1. 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

2. Disclosures I have hypertension
I work with people who have hypertension

3. 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

4. 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.

5. 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:
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:
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: ;
Chobanian AV, et al. JAMA. 2003;289: 5

6. 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:
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: 6

7. 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

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

9. 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
???
9-13 ???

10. 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

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

12. 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?

13. 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

14. 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

15. 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 ??

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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……

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Questions??

37. Contact information
x201