heartbeat – june 2003 continental divide lionel opie md professor and head, heart research...

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Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz Messerli MD Associate Section Head, Hypertension Ochsner Clinic Foundation New Orleans, LA Joseph Izzo MD Vice Chair, Department of Medicine SUNY at Buffalo Buffalo, NY Continental Divide: Hypertension guidelines-- US vs Europe

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Page 1: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Lionel Opie MDProfessor and Head, Heart Research InstituteUniversity of Cape TownCape Town, South Africa

Franz Messerli MDAssociate Section Head, HypertensionOchsner Clinic FoundationNew Orleans, LA

Joseph Izzo MDVice Chair, Department of MedicineSUNY at BuffaloBuffalo, NY

Continental Divide:Hypertension guidelines--US vs Europe

Page 2: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Three key differences

•Simplified classification system

•Aggressive treatment recommendations

•What is the role of thiazide diuretics?

Page 3: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Simplified BP classification

JNC 7

BP Classification SBP mm Hg DBP mm Hg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 hypertension 140–159 or 90–99

Stage 2 hypertension >160 or >100

Page 4: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Aggressiveness and thiazide

How assertive should clinicians be in treating hypertension?

•How quickly clinicians should try to get to goal blood pressures?

What is the role of thiazide diuretics?

•Does JNC 7 say diuretics are preferred agents or are they just one recommendation of many?

Izzo

Page 5: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Two quotes

"Thiazide-type diuretics should be used as initial therapy in most patients with hypertension, either alone or in combination."

JNC 7

"The major classes of hypertensive agents--diuretics, beta blockers, calcium antagonists, ACE inhibitors, ARBs--are suitable for initiation and maintenance of therapy"

European guidelines

Page 6: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Problems with "prehypertensive"

Messerli

The prefix "pre" has negative connotations

"To my way of thinking, to label a person whose blood pressure is 120/80 as prehypertensive is simply inappropriate."

Framingham has shown that if you are age 50-55, the odds of becoming hypertensive in the next 25 years are >90%

Page 7: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Integrated risk factors

Messerli

The European guidelines integrate additional risk factors better than JNC 7 for risk stratification

•Comorbidities

•Target organ disease

In fairness, JNC 7 is the short report

Page 8: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Data beyond randomized trials

Messerli

European guidelines acknowledge event-based trials are too short to assess lifelong hypertension therapy

Used surrogate end points to supplement strong clinical end points

• Subclinical organ damage

•LVH

•Microalbuminuria

Page 9: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Socioeconomic factors

Opie

Large differences in wealth and access in the US

European guidelines state up front that Europe is relatively homogenous and due to state health care, cost is not paramount

JNC 7 has no mention even of ethnic/racial differences, which we know govern many aspects of wealth and access

Page 10: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Population issues

We don't know enough about the response rates of different populations

• Trends favor thiazide diuretics in blacks, ACE inhibitors in whites

The overarching principles don't change by race so should not form a fundamental basis for initial therapy

Socioeconomic issues can be somewhat addressed by generics

Izzo

Page 11: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Population differences

The US population may not be similar in needs to the European population

• Obesity and salt intake are very different than in Northern Europe

Diuretics must be given along with other agents in the US to get good BP control

Control rates are better in the US than in Europe, possibly due to more aggressive treatment

Izzo

Page 12: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Obesity and the metabolic syndrome

Messerli

"The European guidelines clearly state that treatment-induced alterations in cholesterol, potassium, glucose tolerance, etc, although they hardly can be expected to increase cardiovascular events during the short term of a trial, may have an impact during the longer course of the patient's life."

Page 13: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

JAMA 2002; 288:2981-2997

ALLHAT: De novo diabetes

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Events

(%

)

Chlorthalidone Lisinopril Amlodipine

Page 14: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Treating the metabolic syndrome

Messerli

"It was very disappointing for me to see that there are no guidelines given [in JNC 7] how to treat patients with the metabolic syndrome in terms of antihypertensive therapy."

Even in diabetic patients, thiazides lead the list of antihypertesnive drugs

Page 15: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Indications for individual drug classes

JNC 7

Compelling indication

Initial therapy options

Clinical trial basis

Diabetes Thiazide, beta blocker, ACE inhibitor, ARB, CCB

NKF-ADA guideline, UKPDS, ALLHAT

Chronic kidney disease

ACE inhibitor, ARB

NKF guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

Recurrent stroke prevention

Thiazide, ACE inhibitor

PROGRESS

Page 16: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

JAMA 2002; 288:2981-2997

ALLHAT: Primary end point

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Events

(%

)

Chlorthalidone Lisinopril Amlodipine

Page 17: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Indication Clinical trial basis

Heart failure ACC/AHA Heart Failure Guideline,

MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES

Post-MI ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS

High CAD risk ALLHAT, HOPE, ANBP2, LIFE, CONVINCE

Diabetes NKF-ADA guideline, UKPDS, ALLHAT

Chronic kidney disease

NKF guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

Recurrent stroke prevention

PROGRESS

Trial basis for treatment decisions

Page 18: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

JAMA 2002; 288:2981-2997

ALLHAT: Fasting glucose levels

0

5

10

15

20

25

30

35

Fasti

ng

glu

co

se

>1

26

mg

/d

L (

%)

Baseline 2 years 4 years

Chlorthalidone Lisinopril Amlodipine

Page 19: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Compelling Indication

Diuretic BB ACEI ARB CCB AldoANT

HF * * * * *

Post-MI * * *

High coronary disease risk

* * * *

Diabetes * * * * *

Indications for individual drug classes

Page 20: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

ALLHAT: Blood sugar and diabetes

Blood sugar tends to be higher on thiazide, although the impact remains debatable

ALLHAT mean blood sugar:Thiazide: 126.3 mg/dLACE inhibitor: 121.5 mg/dL

New-onset diabetes:Thiazide: 11.6%ACE inhibitor: 8.1%

Izzo

Page 21: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Attenuating the thiazide effect

ACE inhibitor or an ARB completely attenuates the hyperkalemia and hyperglycemia effects caused by diuretics

"I come back to the value of combination therapy and that's where the strength of both documents could lie."

Doctors should be thinking about combination drugs earlier

Izzo

Page 22: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Inappropriate wording

Messerli

"Thiazide should be used in drug treatment in most patients, either alone or combined." -- JNC 7

JNC 7 doesn't prevent anyone from treating a patient with the metabolic syndrome with a thiazide alone

"Except nobody should do that. . . . This is inappropriate wording."

Page 23: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Treating diabetic patients

Messerli

All the studies show 14% to 34% more new-onset diabetes in the diuretic or conventional therapy arm

Even in the INSIGHT study, new-onset diabetes was 23% higher in the diuretic arm

"Clearly I think this should be taken into account."

Page 24: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Thiazide diuretic definitions

Opie

JNC 7 says "thiazide-type diuretics"

•What do you understand by low-dose thiazide?

•Are thiazide diuretics the same as chlorthalidone?

Page 25: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Low-dose thiazide

We have defined lower dose as 12.5 or 25 mg of hydrochlorothiazide

Maximum dose we recommend is 50 mg

Little is known about 50-mg dose, since that hasn't been studied very recently, and the old studies were flawed

Izzo

Page 26: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Chlorthalidone equivalency

No literature or good head-to-head trials on the equivalence of chlorthalidone and hydrochlorothiazide

"My own opinion is that the potency of hydrochlorothiazide is roughly half that of chlorthalidone."

Izzo

Page 27: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Chlorthalidone dosing

ALLHAT doses are above the 25 mg of hydrochlorothiazide we typically employ

Chlorthalidone is somewhere between 150% and 200% more effective than the same milligram amount of hydrochlorothiazide

There is a lot of diuretic on board in these studies, and the hyperglycemia seems to be dose-dependent Izzo

Page 28: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Treating diabetic patients

Messerli

MR FIT study found the mortality rate was unfavorable in the clinics using hydrochlorothiazide and favorable in the clinics using chlorthalidone

"We do not have any head-to-head comparisons, and we probably never will, but this is rather powerful evidence that the two drugs are not the same"

Page 29: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Not enough data

Opie

No good dose-response data with diuretics

"Are you really suggesting we should preferentially use an agent we really don't know that much about?"

Page 30: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Diuretic history

Diuretics were originally used in multiples of the doses used today (gave rise to the worries about side effects)

Doses were lowered over time without the guidance of controlled clinical trials

Found reasonable efficacy with lower doses

Izzo

Page 31: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

ACE-inhibitor history

ACE inhibitors also started with much higher doses than are used today

ACE inhibitors and ARBs may be dosed too low now since they have no dose-dependent side effects

"We do not have very good clinical pharmacology to back up any of these recommendations that we're making."

Izzo

Page 32: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Head to head

Messerli

NIH spent $100 million on ALLHAT

For less than $1 million someone could do a simple head-to-head trial

•Chlorthalidone vs hydrochlorothiazide using simple surrogate end points

Page 33: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Beta blockers

Opie

JNC 6 recommended diuretics and/or beta blockers as initial therapy

•What are the data for beta blockers reducing mortality?

JNC 7 downgraded beta blockers to the level of the other drugs

• What led to the downgrading of the beta blockers?

Page 34: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Beta-blocker data

There were relatively poor data supporting beta blockers as a major approach

JNC 6 recommendation was not particularly supportable

Beta blockers are good to have as an option, especially with prevalence of cardiac disease, since the heart is their major target organ

Izzo

Page 35: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Elderly

Opie

Both the European and the JNC 7 guidelines are focused on the elderly

•Some mention of teenagers

•Not much mention of the middle-aged (40-60) hypertension patients

Page 36: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Uncomplicated hypertension

Messerli

Beta blockers are still lumped with ARBs, ACE inhibitors, calcium-channel blockers

Inappropriate because the evidence is meager for beta blockers in uncomplicated hypertension

•Three independent studies showing no risk reduction with beta blockers for noncardiac end points

Page 37: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Beta blockers in cardiac disease

Messerli

Beta blockers make sense in the post-MI patient

Possibly in diabetes, but not in the cases of uncomplicated hypertension

"I think [beta-blockers] should have been kicked off, just the same as the alpha blockers were, of the basket in which the other drugs are in now. And this is true for both guidelines."

Page 38: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Good indications for beta blockers

Messerli

Many good indications for beta blockers

•CHF

•Post-MI

•SVT

•Subaortic stenosis

"I use beta blockers all the time, just not for uncomplicated hypertension."

Page 39: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Including beta blockers

JNC 7 was designed to be a document that could be looked at prospectively or retrospectively for events associated with hypertension

"Was it reasonable to include beta blockers across the entire spectrum of early to late disease? . . . The answer clearly is yes."

Izzo

Page 40: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Beta-blocker heterogeneity

Messerli

The beta blockers are one of the most heterogeneous drug classes around

•Carvedilol, celiprolol, etc may be more beneficial in the uncomplicated hypertensive patient

No outcome data yet

Page 41: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

ALLHAT and the elderly

Opie

ALLHAT is seen by many as the main study influencing JNC 7

ALLHAT studied a population aged mean 67 years, with five-year follow-up

Earlier studies have found diuretics ineffective in whites under the age of 60

•Did that age factor get discussed in JNC 7?

Page 42: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

ALLHAT influence

JNC 7 is not just an ALLHAT study, although it did have many ALLHAT investigators on the committee

JNC 7 used the totality of evidence•Clinical trials•Expert opinion•No evidence-ranking system •Sifted through as much evidence as

we could

Izzo

Page 43: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Age

Age is a trend that affects clinical judgment

Diuretics affect systolic pressure better in an older person than in a younger

"But those are the kinds of things that we feel expert clinicians should be able to interpret and use on their own."

65 + one day doesn't automatically mean diuretic Izzo

Page 44: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Population vision

Opie

JNC 7 comes out right up front that hypertension is a graded effect, starting from 115/75, with a gradually increasing risk

This breadth of approach was missing from the European guidelines

Page 45: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Minimal benefits

Messerli

Meta-analysis has shown increased risk for 130/80 compared with 115/75, but no one has shown reducing the former to the latter actually helps

"The benefits are probably so small that it's awfully hard to convince anybody that lowering the blood pressure within the normotensive range actually did reduce morbidity and mortality."

Page 46: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Best guess

Lacked intervention trial data for “prehypertensive” patients

Vigorous lifestyle modification recommended for "prehypertensive" patients

Framingham study showed lower blood pressure was at any age, the lower it stayed throughout your life

Izzo

Page 47: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Responsibility of the patient

Best available information is to emphasize a nonpharmacological approach

The concept of "prehypertension" is an attempt to put responsibility on patients to take better care of themselves

It was an attempt to avoid using drugs unnecessarily

Izzo

Page 48: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Fat city

Messerli

The US is the fattest nation on Earth

New Orleans is the fattest city in the US

"Here the attitude is that everybody needs to have a good time first and all other considerations are second. So I'm not really happy about that prehypertensive term for this reason, because it doesn't motivate my patients to do anything."

Page 49: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Action steps

Other terms don't motivate patients either

European guidelines use classifications so narrow that normal variation can change a patient's classification

JNC 7 made every 20/10 increase double the risk and that becomes an action step shared by the physician and the patient

Izzo

Page 50: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

High-risk categories

European guidelines use a higher-risk category for systolic >180, JNC 7 does not

There are no specifics in treatment approach that change between systolic 180 and 160

JNC 7 tried to focus on vigorous early treatment, and higher categories make people complacent at the lower levels

Izzo

Page 51: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Clarity of message

Opie

JNC 7 delivers its message very clearly

"Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator."

-JNC 7

The phrase "thiazide-type diuretics should be used" may not be the best phrasing

Page 52: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Specialists vs general practitioners

European guidelines offer a wonderful balance of approaches, but it is a document for specialists

Busy US primary care providers don't have time to read and use highly detailed documents

"We knew we had to have a punched-up, short document to get their attention at all."

Izzo

Page 53: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Box summaries

Messerli

European guidelines have 16 boxes summarizing major guidelines and position statements

"The physician who is more interested can, at his or her leisure, just expand and read on, or not."

Page 54: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Aggressive early treatment

Opie

JNC 7 more intense and aggressive in its approach than European guidelines

Diuretic therapy is known to take up to three months to be fully effective

Diuretic therapy is salt dependent

"Can you really reconcile the desire to get there quickly with blood-pressure reduction with the prime use of a diuretic?"

Page 55: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Algorithm for treatment

Not at goal blood pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Lifestyle modifications

Initial drug choices

Without compelling indications

Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 hypertension (SBP >160 or DBP >100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

With compelling indications

Drugs for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at goal blood pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist

JNC 7

Page 56: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Doctors don't titrate

Early effective doses make sense because doctors don't titrate drugs

"I'd rather have them use effective doses relatively early in the game than hope that they will titrate when we know they don't do it."

Izzo

Page 57: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

European aggression

Messerli

Not that much of a difference between the US and European approach on early treatment

ACE inhibitors and ARBs also have a lead-in time and are salt-dependent

"I'm not so sure whether it would, in this regard, make a big difference whether you actually start on a diuretic or you start on an ACE inhibitor or calcium antagonist."

Page 58: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Summary: Izzo

The fundamental differences are stylistic

JNC 7 is a digest but one with enough breadth to handle typical problems seen by physicians treating hypertension

The unsaid theme is "lower is better"

Put more pressure on patients and physicians to do a more vigorous job of managing hypertension Izzo

Page 59: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Summary: Izzo

The diuretic recommendation is more interpretive than some would say

"Most" can mean 51% or 99% should be on a diuretic--there should be lots of combination therapy used

"These are only guidelines and they're not intended to replace educated physician judgment, just to be sign posts along the way."

Izzo

Page 60: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Summary: Messerli

Major issues with JNC 7

•Lack of distinct guidelines for metabolic syndrome

•All drug classes considered equally compelling in diabetic patient

Messerli

Page 61: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Summary: Messerli

"The responsible physician's judgment is paramount in managing patients, and I only hope that this judgment is also paramount in reading the guidelines."

"And this is true for the European guidelines as well as the American guidelines."

Messerli

Page 62: Heartbeat – June 2003 Continental Divide Lionel Opie MD Professor and Head, Heart Research Institute University of Cape Town Cape Town, South Africa Franz

Heartbeat – June 2003

Continental Divide

Lionel Opie MDProfessor and Head, Heart Research InstituteUniversity of Cape TownCape Town, South Africa

Franz Messerli MDAssociate Section Head, HypertensionOchsner Clinic FoundationNew Orleans, LA

Joe Izzo MDProfessor of MedicineKaleida Health/Millard Fillmore HospitalBuffalo, NY

Continental Divide:Hypertension guidelines –US vs Europe