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

2. Disclosures
No disclosures

3. 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

4. Hypertension

5. 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.

6. Case Question 1 What goal BP is most appropriate for this patient?
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg

7. Case Question 2 What is the drug of choice to start? HCTZ Norvasc
Lisinopril
Losartan
Bystolic
Combination therapy

8. Classification of BP – JNC 7
Category
Systolic (mmHg)
Diastolic (mmHg)
Normal
< 120
and
< 80
Pre-HTN or
80-89
Hypertension
Stage I
90-99
Stage II
> 160
> 100

9. SBP >140 mmHg ± DBP >90 mmHg
Definitions and classification of office BP levels (mmHg)*
Hypertension:
SBP >140 mmHg ± DBP >90 mmHg
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120–129
and/or
80–84
High normal
130–139
85–89
Grade 1 hypertension
140–159
90–99
Grade 2 hypertension
160–179
100–109
Grade 3 hypertension
≥180
≥110
Isolated systolic hypertension
≥140
<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.

10. JNC 8
2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults
JAMA. 2014;311(5):
December 18, 2013

11. JNC 8: Hypertension Management Questions Guiding Review
In adults with HTN:
Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes?
Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

12. JNC 8: Hypertension Management Evidence 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

13. JNC 8: Hypertension Management Evidence Review
RCT’s December 2009 – August 2013
Major study in hypertension
ACCORD, NEJM 2010
> 2,000 participants
Multicentered
Met all other inclusion/exclusion criteria

14. JNC 8: Graded Recommendations
A – Strong evidence B – Moderate evidence C – Weak evidence D – Against E – Expert Opinion N – No recommendation

15. JNC 8: Drug Treatment Thresholds and Goals
Age > 60 yo
Systolic:
Threshold > 150 mmHg
Goal < 150 mmHg
LOE: Grade A
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg

16. JNC 8: Drug Treatment Thresholds and Goals
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

17. JNC 8: Drug Treatment Thresholds and Goals
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

18. 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)

19. 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

20. 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

21. 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

22. Recent HTN Guideline Statements
2013 ESH/ESC Guidelines for the management of arterial hypertension.
J Hypertnsion 2013;31:
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

23. Blood pressure goals in hypertensive patients
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
mmHg
SBP goal for fit elderly
Aged <80 years
SBP goal for elderly >80 years with SBP
≥160 mmHg
DBP goal for “most”
<90 mmHg
DB goal for patients with diabetes
<85 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure.

24. BP goal in the elderly

25. Hypertension treatment for people with diabetes
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
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

26. Additonal considerations Consider lowering SBP to <140 mmHg
Hypertension treatment for people with nephropathy
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
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

27. What is the goal BP?

29. Comparison of Recent Guideline 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
>150/90 >80 yr
if <80 yr
B-blocker No
Yes
First line Rx
Initiate Therapy
>160/100
"Markedly
w/ 2 drugs
elevated BP"

30. Goal BP Group BP Goal (mm Hg) General DM* CKD** JNC 8:
<60 yr: <140/90
< 140/90
>60 yr: <150/90
ESH/ESC:
< 140/85
Elderly
/90
(SBP < 130 if proteinuria)
(<80 yr: SBP<140)
ASH/ISH
>80 yr: <150/90
(Consider < 130/80 if proteinuria)
AHA/ACC
**KDIGO: <140/90 w/o albuminuria
<130/80 if >30 mg/24hr
*ADA: < 140/80 or lower

31. Recommendations to reduce BP and/or CV risk factors
Lifestyle changes for hypertensive patients
Recommendations to reduce BP and/or CV risk factors
Salt intake
Restrict 5-6 g/day
Moderate alcohol intake
Limit to g/day men, 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
* Unless contraindicated. BMI, body mass index.

33. Thank you for your attention!