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  • 1.The Evidence for Current Cardiovascular Disease Prevention Guidelines: Blood Pressure Control American College of Cardiology Evidence Initiative Subcommittee Best Practice Quality and Guidelines and Prevention Committee

2. Classification of Recommendations and Levels of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers comprehension of the guidelines and will allow queries at the individual recommendation level. 3. Icons Representing the Classification and Evidence Levels for Recommendations I IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb IIII IIa IIb III 4. Evidence for Current Cardiovascular Disease Prevention GuidelinesBlood Pressure Evidence 5. Hypertension* Prevalence (%)High Blood Pressure*: Prevalence Increases with Age National Health and Nutrition Examination Survey (NHANES) III 66%72%51% 38% 18% 3% 18-299%30-3940-4950-5960-6970-7980+AgeThe prevalence of high blood pressure increases with age*Hypertension defined as blood pressure >140/90 mmHg or treatment Source: JNC-VI. Arch Intern Med 1997;157:2413-2446 6. High Blood Pressure*: Prevalence in Different Patient Groups National Health and Nutrition Examination Survey (NHANES)*High blood pressure defined as blood pressure 140/90 mmHg or treatment Source: Yoon SS et al. NCHS Data Brief 2012;107:1-7 7. High Blood Pressure: Lifetime Risk*Risk of hypertension (%)Framingham Heart StudyMenWomenYears *Residual lifetime risk of developing hypertension among people with blood pressure 140/90 or 130/80 mm Hg in patients with DM or chronic kidney disease and Patient prescribed 3 or more antihypertensive medications at optimal doses, including if possible a diuretic or Office BP at goal but patient requiring 4 or more antihypertensive medicationsExclude PseudoresistanceIdentify/Reverse Contributing Lifestyle Factors Obesity Physical inactivity Excessive alcohol ingestion High salt, low fiber dietDiscontinue/Minimize Interfering Substances Non-steroidal anti-inflammatory agents Sympathomimetics (diet pills, decongestants) Stimulants Oral contraceptives Licorice EphedraIs patient adherent with prescribed reigmen? Obtain home, work, or ambulatory BP readings to exclude white coat effectBP=Blood pressure, DM=Diabetes mellitus Source: Calhoun DA et al. Circulation 2008;117:e510-526 13. Resistant Hypertension (Continued) Diagnostic and Treatment AlgorithmScreen for Secondary Causes of HypertensionObstructive sleep apnea (snoring, witnessed apena, excessive daytime sleepiness) Primary aldosteronism (elevated aldosterone/renin ratio) Chronic kidney disease (CrCl 1 CHD risk factor randomized to chlorthalidone, amlodipine, or lisinopril for 5 yearsRate of MI or fatal CHD.20Chlorthalidone Amlodipine Lisinopril.16 .12RR(95% CI)P-valueA/C 0.98(0.90-1.07)0.65L/C(0.91-1.08)0.81.08 .04 00123 4 Years to CHD Event0.99567All three BP lowering agents provide similar efficacy BP=Blood pressure, CHD=Coronary heart disease, HTN=Hypertension, MI=Myocardial infarction Source: ALLHAT Investigators. JAMA 2002;288:2981-2997 18. Blood Pressure Lowering Therapy Evidence: Primary Prevention Losartan Intervention for Endpoint (LIFE) Reduction in Hypertension Study Proportion with CV death, MI, or stroke (%)9,193 high-risk hypertensive* patients with LVH randomized to losartan (100 mg) or atenolol (100 mg) for 5 years 16 12AtenololLosartan8 413% RRR, P=0.0210 0612182430364248546066Study MonthAn ARB provides greater efficacy in patients with LVH *Defined by SBP=160-200 mmHg or DBP=95-115 mmHg ARB=Angiotensin receptor blocker, CV=Cardiovascular, DBP=Diastolic blood pressure, LVH=Left ventricular hypertrophy, MI=Myocardial infarction, SBP=Systolic blood pressure Source: Dahlf B et al. Lancet 2002;359:995-1003 19. Blood Pressure Lowering Therapy Evidence: Primary Prevention Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure Lowering Arm (ASCOT-BPLA)Nonfatal MI and fatal CHD (%)19,342 high-risk hypertensive patients with 3 additional CV risk factors randomized to amlodipine (10 mg) & perindopril (8 mg) or atenolol (100 mg) & bendroflumethiazide (2.5 mg) for 5.5 years 6 Atenolol-based regimen 4Amlodipine-based regimen2 RRR=10%, P=0.10520 012 3 4 5 Time since randomization (years)6Both BP lowering regimens provide similar efficacy BP=Blood pressure, CV=Cardiovascular, CHD=Coronary heart disease, MI=Myocardial infarction Source: Dahlf B et al. Lancet 2005;366:895-906 20. Blood Pressure Lowering Therapy Evidence: Primary Prevention Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure Lowering Arm (ASCOT-BPLA)Secondary endpoints Nonfatal MI + fatal CHD Total coronary endpoint Total CV events/procedures All-cause mortality CV mortality Fatal/nonfatal stroke Fatal/nonfatal HFAmlodipinebased rate/1000 patient years 7.4 14.6 27.4 13.9 4.9 6.2 2.5Atenolol-based rate/1000 patient yearsAmlodipinebased betterAtenololbased better8.5 16.8 32.8 15.5 6.5 8.1 3.0P


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