1. Hypertension Guidelines 2015 Barry D. Bertolet, MD Cardiology Associates of North Mississippi Tupelo – Columbus – Starkville - Oxford

2. Disclosures No disclosures

3. Hypertension Hypertension is the most common condition in primary care. 68 million Americans > 18 years old (31%) have hypertension – that’s 1:3 Incidence increases with age Risk factor for MI, CVA, ARF, death

4. HTN Increases with Age

5. Progression to HTN Increases with Age

6. Hypertension Prevalence and Control in US Adults (%)

7. 2098 Franklin #7 BP and Ischemic Heart Disease Mortality 160180140 Usual SBP (mm Hg) 90100110 IHD Mortality (Floating Absolute Risk and 95% CI) 120 0 4 32 256 7080 Usual DBP (mm Hg) 50-59 60-69 70-79 80-89 40-49 Age at Risk (y) 50-59 60-69 70-79 80-89 40-49 Age at Risk (y) 0 4 32 256 Adapted from Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.

8. 2098 Franklin #8 CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment* *Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572. CV mortality risk SBP/DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75135/85155/95175/105

9. Additive Effects

10. Benefits of Anti-hypertensive Tx

11. Benefits of Anti-Hypertensive Tx

12. How Well Do We Do?

13. Barriers to Success Asymptomatic (silent killer) Non-compliance Therapeutic inertia –Not knowing the definition –Not knowing the goals –Not knowing the meds –Accepting less than ideal reductions

14. 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.

15. Case Question 1 What goal BP is most appropriate for this patient? 1.<150/90 mmHg 2.<130/80 mmHg 3.<140/90 mmHg 4.<140/80 mmHg 5.<140/85 mmHg

16. Case Question 2 What is the drug of choice to start? 1.HCTZ 2.Norvasc 3.Lisinopril 4.Losartan 5.Bystolic 6.Combination therapy

17. JNC -7 Blood Pressure Guidelines

18. JNC-7 Treatment Algorithm

19. JNC-7 Compelling Indications

20. Development of JNC-8 3 critical questions for adults with hypertension –Does initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes? [When to start therapy?] –Does treatment with antihypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes? [How low should I go?] –Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? [What drug do I use?]

21. JNC 8 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults –JAMA. 2014;311(5):507-520 –December 18, 2013

22. 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

23. JNC 8: Hypertension Management Evidence Review RCT’s December 2009 – August 2013 1.Major study in hypertension ACCORD, NEJM 2010 2.> 2,000 participants 3.Multicentered 4.Met all other inclusion/exclusion criteria

24. What is the goal BP?

25. 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 –LOE: Grade A

26. 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

27. 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 –LOE: Grade E

28. Initial Treatment Considerations Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

29. What Are Effective Lifestyle Modifications for HTN? Weight Reduction DASH diet Dietary sodium reduction Physical Activity Decrease alcohol consumption

30. Hypertension

31. Select a Drug Titration Pathway CKD – all races –Initiate ACEI or ARB, alone or in combination with other drug clsses Non CKD – black (Hispanic) –Initiate thiazide-type diuretic or CCB, alone or in combination Non CKD – nonblack –Initiate thiazide-type diuretic or ACEI/ARB or CCB, alone or in combination

33. 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

34. A Word about ACE-I / ARB Combinations It is Dead! Based on the results of the Renal Outcomes With Telmisartan, Ramipril, or Both, in People at High Vascular Risk (ONTARGET) study, the ARB telmisartan to be noninferior to the ACE inhibitor ramipril but the combination of the two together to be associated with more adverse events and no increased benefit. A separate, prespecified analysis looking at renal outcomes in ONTARGET showed that the ARB/ACE- inhibitor combination was associated with an increased risk of dialysis, doubling of serum creatinine, and death, compared with using either agent alone. 34

35. Subsequent Therapies BlackNon-Black Step OneThiazide &/or CCBACE / ARB &/or CCB Step TwoAdd ACE / ARBUse combo Step ThreeAdd beta-blocker &/or aldactone Step FourOthers Reinforce compliance and lifestyle modifications!

36. 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

37. 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

38. What to do?

39. Comparison of Recent Guideline Statements JNC 8ESH/ESCAHA/ACCASH/ISH >140/90 Threshold>140/90 < 60 yrEldery SBP >160>140/90 <80 yr for Drug Rx>150/90 >60 yrConsider SBP>140/90>150/90 >80 yr 140-150 if <80 yr B-blockerNoYesNo First line Rx Initiate Therapy>160/100"Markedly>160/100 w/ 2 drugselevated BP"

40. Goal BP GroupBP Goal (mm Hg) GeneralDM*CKD** JNC 8:<60 yr: <140/90< 140/90 >60 yr: <150/90 ESH/ESC:< 140/90< 140/85< 140/90 Elderly140-150/90(SBP < 130 if proteinuria) (<80 yr: SBP<140) ASH/ISH< 140/90 >80 yr: <150/90(Consider < 130/80 if proteinuria) AHA/ACC< 140/90 *ADA: < 140/80 or lower **KDIGO: <140/90 w/o albuminuria 30 mg/24hr

41. BP goal in the elderly

42. Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by 2013 ESH/ESC Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357 Blood pressure goals in hypertensive patients SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure. 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 <140 mmHg SBP goal for elderly >80 years with SBP ≥160 mmHg 140-150 mmHg DBP goal for “most”<90 mmHg DB goal for patients with diabetes<85 mmHg

43. Reinforce Lifestyle Changes!

44. 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.

45. 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.

46. Case Question 1 What goal BP is most appropriate for this patient? 1.<150/90 mmHg 2.<130/80 mmHg 3.<140/90 mmHg 4.<140/80 mmHg 5.<140/85 mmHg

47. Case Question 1 What goal BP is most appropriate for this patient? 1.<150/90 mmHg 2.<130/80 mmHg 3.<140/90 mmHg 4.<140/80 mmHg 5.<140/85 mmHg

48. Initial Treatment Considerations Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

49. Case Question 2 What is the drug of choice to start? 1.HCTZ 2.Norvasc 3.Lisinopril 4.Losartan 5.Bystolic 6.Combination therapy

50. Case Question 2 What is the drug of choice to start? 1.HCTZ 2.Norvasc 3.Lisinopril 4.Losartan 5.Bystolic 6.Combination therapy

52. Case Question 3 Despite amlodipine 5 mg and HCTZ 25 mg daily, she has a BP of 145/87. What is the next drug of choice to start? 1.HCTZ 2.Norvasc 3.Lisinopril 4.Losartan 5.Bystolic 6.Combination therapy

53. Case Question 3 Despite amlodipine 5 mg and HCTZ 25 mg daily, she has a BP of 145/87. What is the next drug of choice to start? 1.HCTZ 2.Norvasc 3.Lisinopril 4.Losartan 5.Bystolic 6.Combination therapy

54. Subsequent Therapies BlackNon-Black Step OneThiazide &/or CCBACE / ARB &/or CCB Step TwoAdd ACE / ARBUse combo Step ThreeAdd beta-blocker &/or aldactone Step FourOthers Reinforce compliance and lifestyle modifications!

55. Physiological Effects of Diuretics Diuretics ↓ Plasma volume ↓ Cardiac Output Initially Long-term Counter-regulatory Mechanisms ↓ Blood Pressure ↓ Arterial Resistance ↓ Renal Perfusion ↑ Renin/Angiotensin Activity ↑ Arterial Resistance ↑ Blood Pressure Adapted from Moser and Setaro, Med Clin N Am 2004;88:167-187.

56. True or False 65 year old “healthy” man presents for evaluation. Serial BPs show an average of 148/88 with no improvement after a 3 month period of diet and exercise. There is no history of CAD, diabetes, or renal disease. Based on the new HTN guidelines, medical therapy should be initiated.

57. True or False 65 year old “healthy” man presents for evaluation. Serial BPs show an average of 148/88 with no improvement after a 3 month period of diet and exercise. There is no history of CAD, diabetes, or renal disease. Based on the new HTN guidelines, medical therapy should be initiated. False

58. Initial Treatment Considerations Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

59. Case A 78 year old Caucasian man with history of CABG is seen with a BP of 160/104 and confirmed this range on several office visits. He has been placed on a DASH diet for three months. Other than mild dementia, the exam is normal. Lab is remarkable for a Cr 2.4 and LDL 120 mg/dl.

60. Case Question 1 What goal BP is most appropriate for this patient? 1.<150/90 mmHg 2.<130/80 mmHg 3.<140/90 mmHg 4.<140/80 mmHg 5.<140/85 mmHg

61. Case Question 1 What goal BP is most appropriate for this patient? 1.<150/90 mmHg 2.<130/80 mmHg 3.<140/90 mmHg 4.<140/80 mmHg 5.<140/85 mmHg

62. Case A 78 year old Caucasian man with history of CABG is seen with a BP of 160/104 and confirmed this range on several office visits. He has been placed on a DASH diet for three months. Other than mild dementia, the exam is normal. Lab is remarkable for a Cr 2.4 and LDL 120 mg/dl.

63. Initial Treatment Considerations Set blood pressure goal based on age, diabetes, and chronic kidney disease (CKD)

64. Case Question 2 Appropriate initial (and minimum) therapy would include: 1.Aspirin, ACEI, beta-blocker, and atorvastatin 10 mg 2.Aspirin, ACEI, thiazide, and pravastatin 20 mg 3.Aspirin, ACEI, and atorvastatin 40 mg 4.Aspirin and ACEI

65. Case Question 2 Appropriate initial (and minimum) therapy would include: 1.Aspirin, ACEI, beta-blocker, and atorvastatin 10 mg 2.Aspirin, ACEI, thiazide, and pravastatin 20 mg 3.Aspirin, ACEI, and atorvastatin 40 mg 4.Aspirin and ACEI

68. Intensity of Statin Therapy

69. Case Question 2 Appropriate initial (and minimum) therapy would include: 1.Aspirin, ACEI, beta-blocker, and atorvastatin 10 mg 2.Aspirin, ACEI, thiazide, and pravastatin 20 mg 3.Aspirin, ACEI, and atorvastatin 40 mg 4.Aspirin and ACEI

70. Thank you for your attention!