in the name of god
DESCRIPTION
IN THE NAME OF GOD. Hypertension. Mohammad Garakyaraghi,MD Cardiologist Associate Professor. Hypertension. Hypertension is the most common condition in primary care. 1 in 3 patients have hypertension according to NHLBI Risk factor for MI, CVA, ARF, death. New Guidelines for Hypertension. - PowerPoint PPT PresentationTRANSCRIPT
Hypertension is the most common condition in primary care.
1 in 3 patients have hypertension according to NHLBI
Risk factor for MI, CVA, ARF, death
Hypertension
National Institute for Health and Clinical Excellence (NICE), 2011
Kidney Disease: Improving Global Outcome (KDIGO), 2012
European Society of Hypertension/European Society of Cardiology, (ESH/ESC), 2013
American Diabetes Association (ADA), 2014 American Society of Hypertension and the
International Society of Hypertension (ASH/ISH), 2014
Eighth Joint National Committee (JNC8), 2013
New Guidelines for Hypertension
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
JNC 8: Hypertension ManagementEvidence Review
RCT’s December 2009 – August 20131. Major study in hypertension
ACCORD, NEJM 20102. > 2,000 participants3. Multicentered4. Met all other inclusion/exclusion criteria
JNC 8: Hypertension ManagementEvidence Review
Excluded sample size < 100 and f/up period < 1 year
Only included randomized, controlled trials rated as good or fair
Only included studies reporting effects of interventions on:◦ MI◦ Stroke◦ ESRD, doubling of Scr, or halving of GFR◦ Heart failure (HF) or hospitalization for HF◦ Coronary revascularization or other revascularization◦ Mortality (Overall mortality, CVD-related mortality,
CKD-related mortality)
JNC8: Methods
A – Strong evidenceB – Moderate evidenceC – Weak evidenceD – AgainstE – Expert OpinionN – No recommendation
JNC 8: Graded Recommendations
JNC8: Strength of RecommendationGrade Strength of Recommendation
A Strong: High certainty net benefit is substantial
BModerate• Moderate certainty net benefit is moderate to substantial,
or• High certainty that net benefit is moderate
C Weak: At least moderate certainty of small net benefit
EExpert Opinion• Insufficient evidence, or • Evidence is unclear or conflicting• Further research is recommended in this area
In adults with HTN, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
In adults with HTN, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
In adults with HTN, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?
JNC8: Key Questions
Age > 60 yo◦ Systolic:
Threshold > 150 mmHg Goal < 150 mmHg
LOE: Grade A
◦ Diastolic: Threshold > 90 mmHg Goal < 90 mmHg
LOE: Grade A
JNC 8: Drug TreatmentThresholds 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
JNC 8: Drug TreatmentThresholds 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
JNC 8: Drug TreatmentThresholds and Goals
Nonblack, including DM◦ Thiazide diuretic, CCB, ACEI, ARB
LOE: Grade B
Black, including DM◦ Thiazide diuretic, CCB
LOE: Grade B (Grade C for diabetics)
JNC 8: Initial Drug Choice
Age > 18 yo with CKD and HTN (regardless of race or diabetes)◦ Initial (or add-on) therapy should include an ACEI
or ARB to improve kidney outcomes LOE: Grade B
◦ Blacks w/ or w/o proteinuria ACEI or ARB as initial therapy (LOE: Grade E)
◦ No evidence for RAS-blockers > 75 yo Diuretic is an option for initial therapy
JNC 8: Initial Drug Choice
If goal BP not met after 1 month of treatment:◦ Increase dose of initial drug, or◦ Add a second drug (Thiazide, CCB, ACEi, or ARB)
If goal BP not met with 2 medications:◦ Add and titrate a third medication (Thiazide, CCB,
ACEi, or ARB)◦ Do not use ACE and ARB together
Other classes may be used in the following scenarios:◦ Goal BP not met with 3 medications◦ Contraindication to thiazide, ACE/ARB, or CCB
JNC8: Treatment Strategies (Grade E)
Titrate to max dose, then add a second drug
Add a second drug before achieving max dose of the initial drug
Start with 2 drugs at the same time◦ If SBP ≥ 160mmHg and/or DBP ≥ 100 mmHg◦ If SBP ≥ 20mmHg above goal and/or DBP ≥
10mmHg above goal
***Consider scheduling follow-up with the Enhanced Care Clinic for titration of BP Meds
Strategies to Dose Antihypertensive Drugs
Comparison of RecentGuideline Statements
JNC 8 ESH/ESC AHA/ACC ASH/ISH
>140/90
Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr
for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr
140-150 if <80 yr
B-blocker No Yes No NoFirst line Rx
Initiate Therapy >160/100 "Markedly >160/100 >160/100
w/ 2 drugs elevated BP"
Goal BPGroup BP Goal (mm Hg)
General DM* CKD**JNC 8: <60 yr: <140/90 < 140/90 < 140/90
>60 yr: <150/90
ESH/ESC: < 140/90 < 140/85 < 140/90
Elderly 140-150/90 (SBP < 130 if proteinuria)(<80 yr: SBP<140)
ASH/ISH < 140/90 < 140/90 < 140/90>80 yr: <150/90 (Consider < 130/80 if proteinuria)
AHA/ACC < 140/90 < 140/90 < 140/90
*ADA: < 140/80 or lower **KDIGO: <140/90 w/o albuminuria<130/80 if >30 mg/24hr
Comparison of JNC Guidelines
JNC7• Nonsystematic literature
review and expert opinion• Range of study designs• No grading system for
recommendations• Recommendations:
– Lifestyle modifications– Initial therapy for HTN– Compelling indications– Addressed secondary HTN and
resistant HTN
JNC8• Systematic review • Randomized, controlled trials
(RCT) only• Graded recommendations• Recommendations:
– No specific lifestyle recommendations
– Initial therapy for HTN– Racial, CKD, and diabetic
subgroups addressed – Addressed three key questions
Recommendations for General Population Age ≥ 60 Years
JNC 7
• BP Goal < 140/90 mmHg(No age recommendations)
JNC8• BP Goal < 150/90 mmHg
– Rated Grade A
Evidence for JNC8
• HYVET Trial• SHEP Trial• JATOS Trial• VALISH Trial
Recommendations for General Population Age < 60 Years
JNC 7
• BP Goal < 140/90 mmHg
JNC8• SBP Goal < 140 mmHg
– Grade E
• DBP Goal < 90 mmHg– Ages 30-59 years (Grade A)– Ages 18-29 years (Grade E)
Evidence for JNC8
• HDFP Trial• Hypertension-Stroke
Cooperative Trial• MRC Trial• ANBP Trial• VA Cooperative Trial
Recommendations for General Non-black Population (Including DM)
JNC 7
• First-line: Thiazide diuretics (no racial distinction made)
JNC8• First-line
– Thiazide diuretics– CCB– ACE inhibitor– ARB
• Grade B
Evidence for JNC8
• ALLHAT Trial• BP control more important
than medication used• Alpha blockers not
recommended first-line• LIFE Study
• Beta-blockers not recommended first-line
• Insufficient evidence to recommend other classes
Recommendations for General Black Population (Including DM)
JNC 7
• First-line: Thiazide diuretics(no racial distinction made)
JNC8• Initial treatment for black
population (Grade B) with DM (Grade C)– Thiazide diuretics– CCB
ALLHAT Trial• Pre-specified subgroup
analysis • Thiazide more effective in
improving CV outcomes compared to ACEi in black patient subgroup• 51% higher rate of stroke (RR
1.51; 95% CI 1.22-1.86) with use of ACEi as initial therapy in black patients (compared to CCB)
• 46% of patients in subgroup analysis had DM
Recommendations for General Population Age ≥ 18 with CKD
JNC 7
• Goal BP: < 130/80 mmHg• First-line agent: ACEi or ARB
JNC8• Goal BP: < 140/90 mmHg
– Grade E
• Initial or add-on treatment: ACEi or ARB – Grade B– Regardless of race or DM
status
Evidence for JNC8• AASK Trial• MDRD Trial
• Potential benefit of goal <130/80 for patients with proteinuria (>3g/24 hours)
• REIN-2 Trial• No trials showed goal
<130/80 mmHg significantly lowered kidney or CV end points compared to 140/90
Recommendations for General Population Age ≥ 18 with DM
JNC 7
• Goal BP: < 130/80 mmHg
JNC8• Goal BP: < 140/90 mmHg
– Grade E
Evidence for JNC8• ACCORD-BP Trial
• No difference in outcomes with SBP < 140 vs. SBP < 120
• No good or fair quality trials to support DBP < 80
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 elderlyAged <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
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
Recommendations Additonal considerations
Mandatory: initiate drug treatment in patients with SBP ≥160 mmHg
• Strongly recommended: start drug treatment when SBP ≥140 mmHg
SBP goals for patients with diabetes: <140 mmHg
DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are recommended and may be used in patients with diabetes
• RAS blockers may be preferred• Especially in presence of preoteinuria or
microalbuminuria
Choice of hypertension treatment must take comorbidities into account
Coadministration of RAS blockers not recommended
• Avoid in patients with diabetes
Hypertension treatment for people with diabetes
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.
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
Recommendations Additonal considerations
Consider lowering SBP to <140 mmHg
Consider SBP <130 mmHg with overt proteinuria • Monitor changes in eGFR
RAS blockers more effective to reduce albuminuria than other agents
• Indicated in presence of microalbuminuria or overt proteinuria
Combination therapy usually required to reach BP goals
• Combine RAS blockers with other agents
Combination of two RAS blockers • Not recommended
Aldosterone antagonist not recommended in CKD
• Especially in combination with a RAS blocker• Risk of excessive reduction in renal function,
hyperkalemia
Hypertension treatment for people with nephropathy
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.
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
Lifestyle changes for hypertensive patients
* Unless contraindicated. BMI, body mass index.
Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day
Moderate alcohol intake Limit to 20-30 g/day men,10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
BMI goal 25 kg/m2
Waist circumference goal Men: <102 cm (40 in.)*Women: <88 cm (34 in.)*
Exercise goals ≥30 min/day, 5-7 days/week(moderate, dynamic exercise)
Quit smoking
Goal BP for patients with DM◦ Less than 140/80 mmHg
ACCORD-BP trial HOT Trial
Showed 51% reduction in major CV events in patients with DM Post-hoc analysis of small subgroup of the study (not pre-specified) Evidence graded as low quality by JNC8
Preferred Agents◦ ACEi or ARB
HOPE Study Included non-hypertensive patients Decreased risk of stroke with ACEi
◦ Despite conflicting evidence, continue to recommend ACE/ARB first-line Cite high CVD risk and high prevalence of undiagnosed CVD in patients
with DM
ADA Guidelines for 2014