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

Disclosures No disclosures

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? <150/90 mmHg <130/80 mmHg <140/90 mmHg <140/80 mmHg <140/85 mmHg

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

Classification of BP – JNC 7 Category Systolic (mmHg) Diastolic (mmHg) Normal < 120 and < 80 Pre-HTN 120-139 or 80-89 Hypertension Stage I 140-159 90-99 Stage II > 160 > 100

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.

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 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?

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

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

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

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

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

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

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 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 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.

BP goal in the elderly

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.

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.

What is the goal BP?

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 140-150 if <80 yr B-blocker No Yes First line Rx Initiate Therapy >160/100 "Markedly w/ 2 drugs elevated BP"

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 140-150/90 (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

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 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 * Unless contraindicated. BMI, body mass index.

Thank you for your attention! smithj@lourdesnet.org