Hypertension guidelines What’s all the controversy about 2015 Kevin M Hayes D.O. FACC

Disclosures Nothing to disclose

Hypertension guidelines Thanks for clearing that up for me – NOT Really

Objectives Brief review of pathophysiology Scope of the problem JNC – 8 ACC / AHA “End of the day”

HTN leads to an increased risk of death from stroke and heart disease 8x Cardiovascular Mortality Risk 4x 2x Hypertension is a serious health issue Hypertension significantly increases ones risk of CV mortality For every 20mm Hg, one doubles their CV mortality risk CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2 Systolic BP / Diastolic BP (mmHg) Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913

Prevalence of risk factors – Western population ( Framingham) Hypertension – 20 % > 65 y.o. 65 % Smoking 31% Overweight 54% Hyperlipidemia 55%

Problem Magnitude Hypertension( HTN) is the most common primary diagnosis in America. 35 million office visits are as the primary diagnosis of HTN. 50 million or more Americans have high BP. Worldwide prevalence estimates for HTN may be as much as 1 billion. 7.1 million deaths per year may be attributable to hypertension.

Figure 10. Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade. Figure 10. Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade. Source: Reprinted with permission from Elsevier (The Lancet, 2002;360:1903–1913). Aram V. Chobanian et al. Hypertension. 2003;42:1206-1252 Copyright © American Heart Association, Inc. All rights reserved.

Types of Hypertension Secondary HTN: less common cause of HTN ( 5%). Primary HTN: also known as essential HTN. accounts for 95% cases of HTN. no universally established cause known. Secondary HTN: less common cause of HTN ( 5%). secondary to other potentially rectifiable causes.

Identifiable Causes of HTN Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Figure 16. Algorithm for treatment of hypertension. Aram V. Chobanian et al. Hypertension. 2003;42:1206-1252 Copyright © American Heart Association, Inc. All rights reserved.

JNC – 8 Expert writing group

In patients 60 years or over, start treatment in blood pressures >150 mm Hg systolic or >90 mm Hg diastolic and treat to under those thresholds. In patients <60 years, treatment initiation and goals should be 140/90 mm Hg, the same threshold used in patients >18 years with either chronic kidney disease (CKD) or diabetes. In nonblack patients with hypertension, initial treatment can be a thiazide-type diuretic, CCB, ACE inhibitor, or ARB, while in the general black population, initial therapy should be a thiazide-type diuretic or CCB. In patients >18 years with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

JNC 8 is mostly in line with the European Society of Hypertension (ESH) guidelines released earlier this year, which suggested a target of <140 mm Hg systolic BP for "all" patients, with some caveats In patients with diabetes, the ESH guidelines suggest a diastolic BP of <85 mm Hg, and for patients under 80 years, they suggest a target of between 140 and 150, going lower only if the patient is fit and in good health

Copyright © 2015 American Medical Association. All rights reserved. JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427 Date of download: 4/23/2015 Copyright © 2015 American Medical Association. All rights reserved.

Treatment of Hypertension in Patients With Coronary Artery Disease A Scientific Statement From the American Heart Association, American College of Cardiology, and American Society of Hypertension Circulation – May 2015

We felt the best evidence [to prevent future cardiovascular events] was to reduce pressure below 140/90 mm Hg, but a goal pressure of less than 130/80 mm Hg may be appropriate in some cases; we left it to the discretion of physicians to decide which blood pressure target to choose,”

CAD PATIENTS - >80 Y.O. – LESS THAN 150/90 ACC/AHA 2015 CAD PATIENTS - >80 Y.O. – LESS THAN 150/90

Hypertension guidelines Now I’m really confused

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