Transcript Hypertension Guideline Update

Making Sense of the New
Guidelines: Hypertension
The More We Learn, the Less We Know
Zeb K. Henson, M.D.
Assistant Professor, Department of Medicine & Department of Pediatrics
University of Mississippi Medical Center
Financial Disclosures
• Nothing to disclose
Objectives
• Briefly review 2014 JAMA
HTN Guidelines
“Don’t run back inside,
• Use clinical scenarios to
discuss and provide
Darling, you know just what
justification for some of
I’m here for…”
these recommendations
• Discuss clinical barriers to
implementation of these
guidelines
JNC 7 Review
Issues addressed in JNC-7
Prevalence and Burden
Measurement
Definition
Lifestyle and Pharmacologic
Treatment
Secondary Hypertension
Resistant Hypertension
JNC-7 Classifications of HTN:
Lifestyle Modifications
Not at goal BP <140/90,
or <130/80 for diabetes, CKD or
CAD, or <120/80 for LV dysfunction
Initial Drug Choices
No Compelling Indications
Stage 1 HTN
1. Thiazides for most
2. Consider ACEI,
ARB, BB, CCB or
combo
Stage 2 HTN
Two-drug combo
for most; usually
thiazide and ACEI,
ARB, BB, or CCB
Compelling Indications
Drugs for compelling
indications; others as
needed
“Compelling Indications”
Growing Up
ACCOMPLISH
ALTITUDE
ACCF/AHA
ONTARGET
CAMELOT
REIN-2
2003
JNC-7
2005
ESH/ESC
HYVET
ACCORD-BP
AHA
2007
2009
ESH/ESC
NICE
ASH/ISH
2011
2014
JNC-8
The story of the committee…
End Result
It’s not JNC 7;
nor was it ever meant to be.
It’s “the facts” of what we have
learned from RCTs.
2014 JAMA HTN Guidelines
Clinical Questions
1. “In adults with hypertension, does initiating
antihypertensive pharmacologic therapy at specific BP
thresholds improve health outcomes?”
2. “In adults with hypertension, does treatment with
antihypertensive pharmacologic therapy to a specified BP
goal lead to improvements in health outcomes?”
3. “In adults with hypertension, do various antihypertensive
drugs or drug classes differ in comparative benefits and
harms on specific health outcomes?”
2014 JAMA Hypertension Guideline
Recommendations
Recommendation
1. General population > 60 y/o, initiate medications and treat to BP
goal of 150/90 mmHg.
Level of Evidence
A
2. General population < 60 y/o, initiate medications and treat to
DBP goal of 90 mmHg.
A/E
3. General population < 60 y/o, initiate medications and treat to
SBP goal of 140 mmHg.
E
4. In population > 18 y/o with CKD, initiate medications and treat to
BP goal of 140/90 mmHg.
E
5. In population > 18 y/o with DM, initiate medication and treat to
BP goal of 140/90 mmHg.
E
2014 JAMA Hypertension Guideline
Recommendations
Recommendation
Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
B
7. In general black population (including DM), initial anti-hypertensive
therapy should include thiazide diuretic or CCB.
C
8. In population with CKD, initial (or add-on) anti-hypertensive
therapy should include ACE-I or ARB.
B
9. Main objective of therapy is to attain and maintain a BP goal and
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
E
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: 6/17/2014
Copyright © 2014 American Medical
Association. All rights reserved.
A 67 year old male presents to your primary care clinic having recently moved
to town. He has no complaints. His PMHx includes high cholesterol (with an
unknown LDL) for which he takes Simvastatin 10mg. He had one prior
hospitalization for chest pain, but was told “nothing was wrong” with his
heart after a 1 night hospital stay. He has a 15 pck-yr history of tobacco use
and quit 17 years ago. He swims regularly and abides by a strict
Mediterranean diet.
On exam, his BP = 146/86 (repeated to verify) and other vital signs are
normal. His cardiovascular and eye exam are unremarkable.
Lab studies reveal a normal CBC, normal serum creatinine, and no
proteinuria. His EKG exhibits voltage criteria for LVH.
How would you manage his BP (assume his reading is verified by home
monitoring)?
A.
B.
C.
D.
E.
Encourage more exercise and a better diet
Order 24 hr ambulatory monitoring and decide therapy based on those
results
Begin therapy with a thiazide-type diuretic
Inform him that based on new guidelines, no anti-hypertension therapy
is needed
Let him decide if he wants to take medicines
Closer Look
Recommendation
Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP
goal of 150/90 mmHg.
What do we do with HTN in the elderly?
(Better yet, who is elderly?)
A
HTN in the Elderly
• Comparison:
– 2014 JAMA: > 60 y/o = < 150/90
– ESH/ESC: >80 y/o or elderly < 80 y/o = < 150/90
– CHEP: >80 y/o = < 150/90
– NICE: > 80 y/o = < 150/90
– ASH/ISH: > 80 y/o = < 150/90
Closer Look
Corollary Recommendation
1. General population > 60 y/o, if treatment results in BP < 140/90
mmHg and is well-tolerated, treatment does not need to be adjusted
Level of Evidence
E
**No convincing evidence that 140/90 is too low**
HTN in the Elderly
Advantages
• Decreased medication
burden
Disadvantages
• Individual consequences
• Evidence-”proven”
• Population consequences
2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment in the elderly
Clinical scenario
Recommendations
Elderly patients with SBP ≥160 mmHg
• Reduce SBP to 140-150 mmHg
Fit elderly patients aged <80 years with initial
SBP ≥140 mmHg
• Consider antihypertensive treatment
• Target SBP: <140 mmHg
Elderly >80 years with initial SBP ≥160 mmHg
• Reduce SBP to 140-150 mmHg
providing in good physical and mental condition
Frail elderly
• Hypertension treatment decision at discretion of
treating clinician, based on monitoring of
treatment clinical effects
Continuation of well- tolerated hypertension
treatment
• Consider when patients become octogenarians
All hypertension treatment agents are
recommended and may be used in elderly
• Diuretics, CCBs, preferred for isolated systolic
hypertension
SBP, systolic blood pressure; CCB, calcium channel blockers.
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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What would I do?
A.
B.
C.
D.
E.
Encourage more exercise and a better diet
Order 24 hr ambulatory monitoring and decide therapy based on those
results
Begin therapy with a thiazide-type diuretic
Inform him that based on new guidelines, no anti-hypertension therapy
is needed
Let him decide if he wants to take medicines
A 43 y/o woman with HTN returns for a follow up visit of her BP.
She is without complaints but admits that she has gained about
15 pounds over the last year due to stress, poor diet, and
inactivity. At her last visit 6 months ago, her BP was 132/78
mmHg on Lisinopril HCTZ 20/12.5mg.
On exam today, her BP is 138/88 (and verified on repeat). Her
exam is unchanged. Her serum creatinine is 1.3 mg/dL, and her
RUA reveals > 500 mg/dL of proteinuria.
What would be your next step in managing her blood pressure
and proteinuria?
A. Encourage improved lifestyle adherence and weight
reduction but make no medication changes
B. Increase her thiazide diuretic
C. Increase her ACE-inhibitor
D. Increase both her ACE-I and her TZD
Closer Look
Recommendation
4. In population > 18 y/o with CKD, initiate medications and treat to
BP goal of 140/90 mmHg.
Comparison:
– ESH/ESC: no proteinuria = < 140/90
with proteinuria = < 130/90
-- CHEP: < 140/90 for all
-- KDIGO: no proteinuria = < 140/90
with proteinuria = < 130/80
Level of Evidence
E
Why the confusion?
RCTs
• Modification of Diet in
Renal Disease (MDRD)
Meta-analyses
• Annals of Internal
Medicine (2011)
• African-American Study
of Kidney Disease and
Hypertension (AASK)
• Canadian Medical
Association Journal
(2013)
• Ramipril Efficacy in
Nephropathy (REIN-2)
VS.
What would I do?
A.
B.
C.
D.
Encourage improved lifestyle adherence and weight reduction but make
no medication changes
Increase her thiazide diuretic
Increase her ACE-inhibitor
Increase both her ACE-I and her TZD
Nothing beyond “expert opinion” to govern specific
medication titration.
A 43 y/o AAM w/ Type 2 DM and HTN, presents for follow up.
His is asymptomatic and adherent to his medication regimen:
Metformin 500mg BID, Lis/HCT 20/25mg daily, Amlodipine 5mg,
and ASA 81mg.
On exam, his BP = 138/88 mmHg. His cardiovascular exam is
normal. He has decreased pinprick sensation in his bilateral
great toes. Peripheral pulses are normal.
On lab review, his CBC, BMP, and RUA are normal. His A1c=8.3%.
In addition to adjusting his Type 2 DM medication regimen, what
additional changes would you make?
A.
B.
C.
D.
None
Increase Amlodipine to 10mg
Increase Lisinopril to 40mg
Add an additional BP agent, such as a beta-blocker
Closer Look
Recommendation
5. In population > 18 y/o with DM, initiate medication and treat to
BP goal of 140/90 mmHg.
Comparison:
–
–
–
–
ESH/ESC: < 140/85
ASH/ISH: < 140/90
CHEP: < 130/80
ADA: < 140/80
Level of Evidence
E
Why the confusion?
• Not enough patients
• Not enough uniformity in evidence
• Therefore, did not make recommendation
different than “usual” BP control
What would I do?
A.
B.
C.
D.
None
Increase Amlodipine to 10mg
Increase Lisinopril to 40mg
Add an additional BP agent, such as a beta-blocker
Nothing beyond “expert opinion” to govern specific
medication titration.
The “other” recommendations…
Closer Look
Recommendation
Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
B
7. In general black population (including DM), initial anti-hypertensive
therapy should include thiazide diuretic or CCB.
C
8. In population with CKD, initial (or add-on) anti-hypertensive
therapy should include ACE-I or ARB.
B
Too many comparisons to list
What’s the controversy?
• “Demotion” of beta-blockers
– Admittedly doesn’t include newer agents
• “Demotion” of ACE-I and ARBs in AfricanAmericans
– Unless CKD
• Absence of a specific recommendation for ACE-I
and ARBs in Diabetics
– In absence of albuminuria
2014 JAMA Hypertension Guideline
Recommendations
Recommendation
1. General population > 60 y/o, initiate medications and treat to BP
goal of 150/90 mmHg.
Level of Evidence
A
2. General population < 60 y/o, initiate medications and treat to
DBP goal of 90 mmHg.
A/E
3. General population < 60 y/o, initiate medications and treat to
SBP goal of 140 mmHg.
E
4. In population > 18 y/o with CKD, initiate medications and treat to
BP goal of 140/90 mmHg.
E
5. In population > 18 y/o with DM, initiate medication and treat to
BP goal of 140/90 mmHg.
E
2014 JAMA Hypertension Guideline
Recommendations
Recommendation
Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
B
7. In general black population (including DM), initial anti-hypertensive
therapy should include thiazide diuretic or CCB.
C
8. In population with CKD, initial (or add-on) anti-hypertensive
therapy should include ACE-I or ARB.
B
9. Main objective of therapy is to attain and maintain a BP goal and
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
E
Concluding Remarks
• Five of 10
recommendations are
“E”
• No recommendation to
decrease medicines in
well-controlled elderly
• Only deals with one risk
factor—BP
• More recommendations
to come
– AHA/ACC Guidelines
– SPRINT
Their own conclusions
• “The relationship between naturally occurring BP
and risk is linear down to very low BP, but the
benefit of treating to these lower levels with
antihypertensive drugs is not established.”
• “These lifestyle treatments have the potential to
improve BP control and even reduce medication
needs…we support the recommendations of the
2013 Lifestyle Work Group.”
Their own conclusions
• “The recommendations from this evidence-based
guideline from panel members appointed to the
Eighth Joint National Committee (JNC 8) offer
clinicians an analysis of what is known and not
known about BP treatment thresholds, goals, and
drug treatment strategies to achieve those goals
based on evidence from RCTs. However, these
recommendations are not a substitute for clinical
judgment, and decisions about care must
carefully consider and incorporate the clinical
characteristics and circumstances of each
individual patient.”