Adults
• Atherosclerosis Risk in Communities Study (ARIC)
• 6088 subjects, mean age 75.6 years, 2011-2013
JNC 7
62.8%
JNC 8
79.4%
• 16.6% reclassified as at goal blood pressure (1 in 6)
• 20.6% reclassified with DM and CKD
• 11.6% reclassified without DM and CKD
• Despite less aggressive goals, >20% patients
remained uncontrolled by the new criteria
Miedema MD et al. Hypertension. Sept 2015
Department of Medicine
Cardiovascular Division
The prevalence of at-goal blood pressure according to Seventh Joint National Committee (JNC7) and Eighth Joint
National Committee Panel (JNC8P) blood pressure guidelines in black and white individuals stratified by diabetes
mellitus (DM) or chronic kidney disease (CKD) in 6088 participants from the fifth visit of the Atherosclerosis Risk in
Communities Study, 2011–2013.
Michael D. Miedema et al. Hypertension. 2015;66:474-480
Copyright © American Heart Association, Inc. All rights reserved.
Department of Medicine
Cardiovascular Division
Summary
• The 2014 HTN guidelines are controversial
regarding the appropriate BP target in older
adults
• SPRINT may give us a more definitive answer
• Need more comprehensive algorithms that
include risk/benefit of antihypertensive therapy
• For those with resistant HTN, consider addition
of mineralocorticoid antagonist
• Expect new set of guidelines in the near future
• Guidelines are just that – guidelines. Treat the
patient in front of you!
Department of Medicine
Cardiovascular Division
Thank you!