© Continuing Medical Implementation …...bridging the care gap Hypertension Evidence and CHS Guidelines 2005

© Continuing Medical Implementation …...bridging the care gap Evidence Evolution Hard end-points –Mortality –CVD events –Cerebrovascular events –PVD events –CHF –Progression to ESRD Surrogate end-points –Rising CR –Progression to proteinuria –Progression/regression of micro-albuminuria

© Continuing Medical Implementation …...bridging the care gap

Evidence Evolution MRC-1985 HAPPHY-1987 EWPHE-1991 STOP-1991 SHEP STONE-1996 SYS-EUR-1997SYS-EUR SYS-CHINA SYS-CHINA HOT-1998HOT UKPDS -1998UKPDS CAPPP-1999CAPPP STOP STOP 2 HOPE -2000HOPE MICRO-HOPE -2000MICRO-HOPE INSIGHT -2000INSIGHT NORDIL -2000NORDIL CALM -2000CALM INDT -2001INDT IRMA -2001IRMA RENAAL -2001RENAAL PROGRESS -2001PROGRESS LIFE-2002LIFE SCOPE 2002SCOPE ALLHAT 2002ALLHAT

© Continuing Medical Implementation …...bridging the care gap CHS Guideline Evolution 2002 Impact of the ALLHAT ALLHAT Consideration of –PROGRESS PROGRESS –IDNT IDNT –RENAAL RENAAL –ANBP ANBP2

© Continuing Medical Implementation …...bridging the care gap

Guideline Evolution 2004 Hypertension ALLHAT ALLHAT LIFE LIFE ANBP ANBP2 OPTIMAAL OPTIMAAL EPHESUS EPHESUS CHARM CHARM Psaty-Network meta-analysis Law Meta-analysis Staessen Meta-regression analysisStaessen Meta-regression analysis Post stroke PROGRESS PROGRESS ASA and Statins HOT HOT ASCOT-LLA ASCOT-LLA PROSPER PROSPER HPS HPS ALLHAT-LLT ALLHAT-LLT

© Continuing Medical Implementation …...bridging the care gap CHS January 2004 Indications for drug therapy in adults with hypertension without compelling indications for specific agents: 1.Strongly consider antihypertensive therapy if DBP 90 with TOD or CV risk factors –Elevated SBP, smoking, dyslipidemia, strong FH CAD, truncal obesity, sedentary lifestyle 2. Rx antihypertensive therapy for DBP 100 or SBP 160 without TOD or CV risk factors 3.Rx statin therapy in HTN patients > 40 yr of age with 3 or more CV risk factors or established atherosclerotic disease 4.Strongly consider low dose ASA in HTN patients > 50 yr of age. (Caution if BP not controlled)

© Continuing Medical Implementation …...bridging the care gap Cardiovascular risk factors for consideration of statin therapy in non-hyperlipidemic patients with hypertension (derived from ASCOT-LLA)ASCOT-LLA Cardiovascular risk factors for consideration of statin therapy in non-hyperlipidemic patients with hypertension (derived from ASCOT-LLA)ASCOT-LLA Male Age 55 years or older Left ventricular hypertrophy Other electrocardiogram abnormalities: –left bundle branch block, left ventricular strain pattern, abnormal Q waves –or ST-T changes compatible with ischemic heart disease Peripheral arterial disease Previous stroke or transient ischemic attack Microalbuminuria or proteinuria Diabetes mellitus Smoking Family history of premature cardiovascular disease TC/HDL 6

© Continuing Medical Implementation …...bridging the care gap CHS January 2004 Recommendations for individuals with diastolic hypertension with or without systolic hypertension. Initial therapy: Grade A: –thiazide diuretics Grade B: – -blockers (in those younger than 60 years) –ACE inhibitors (in non-Blacks) –long-acting dihydropyridine CCBs –angiotensin receptor antagonists (ARBs) If adverse effects substitute another drug from this group Avoid hypokalemia: Use K sparing diuretic with thiazides Use combination therapy if partial response Add other classes if poor control – - blocker, centrally acting agents or non-DHP CCB - blocker not recommended as first line agents

© Continuing Medical Implementation …...bridging the care gap CHS January 2004 Recommendations for individuals with Isolated Systolic Hypertension Initial therapy: Grade A: –thiazide diuretics –long-acting dihydropyridine CCBs Grade B: –angiotensin receptor antagonists (ARBs) If adverse effects substitute another drug from this group Avoid hypokalemia: Use K sparing diuretic with thiazides Use combination therapy if partial response Add other classes if poor control or adverse effects – - blocker, ACE inhibitors, centrally acting agents or non-DHP CCB -blockers and -blockers are not recommended as first line agents

CHS January 2004 Considerations for individualization of anti-hypertensive therapy IndicationInitial TherapySecond line RxNotes/Cautions DM with nephropathyACE-i or ARB addition thiazide, * - blockers, LA-CCB, ACE/ARB combo *Cardioselective -blockers If CR >150 mmol/l use loop diuretic for volume control DM without nephropathy ACE-i or ARB or thiazide Combo1st line Rx or * - blockers, LA-CCB Angina -blockers + strongly consider ACE-i LA-CCBAvoid short acting nifedipine Prior MI -blockers + ACE-i Combine additional Rx CHF -blockers + ACE-i + spironolactone (ARB if ACE-i intolerant ) Hydralazine /ISDN: thiazide or loop diuretics as additive therapy Avoid non DHP-CCB (diltiazem, verapamil) Prior CVA or TIAACE-i/diuretic combination BP reduction recurrent events Renal DiseaseACE-i/diuretic as additive Rx ARB if ACE-i intolerant Combo other agents Avoid ACE-i if bilateral Renal artery stenosis LVHACE-I, ARBs, DHP- CCB, thiazide, - blockers < 55 yr Avoid hydralazine and minoxidil

© Continuing Medical Implementation …...bridging the care gap Guideline Evolution 2005 SHEAF Study Ohasama Cohort OvA Study Staessen et alStaessen et al Thijs et alThijs et al VALUE ACTION INVEST VALIANT BP Lowering Treatment Trialists Collaboration

© Continuing Medical Implementation …...bridging the care gap Guideline Evolution 2005 Key Messages –Expedited diagnosis of hypertension (HTN) –Use any validated technology to diagnose HTN Office BP Ambulatory BP Self/Home BP –Focus on BP control rather than preferred first line agent

© Continuing Medical Implementation …...bridging the care gap Guideline Evolution 2005 Integrate global CVD management into HTN management plan Lifestyle modifications are key Combination therapies (lifestyle and Rx) to achieve target Focus on adherence

16 Choice of Pharmacological Treatment Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? Individualized Treatment (with compelling indications) YES Treatment in the absence of compelling indication NO

17 Choice of pharmacological treatment for hypertensive patients without other compelling indications: Treatment of Systolic Diastolic hypertension Treatment of Isolated Systolic hypertension

18 Treatment of Adults with Systolic-Diastolic Hypertension without Other Compelling Indications INITIAL TREATMENT AND MONOTHERAPY * Not indicated as first line therapy over 60 Beta- blocker* Long- acting CCB Thiazide ACE-I ARB Lifestyle modification therapy TARGET <140 mm Hg systolic and < 90 mmHg diastolic

19 Combination Therapy for Systolic-Diastolic Hypertension without Other Compelling Indications CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Resistant Hypertension? If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). 2. Triple or Quadruple Therapy 1. Dual Combination Therapy If partial response to monotherapy

20 Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications * Not indicated as first line therapy over 60 CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Dual Combination Triple or Quadruple Therapy Lifestyle modification therapy Thiazide diuretic ACE-I Long-acting CCB Beta- blocker* ARB TARGET <140 mm Hg systolic and < 90 mmHg diastolic

21 Choice of pharmacological treatment for hypertensive patients with other compelling indications Treatment of diastolic-systolic hypertension Treatment of isolated systolic hypertension

22 Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications INITIAL TREATMENT AND MONOTHERAPY Thiazide diuretic Long-acting DHP CCB Lifestyle modification therapy ARB TARGET <140 mmHg Systolic BP

23 Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Thiazide diuretic Long-acting DHP CCB Dual combination Triple or Quadruple* combination Lifestyle modification therapy ARB TARGET <140 mmHg Systolic BP * If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

© Continuing Medical Implementation …...bridging the care gap Anti-Hypertensive Therapeutic Classification ACE inhibitor ARB (K sparing) DIURETIC (Thiazide) -blocker* Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker

© Continuing Medical Implementation …...bridging the care gap First Line Therapy ACE inhibitor ARB (K sparing) DIURETIC (Thiazide) -blocker* Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker

© Continuing Medical Implementation …...bridging the care gap Systolic/Diastolic HTN ACE inhibitor ARB -blocker* (K sparing) DIURETIC (Thiazide) Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker

© Continuing Medical Implementation …...bridging the care gap Post-CVA or TIA ACE inhibitor ARB -blocker* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB* (K sparing) DIURETIC (Thiazide)

© Continuing Medical Implementation …...bridging the care gap Isolated Systolic HTN-Elderly ACE inhibitor ARB -blocker Long Acting DHP-CCB (K sparing) DIURETIC (Thiazide)

© Continuing Medical Implementation …...bridging the care gap Isolated Systolic HTN-Elderly ACE inhibitor/ ARB -blocker Long Acting DHP-CCB (K sparing) DIURETIC (Thiazide)

© Continuing Medical Implementation …...bridging the care gap CAD - Chronic Angina ACE inhibitor ARB -blocker* Consider adding ACE-I for all patients with documented CAD (Grade A) based on HOPE and EUROPA HOPEEUROPA Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker (K sparing) DIURETIC (Thiazide)

© Continuing Medical Implementation …...bridging the care gap CAD-Recent MI or LV Dysfunction ACE inhibitor -blocker* Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker (K sparing) DIURETIC (Thiazide)

© Continuing Medical Implementation …...bridging the care gap CHF + HTN ACE inhibitor ARB if ACE intolerant DIURETIC (loop/spironolactone) -blocker Long Acting DHP-CCB

© Continuing Medical Implementation …...bridging the care gap DM without Nephropathy BP Target < 130/80 ACE inhibitor or ARB -blocker* ( K sparing) DIURETIC or (Thiazide) Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker

© Continuing Medical Implementation …...bridging the care gap DM with Nephropathy First line therapy: ACE inhibitor or ARB -blocker* ( K sparing) DIURETIC (Thiazide) Long Acting CCB* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker

© Continuing Medical Implementation …...bridging the care gap DM with Nephropathy Second line therapy: ACE inhibitor or ARB -blocker* ( K sparing) DIURETIC (Thiazide) *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB*

© Continuing Medical Implementation …...bridging the care gap DM with Nephropathy Second line therapy: ACE inhibitor or ARB Cardioselective -blocker* ( K sparing) DIURETIC (Thiazide) *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB*

© Continuing Medical Implementation …...bridging the care gap ( K sparing) DIURETIC (Thiazide) DM with Nephropathy Second line therapy: ACE inhibitor or ARB -blocker* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB*

© Continuing Medical Implementation …...bridging the care gap ( K sparing) DIURETIC (Thiazide) DM with Nephropathy Second line therapy: ACE inhibitor and ARB -blocker* *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB*

© Continuing Medical Implementation …...bridging the care gap Non-diabetic Nephropathy BP Target < 125/75 ACE inhibitor ARB if ACE intolerant -blocker* DIURETIC (Thiazide or loop) As additive therapy *Caution combining non-DHP-CCB (especially verapamil) with a -blocker Long Acting CCB*

© Continuing Medical Implementation …...bridging the care gap See for Complete Recommendationswww.hypertension.ca See for Complete Recommendationswww.hypertension.ca

© Continuing Medical Implementation …...bridging the care gap Global Vascular Protection for Patients with Hypertension Diet (DASH) Weight loss (waist < 102 cm M and 88 cm F) Exercise- 30 to 60 min 4-7 days/week Smoking Cessation Moderate Alcohol intake Low dose ASA if BP controlled Statin ACE inhibitors for established vascular disease ACE inhibitors or ARBs for diabetics or patients with kidney disease

42 Important Messages for the Management of Hypertension Expedite the diagnosis of hypertension Assess the risk Treat to target Lifestyle Combination therapy Promote adherence

43 Summary Hypertension is a major factor responsible for progression of atherosclerotic disease. Therefore, a comprehensive treatment of hypertension should aim at CV risk reduction strategies, including management of all associated risk factors.