Hypertension Guidelines 2014 Jason A. Smith, DO Associated Cardiovascular Consultants at Lourdes...

Hypertension Guidelines 2014Jason A. Smith, DO

Associated Cardiovascular Consultants at

Lourdes Cardiology Services

Disclosures

No disclosures

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Hypertension

• Hypertension is the most common condition in primary care.

• 1 in 3 patients have hypertension according to NHLBI

• Risk factor for MI, CVA, ARF, death

Hypertension

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 micro-albumin is mildly elevated.

Case Question 1

• What goal BP is most appropriate for this patient?1. <150/90 mmHg

2. <130/80 mmHg

3. <140/90 mmHg

4. <140/80 mmHg

5. <140/85 mmHg

Case Question 2

• What is the drug of choice to start?1. HCTZ

2. Norvasc

3. Lisinopril

4. Losartan

5. Bystolic

6. Combination therapy

Classification of BP – JNC 7

CategorySystolic (mmHg)

Diastolic (mmHg)

Normal < 120 and < 80

Pre-HTN 120-139 or 80-89

Hypertension

Stage I 140-159 or 90-99

Stage II > 160 or > 100

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2013 ESH/ESC Guidelines for the management of arterial hypertension

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

Definitions and classification of office BP levels (mmHg)*

Category Systolic Diastolic

Optimal <120 and <80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension ≥180 and/or ≥110

Isolated systolic hypertension ≥140 and <90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

Hypertension:SBP >140 mmHg ± DBP >90 mmHg

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 ManagementQuestions Guiding Review

• In adults with HTN:1. Does initiating antihypertensive

pharmacologic therapy at specific BP thresholds improve health outcomes?

2. Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes?

3. Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

JNC 8: Hypertension ManagementEvidence 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 ManagementEvidence Review

• RCT’s December 2009 – August 20131. Major study in hypertension

• ACCORD, NEJM 2010

2. > 2,000 participants

3. Multicentered

4. Met all other inclusion/exclusion criteria

JNC 8: Graded Recommendations

A – Strong evidence

B – Moderate evidence

C – Weak evidence

D – Against

E – Expert Opinion

N – No recommendation

JNC 8: Drug TreatmentThresholds 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


• 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 18-39


• 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

JNC 8: Initial Drug Choice

• Nonblack, including DM– Thiazide diuretic, CCB, ACEI, ARB

• LOE: Grade B

• Black, including DM– Thiazide diuretic, CCB

• LOE: Grade B (Grade C for diabetics)

JNC 8: Initial Drug Choice

• Age > 18 yo with CKD and HTN (regardless of race or diabetes)– Initial (or add-on) therapy should include

an ACEI or ARB to improve kidney outcomes

• LOE: Grade B

– Blacks w/ or w/o proteinuria• ACEI or ARB as initial therapy (LOE: Grade E)

– No evidence for RAS-blockers > 75 yo• Diuretic is an option for initial therapy

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– LOE: Grade E

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




Blood pressure goals in hypertensive patients

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

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 elderlyAged <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

BP goal in the elderly




Recommendations Additonal considerations

Mandatory: initiate drug treatment in patients with SBP ≥160 mmHg

• Strongly recommended: start drug treatment when SBP ≥140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg

All hypertension treatment agents are recommended and may be used in patients with diabetes

• RAS blockers may be preferred• Especially in presence of preoteinuria or

microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not recommended

• Avoid in patients with diabetes

Hypertension treatment for people with diabetes

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.




Recommendations Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria • Monitor changes in eGFR

RAS blockers more effective to reduce albuminuria than other agents

• Indicated in presence of microalbuminuria or overt proteinuria

Combination therapy usually required to reach BP goals

• Combine RAS blockers with other agents

Combination of two RAS blockers • Not recommended

Aldosterone antagonist not recommended in CKD

• Especially in combination with a RAS blocker• Risk of excessive reduction in renal function,

hyperkalemia

Hypertension treatment for people with nephropathy

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

What is the goal BP?

Comparison of RecentGuideline Statements

JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90

Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr

for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr140-150 if <80 yr

B-blocker No Yes No NoFirst line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100w/ 2 drugs elevated BP"

Goal BP

Group BP Goal (mm Hg)General DM* CKD**

JNC 8: <60 yr: <140/90 < 140/90 < 140/90>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)

ASH/ISH < 140/90 < 140/90 < 140/90

>80 yr: <150/90 (Consider < 130/80 if proteinuria)

AHA/ACC < 140/90 < 140/90 < 140/90

*ADA: < 140/80 or lower**KDIGO: <140/90 w/o albuminuria

<130/80 if >30 mg/24hr




Lifestyle changes for hypertensive patients

* Unless contraindicated. BMI, body mass index.

Recommendations to reduce BP and/or CV risk factors

Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week(moderate, dynamic exercise)

Quit smoking

Thank you for your attention!

[email protected]

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