Hypertension Guidelines 2014 Jason A Smith DO Associated

Hypertension Guidelines 2014 Jason A. Smith, DO Associated Cardiovascular Consultants at Lourdes Cardiology Services

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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

Hypertension

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 microalbumin is mildly elevated.

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

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

Classification of BP – JNC 7 Category Systolic (mm. Hg) Diastolic (mm. Hg) Normal < 120 and < 80 Pre-HTN 120 -139 or 80 -89 Stage I 140 -159 or 90 -99 Stage II > 160 or > 100 Hypertension

2013 ESH/ESC Guidelines for the management of arterial hypertension Definitions and classification of office BP levels (mm. Hg)* Hypertension: SBP >140 mm. Hg ± DBP >90 mm. Hg Category Systolic Diastolic Optimal <120 and <80 Normal 120– 129 and/or 80– 84 High normal 130– 139 and/or 85– 89 Grade 1 hypertension 140– 159 and/or 90– 99 Grade 2 hypertension 160– 179 and/or 100– 109 Grade 3 hypertension ≥ 180 and/or ≥ 110 Isolated systolic hypertension ≥ 140 and <90 * The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated. 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 Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

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

JNC 8: Hypertension Management Questions Guiding Review • In adults with HTN: 1. Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? 2. Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes? 3. Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

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

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

JNC 8: Graded Recommendations A – Strong evidence B – Moderate evidence C – Weak evidence D – Against E – Expert Opinion N – No recommendation

JNC 8: Drug Treatment Thresholds and Goals • Age > 60 yo – Systolic: • Threshold > 150 mm. Hg • Goal < 150 mm. Hg – LOE: Grade A – Diastolic: • Threshold > 90 mm. Hg • Goal < 90 mm. Hg – LOE: Grade A

JNC 8: Drug Treatment Thresholds and Goals • Age < 60 yo – Systolic: • Threshold > 140 mm. Hg • Goal < 140 mm. Hg – LOE: Grade E – Diastolic: • Threshold > 90 mm. Hg • Goal < 90 mm. Hg – LOE: Grade A for ages 40 -59; Grade E for ages 1839

JNC 8: Drug Treatment Thresholds and Goals • Age > 18 yo with CKD or DM – JNC 7: < 130/80 (MDRD NEJM 1994) – Systolic: • Threshold > 140 mm. Hg • Goal < 140 mm. Hg – LOE: Grade E – Diastolic: • Threshold > 90 mm. Hg • Goal < 90 mm. Hg – LOE: Grade E

JNC 8: Initial Drug Choice • 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: 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 – LOE: Grade E

Dissenting Editorial • Ann Intern Med. January 14, 2014 • 5/17 authors (29%) • “Insufficient evidence” to increase target SBP to 150 mm. Hg. • Expertise vs. Scientific Evidence

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

2013 ESH/ESC Guidelines for the management of arterial hypertension Blood pressure goals in hypertensive patients 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 mm. Hg SBP goal for elderly • Ages <80 years • Initial SBP ≥ 160 mm. Hg 140 -150 mm. Hg SBP goal for fit elderly Aged <80 years <140 mm. Hg SBP goal for elderly >80 years with SBP • ≥ 160 mm. Hg 140 -150 mm. Hg DBP goal for “most” <90 mm. Hg DB goal for patients with diabetes <85 mm. Hg SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure. 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 Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

BP goal in the elderly

2013 ESH/ESC Guidelines for the management of arterial hypertension Hypertension treatment for people with diabetes Recommendations Additonal considerations Mandatory: initiate drug treatment in patients with SBP ≥ 160 mm. Hg • Strongly recommended: start drug treatment when SBP ≥ 140 mm. Hg SBP goals for patients with diabetes: <140 mm. Hg DBP goals for patients with diabetes: <85 mm. Hg 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 • Avoid in patients with diabetes Coadministration of RAS blockers not recommended SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system. 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 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 Hypertension treatment for people with nephropathy Recommendations Additonal considerations Consider lowering SBP to <140 mm. Hg Consider SBP <130 mm. Hg with overt proteinuria • Monitor changes in e. GFR 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 SBP, systolic blood pressure; CKD, chronic kidney disease; e. GFR, estimated glomerular filtration rate; RAS, renin–angiotensin system. 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 Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

What is the goal BP?

Comparison of Recent Guideline Statements JNC 8 ESH/ESC AHA/ACC ASH/ISH >140/90 <80 yr >150/90 >80 yr >140/90 Threshold for Drug Rx >140/90 < 60 yr Eldery SBP >160 >150/90 >60 yr Consider SBP 140 -150 if <80 yr B-blocker First line Rx No Yes No No Initiate Therapy w/ 2 drugs >160/100 "Markedly elevated BP" >160/100

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

2013 ESH/ESC Guidelines for the management of arterial hypertension Lifestyle changes for hypertensive patients 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/m 2 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 * Unless contraindicated. BMI, body mass index. 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 Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

Thank you for your attention! smithj@lourdesnet. org