1. Treatment Guidelines HTN
Wendy Langen
2016

2. JNC 7 to 8 in 2014
Joint National Committee is a panel of physicians and scientists from various disciplines like diabetes, hypertension, cardiology, nephrology, geriatrics, nursing, pharmacology, etc.
Published in JAMA

3. Not everyone agrees There is some criticism of the JNC 8 guidelines.
Focused only on whether initiating medication, and treating to a specific goal improves health, and which drugs work best in which populations.

7. JNC 7 to 8
Definitions have not changed.
Goals have changed.

8. Topic
JNC7
JNC 8
Methods
Literature review
RCTs only
Definitions
HTN and preHTN
same
Goals
Different for DM, CKD
Same for comorbid conditions
Different for age groups
Lifestyle modification
Based on literature review
Based on Lifestyle Work Group
Drugs
5 classes included BBs
4 classes, initial based on race, CM, CKD

9. NHANES 2005-2008 study 30% of US population has HTN
Of those, 50% are controlled
HTN is the most common risk for CVD
What does the ADA call CVD?
ASCVD

10. NHANES = National Health and Nutrition Examination Survey
NHANES 2= 7830 subjects

11. More new data Hypertensive therapy lowers MI and CHF risk by 20-25%
Hypertensive therapy lowers CVA risk by %

12. Levels of evidence from Evidence-based and NHLBI
High- Good RCTs, metaanalysis, Highly certain so not more big studies
Moderate- RCTs, some NRCTs, metaanalysis, may be studied more so may change
Low- RCTs with limitations, NRCTs, cases, metaanalysis, Likely to be studied more and change

13. Strength of recommendation
A- strong
B moderate
C weak
D recommend against
E expert opinion recommends, but no evidence
N No recommendation for or against

14. Blood Pressure Classification
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139 or
80–89
Stage 1 Hypertension
140–159 or
90–99
Stage 2 Hypertension
>160 or
>100

15. A patient with a BP of 120/80 would be classified as
Normal
Prehypertensive
Stage 1 Hypertensive
Stage 2 Hypertensive
Stage 3 Hypertensive

16. A patient with a BP of 180/80 would be classified as
Normal
Prehypertensive
Stage 1 Hypertensive
Stage 2 Hypertensive
Stage 3 Hypertensive

17. A patient with a BP of 160/100 would be classified as
Normal
Prehypertensive
Stage 1 Hypertensive
Stage 2 Hypertensive
Stage 3 Hypertensive

18. Treatment, JNC 8
Treatment now varies depending on age, race, and kidney, diabetes status
In general, Lifestyle modification for preHTN or HTN in everyone
Stage 1, initiate care if >150/90 in everyone, >140/90 for diabetics, CKD and <60 years old
Stage 2, initiate 2 drug classes for better control

19. From AFP
• In the general population, pharmacologic treatment should be initiated when blood pressure is 150/90 mm Hg or higher in adults 60 years and older, or 140/90 mm Hg or higher in adults younger than 60 years.
• In patients with hypertension and diabetes, pharmacologic treatment should be initiated when blood pressure is 140/90 mm Hg or higher, regardless of age.

20. Benefits of lowering BP
You must treat:
125 for 5 years to prevent a death
67 for 5 years to prevent a stroke
100 for 5 years to prevent an MI (fatal or not)
This is from Prof. Demshok’s website.

21. The previous statistic is an example of
Prevalence
Incidence
An epidemic
NNT
False positive

22. Screening USPSTF Screen every 3-5 years in normotensive, non risk
Screen yearly for Prehypertensive, or those with risk
They like ambulatory, if possible

23. Kinds of BP Office BP- auscultated, like we taught you
AOBP= automated office BO- with the machine (readings lower, thresholds higher)
ABPM= Ambulatory BP monitoring

24. Office BP Measurement
Use auscultatory method with a properly calibrated and validated instrument.
Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.
Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made.
Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

25. Self-Measurement of BP
Provides information on:
Response to antihypertensive therapy
Improving adherence with therapy
Evaluating white-coat HTN
Home measurement of >135/85 mmHg is generally considered to be hypertensive.
Home measurement devices should be checked regularly.

26. Home BP measurements can do all of the following except:
Evaluate response to therapy
Improve adherence to therapy
Guide patient’s choice of medication
Evaluate white coat hypertension

27. Patient Evaluation
Evaluation of patients with documented HTN has three objectives:
Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.
Reveal identifiable causes of high BP.
Assess the presence or absence of target organ damage and CVD.

28. CVD Risk Factors Hypertension* Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.

29. Identifiable Causes of Hypertension
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
*Oral contraceptives

30. Target Organ Damage Heart Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

34. Lifestyle Modification
Approximate SBP reduction (range)
Weight reduction
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg

36. http://www. uptodate. com/contents/image

37. Treatment, JNC 8
Treatment now varies depending on age, race, and kidney, diabetes status
In general, Lifestyle modification for preHTN or HTN in everyone
Stage 1, initiate care if <150/90 in everyone, <140/90 for diabetics, CKD and <60 years old
Stage 2, initiate 2 drug classes for better control

38. Initiate medication JNC 8
For people >60 years old- At SBP>150 or DBP >90 (1) Goal is <150/<90
For people < 60 at DBP >90, goal is <90 (2) but there is some reason to start at 140 and go down to 140 (3) expert opinion

39. For >18 with CKD or DM initiate at >140/ 90 and goal is <140/ 90 (4, 5) expert opinion
Recommendations 6- 8 refer to initial drug of choice
Treat to goal, even if you have to use 2 or 3 different drugs, but not ACE-I and ARB together

43. What is the treatment guideline for a 50 year old non-black patient with BP of 120/80?
Tell them to keep up the good work
Encourage lifestyle modification
Start diuretic
Start ACE-I
Start diuretic and ACE-I

44. and anyone with DM or CKD < 150/90 for > 60
Treatment goals- JNC 8
<140/90 for ages 18-59
and anyone with DM or CKD
< 150/90 for > 60

46. What is the treatment goal for a 50 year old?
<130/85
<140/90
<150/90
<160/100

47. What is the treatment goal for a 70 year old?
<130/85
<140/90
<150/90
<160/100

48. What is the treatment goal for a 50 year old with diabetes?
<130/85
<140/90
<150/90
<160/100

49. What is the treatment goal for a 70 year old with diabetes?
<130/85
<140/90
<150/90
<160/100

50. Initial drug to use Anyone with CKD- Ace- I or ARB
Black people- CCB or diuretic
Black people with diabetes- CCB or diuretic
Nonblack people- ACE-I, ARB, CCB or diuretic
Nonblack people with diabetes- ACE-I, ARB, CCB or diuretic

51. http://www. uptodate. com/contents/image

52. Antihypertensive drugs
Indication
Antihypertensive drugs
Compelling indications (major improvement in outcome independent of blood pressure)
Systolic heart failure
ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist*
Post-myocardial infarction
ACE inhibitor, beta blocker, ARB, aldosterone antagonist
Proteinuric chronic kidney disease
ACE inhibitor or ARB
Angina pectoris
Beta blocker, calcium channel blocker
Atrial fibrillation rate control
Beta blocker, nondihydropyridine calcium channel blocker
Atrial flutter rate control

53. Likely to have a favorable effect on symptoms in comorbid conditions
Benign prostatic hyperplasia
Alpha blocker
Essential tremor
Beta blocker (noncardioselective)
Hyperthyroidism
Beta blocker
Migraine
Beta blocker, calcium channel blocker
Osteoporosis
Thiazide diuretic
Raynaud's syndrome
Dihydropyridine calcium channel blocker

54. Contraindications
Angioedema
ACE inhibitor
Bronchospastic disease
Beta blocker
Depression
Reserpine
Liver disease
Methyldopa
Pregnancy (or at risk for)
ACE inhibitor, ARB, renin inhibitor
Second or third degree heart block
Beta blocker, nondihydropyridine calcium channel blocker

55. May have adverse effect on comorbid conditions
Depression
Beta blocker, central alpha-2 agonist
Gout
Diuretic
Hyperkalemia
Aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor
Hyponatremia
Thiazide diuretic
Renovascular disease
ACE inhibitor, ARB, or renin inhibitor

56. What should you start for a non-black 50 year-old male with diabetes and a BP of 160/96?
Ace-I
Beta-blocker
CCB
Diuretic
Spironolactone

57. What should you start for a non-black 50 year-old male with migraine and a BP of 160/96?
Betablocker

58. What should you start for a black 50 year-old male with diabetes and a BP of 160/96?
Ace-I
Beta-blocker
CCB
Diuretic
Spironolactone

59. What should you start for a non-black 30 year-old female with a BP of 160/96?
Ace-I
Beta-blocker
CCB
Diuretic
Spironolactone

60. Not everyone agrees
There is evidence to suggest we need to be wary of low blood pressures, especially in the elderly (HOT)

62. Isolated Systolic Hypertension
ISH = SBP>160 and DBP<90
ISH increases pulse pressure
Remember, less elasticity of arteries causes higher SBP and less DBP

63. What is the treatment guideline for a 50 year-old with BP of 150/92?
Encourage lifestyle modification
Start diuretic
1 and 2
Start ACE-I

64. What is the treatment guideline for a nonblack 50 year old with BP of 174/92?
Tell them to keep up the good work
Encourage lifestyle modification
Start diuretic
Start ACE-I
Start diuretic and ACE-I

65. Followup and Monitoring
Patients should return for followup and adjustment of medications until the BP goal is reached.
More frequent visits for stage 2 HTN or with complicating comorbid conditions.
Serum potassium and creatinine monitored 1–2 times per year.

66. Followup and Monitoring (continued)
After BP at goal and stable, followup visits at 3- to 6-month intervals.
Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

67. *Always use an ACE-I or ARB for
DM, nonblack
Chronic Kidney disease, any race
Heart failure or previous MI with wall motion abnormalities
Unless they are a woman of child-bearing age, or have a Hx of angioedema, or failed trail of ACE- I AND ARB, then document why they are not taking the ACE-I

68. *Always use a BB for Previous MI Unless they have 2 or 3 AVB or
Unless they have Reactive airway disease (asthma) or
Unless they have acute heart failure (SOB)

69. Which of the following should be used in a heart failure patient?
Thiazide diuretic
Beta blocker
ACE-I
ARB
Aldosterone antagonist
All of the above may be used

70. Which of the following should be used in a chronic kidney disease patient?
Thiazide diuretic
Beta blocker
ACE-I
CCB
Aldosterone antagonist
All of the above may be used

71. Postural Hypotension
Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs.
BP in these individuals should be monitored in the upright position.
Avoid volume depletion and excessively rapid dose titration of drugs.

72. Hypertension in Women
Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.
Development of HTN—consider other forms of contraception.
Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.

73. Which of the following should be used in a 26 year-old woman?
Thiazide diuretic
Beta blocker
ACE-I
ARB
Aldosterone antagonist
All of the above may be used

74. Hypertensive Urgencies and Emergencies
Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy.
Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.

75. *“Malignant Hypertension”
High BP with retinal hemorrhages, exudates, or papilledema.
Usually with diastolic >120 or marked increase
Hypertensive encephalopathy

76. *“Hypertensive urgency”
Severe HTN diastolic >120 in asymptomatic Pt
“No evidence for Rapid reduction of BP”

77. Additional Considerations in Antihypertensive Drug Choices
Potential favorable effects
Thiazide-type diuretics useful in slowing demineralization in osteoporosis.
BBs useful in the treatment of atrial tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN.
CCBs useful in Raynaud’s syndrome and certain arrhythmias.
Alpha-blockers useful in prostatism.

78. Additional Considerations in Antihypertensive Drug Choices
Potential unfavorable effects
Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia.
BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or third-degree heart block.
ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.
ACEIs should not be used in individuals with a history of angioedema.
Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.

79. Which of the following should be used in a 74 year old man with BPH?
Thiazide diuretic
Beta blocker
ACE-I
ARB
Alfa-blocker
All of the above may be used

80. Which of the following should be avoided in a patient with reactive airway disease?
Thiazide diuretic
Beta blocker
ACE-I
ARB
Alfa-blocker
All of the above may be used

81. Which of the following should be used in a 70 year old woman with Reynaud’s syndrome?
Thiazide diuretic
Beta blocker
ACE-I
CCB
Aldosterone antagonist
All of the above may be used

82. Which of the following should be used in a 76 year old woman with osteoporosis?
Thiazide diuretic
Beta blocker
ACE-I
CCB
Aldosterone antagonist
All of the above may be used

83. Which of the following should be used in a 68 year old man with essential tremor?
Thiazide diuretic
Beta blocker
ACE-I
CCB
Aldosterone antagonist
All of the above may be used

84. Which of the following should be avoided in a patient with a history angioedema?
Thiazide diuretic
Beta blocker
ACE-I
CCB
Alfa-blocker
All of the above may be used

85. A 70 year old nonblack new patient is diagnosed with diabetes in the office today. His BP is 170/96. What is the best choice of treatment for the HTN?

86. Lifestyle modification only
Lifestyle modification and Start ACE-I
Lifestyle modification and diuretic
Lifestyle modification and ACE-I and diuretic

87. A 50 year old non-black new patient is diagnosed with diabetes in the office today. His BP is 170/96. What is the best choice of treatment for the HTN?

88. Lifestyle modification only
Lifestyle modification and Start ACE-I
Lifestyle modification and diuretic
Lifestyle modification and ACE-I and diuretic

89. A 50 year old black new patient is diagnosed with diabetes in the office today. His BP is 170/96. What is the best choice of treatment for the HTN?

90. Lifestyle modification and CCB
Lifestyle modification and Start ACE-I
Lifestyle modification and diuretic
Lifestyle modification and CCB and diuretic

91. A 50 year old non-black new patient is diagnosed with diabetes in the office today. His BP is 170/96. What is his treatment goal?

92. What is the treatment goal for a 50 year old diabetic?
<130/85
<140/90
<150/90
<160/100

93. Questions? What is on the test? Normal, PreHTN, Stage 1 and 2
Treatment goals and first-line pharm treatment, cases
Do you like the black and white slides?
Or the UptoDate or blue ones?
Questions in slides?

94. *Exercise Find a partner quickly and quietly
One partner is the patient and one the PA-S
Patient present with Stage 1 or 2 HTN and some “compelling indication”
PA-S choose a med class
Convince your patient to take BP medication .

95. *Exercise Patients: How did you feel?
Tell your PA-S if you would take the medicine.
Tell them if you would send your grandmother to them
Tell them one thing they did well
Tell them one thing they could improve
Switch

96. References
JNC 8 in JAMA
UptoDate Topic 3861 Version 18.0 What is goal blood pressure in the treatment of hypertension? Johannes FE Mann, MD Karl F Hilgers, MD
UptoDate Topic 3852 Version 28.0 Overview of hypertension in adults. Jan Basile, Michael J Bloch
UptoDate Topic 3869 Version 32.0 Choice of drug therapy in primary (essential) hypertension: Recommendations. Johannes FE Mann

97. References
UptoDate Topic 3863 Version 18.0 Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension. Brent M Egan
JNC 7 is posted on NHLBI website. It is now out of date but
Blue slides that are still relevant are from nhlbi site
Starred ones from:
Kaplan NM, Domino FJ UptoDate Topic 3852 Version 18.0
J Am Coll Cardiol, 2011; 57: , doi: /j.jacc (Published online 25 April 2011).