Clinical Update on the JNC 7/8 Hypertension Guidelines CDR Dean T. Goroski, PharmD, BCPS Advanced Practice Clinical Pharmacist Congestive Heart Failure Clinic Manager Yakama Indian Health Clinic USPHS COA Symposium June 21, 2011

Disclosures I have hypertension I work with people who have hypertension

Overview Discuss potential changes to the JNC hypertension guidelines and the rationale behind these changes. Describe strategies to help implement antihypertensive regimens with greatest chances of success in meeting patient specific BP goals Identify opportunities for pharmacists to proactively collaborate with providers and patients to develop antihypertensive strategies best suited for individual patients

Why do we treat hypertension? Objective measurement we can modify….but Reduce cardiovascular risk Reduce all cause morbidity and mortality Reduce the incidence and progression of left ventricular hypertrophy Prevention of atherosclerosis, retinopathy, renal failure, etc.

Cardiovascular Mortality Risk Increases as Blood Pressure Rises* 8x 8 7 6 5 4x Cardiovascular Mortality Risk 4 3 2x 2 1 Cardiovascular Mortality Risk Increases as Blood Pressure Rises Lewington et al. (2002) evaluated data from approximately 1 million adults who participated in 61 prospective observational studies on blood pressure and mortality. In adults between the ages of 40 and 69 years, each 20/10-mm Hg increase in blood pressure doubled the risk of mortality from stroke, ischemic heart disease, and other vascular causes. This finding was the same for men and women. It is included as a key message in the 2003 JNC-7 report on high blood pressure. References: Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, for the Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913. Chobanian AV, Bakris GL, Black HR, et al, for the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. 115/75 135/85 155/95 175/105 Systolic/Diastolic Blood Pressure (mm Hg) *Measurements taken in individuals aged 40–69 years, beginning with a blood pressure of 115/75 mm Hg. Lewington S, et al. Lancet. 2002;360:1903-1913; Chobanian AV, et al. JAMA. 2003;289:2560-2572. 5

Complications of Hypertension: End-Organ Damage Hemorrhage, Stroke LVH, CHD, CHF Complications of Hypertension: End-Organ Damage Hypertension is an important contributing risk factor for end-organ damage and for the development of cardiovascular and other diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, cardiac disease, renal failure, and proteinuria. Blood pressure reduction has been shown to decrease the rate of stroke, myocardial infarction, end-stage renal disease, and proteinuria. Reference: Chobanian AV, Bakris GL, Black HR, et al, for the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. Peripheral Vascular Disease Renal Failure, Proteinuria Retinopathy CHD = coronary heart disease CHF = congestive heart failure LVH = left ventricular hypertrophy Chobanian AV, et al. JAMA. 2003;289:2560-2572. 6

Overview Discuss potential changes to the JNC hypertension guidelines and the rationale behind these changes Describe strategies to help implement antihypertensive regimens with greatest chances of success in meeting patient specific BP goals Identify opportunities for pharmacists to proactively collaborate with providers and patients to develop antihypertensive strategies best suited for individual patients

JNC Hypertension Guidelines Developed by NHLBI since 1976 Guidelines, not requirements Originally updated every 4 years

JNC Guidelines JNC 1 1976 JNC 2 1980 4 JNC 3 1984 JNC 4 1988 JNC 5 1992 JNC 6 1997 5 JNC 7 2003 6 JNC 8 2012 9+ JNC 9 2021-2025 ??? 9-13 ???

Dependence on Guidelines? Review primary literature, studies, other professional guidelines Develop your own patient population specific guidelines Use professional training to decipher the trials and implement changes proactively Evaluate other guideline and recommendations

HTN Trials since JNC7 ACCORD HYVET ONTARGET LIFE ASCOT-BPLA ANBP-2 ACCOMPLISH ALLHAT(reviewed)

ACCORD We have upper limit BP recommendations, what about the lower end? Results—trial did not support aggressive BP lowering therapy <120/80 Does this change the <130/80 recommendation in DM and CKD?

HYVET Addresses questions of beneficence of antihypertensive therapy in the very elderly (80+) aka risk vs. benefit Significantly decreased death from stroke and all cause death Treat HTN in very elderly to goal <150/80

ONTARGET ACEI vs. ARB vs. Combination therapy ARBs no better than ACEIs for reducing fatal and nonfatal cardiovascular events Combination therapy no better than ACEI, significantly increased risk of renal dysfunction DO NOT use ACEI and ARB together VALIANT trial also supports this conclusion in post-MI and heart failure

LIFE Losartan vs. atenolol for endpoint reduction, HCTZ as add on therapy Combination therapy needed Again---ARBs (and ACEIs) significantly reduce incidence of new onset DM Losartan significantly reduced CV outcomes vs. atenolol ?? White vs. black populations ??

Other HTN Guidelines Canadian Hypertension Guidelines CHEP—annually updated since 2000 European Society of Hypertension/ESC Japanese Society for Hypertension World Health Organization International Society of Hypertension

NOW—on Thiazides….. ACCOMPLISH ALLHAT ANBP-2 ASCOT

ACCOMPLISH 11290 patients with HTN and high risk CV Benazepril 20mg/amlodipine 5mg or benazepril 20mg/HCTZ 12.5mg Benazepril force titrated to 40mg Amlodipine or HCTZ titrated per provider Goal <140/90(<130/80 recommended for diabetes or renal insufficiency) Primary outcomes—death from CV, non-fatal MI, non-fatal stroke, hosp for angina, resuscitation after SCD, and coronary revascularization

ACCOMPLISH-take home points ACEI-CCB vs ACEI-HCTZ—19.6 RRR (HR 0.80, P<0.001) for CV morbidity/mortality BP goal <140/90 at 3 yr follow up—ACEI-CCB 81.7% vs ACEI-HCTZ 78.5% HCTZ not chlorthalidone Mean dose of HCTZ 19.3mg daily High percentage of high risk pts Combination therapy successful to meet goals

ALLHAT 42418 patients 55yrs and older with HTN and 1 other risk factor for CHD Randomized and titrated on chlorthalizone, amlodipine, lisinopril or doxazosin (Step 1) Adding open label atenolol, clonidine, or reserpine (Step 2) Adding hydralazine (Step 3) Assessed metabolic syndrome and race

ALLHAT-take home points Doxazosin stopped early for high CV risk Amlodipine vs chlorthalidone HF RR 1.38 (p<0.001) Lisinopril vs chlorthalidone Significantly increased risk for stroke, combined CVD, and HF in lisinopril group

ALLHAT-take home points Largely basis for JNC 7 Used chlorthalidone, not HCTZ Step 2 and 3 meds not optimal Critics of ALLHAT reject JNC 7 Salt vs plasma renin activity Hypothesis generating in secondary outcomes Considered first step therapy, but no washout, no initial BP to judge response

ANBP-2 Enalapril vs. HCTZ in 6083 patients aged 65-84 11% reduction in CV events in enalapril Results contradict ALLHAT HCTZ used versus chlorthalidone in ALLHAT Limitations Population 95% white, ALLHAT 35% black Changes in defined outcomes Relative benefit limited to men?

ASCOT-BPLA 19257 patients aged 40-79 with 3+ CV risks Amlodipine +/- perindopril vs. atenolol +/- bendroflumethiazide and potassium Terminated early despite primary endpoints failing to reach significance Secondary and tertiary endpoints did have significance Not directly comparing two drugs……

Thiazide summary Choice of medication Dose of medication First line? Compelling indications? Excellent in combinations Watch hypokalemia

Overview Discuss potential changes to the JNC hypertension guidelines and the rationale behind these changes. Describe strategies to help implement antihypertensive regimens with greatest chances of success in meeting patient specific BP goals Identify opportunities for pharmacists to proactively collaborate with providers and patients to develop antihypertensive strategies best suited for individual patients

Strategies for success Review local statistics on HTN treatment Formulary maintenance and critical review Develop adherence strategies Assess and address lifestyle modifications Self monitored blood pressures

Review local statistics Run reports to review: Current prescribing patterns Percentage of clinic patients at goal Percentage of provider patients at goal Regular review and report to reinforce Review morbidity and mortality reports Develop performance measures/incentives

Review local formulary Keep formulary choices up to date with current literature/studies/guidelines Supply well validated medication choices Remove less favorable drugs when possible Incorporate formulary into local guidelines Recognize total benefit of medications, not just medication costs

Develop adherence strategies Well defined follow up Appts, phone calls, nutrition consults, labs Healthcare team approach Provider, nurse, pharmacist Lifestyle changes Physiologic, psychologic, pharmacologic in addition to nutritional Patient involvement in all aspects

Address compliance issues Medication issues Lifestyle issues Social nutritional habits Medication/provider access issues Continuity of care Implement changes to help with compliance Customer service

Overview Discuss potential changes to the JNC hypertension guidelines and the rationale behind these changes. Describe strategies to help implement antihypertensive regimens with greatest chances of success in meeting patient specific BP goals Identify opportunities for pharmacists to proactively collaborate with providers and patients to develop antihypertensive strategies best suited for individual patients

Opportunities to collaborate Know your guidelines and local populations Offer clinical services and input regularly Offer clinical inservices on hypertension BP checks—pharmacy or nursing Laboratory monitoring Pharmaceutical knowledge on side effects, beneficial effects Develop clinical resources for providers

Opportunities to collaborate Clinical consultation services Ask patients about follow up labs/BP checks Impromptu clinical consultation with patient A fib and BP assessment at coag visits Medication synchronization visits Have nutrition and lifestyle handouts at the pharmacy Know some clinical pearls on HTN meds

Overview Discuss potential changes to the JNC hypertension guidelines and the rationale behind these changes. Describe strategies to help implement antihypertensive regimens with greatest chances of success in meeting patient specific BP goals Identify opportunities for pharmacists to proactively collaborate with providers and patients to develop antihypertensive strategies best suited for individual patients

Questions??

Contact information Dean.goroski@ihs.gov 509-865-2102 x201