Ben SelphMercer COPHS, Class of 2012

SEGA Geriatrics

NICE Guidelines for Hypertension

Importance of lowering blood pressureLowering blood pressure can significantly

decrease risk of CV disease.61 prospective observational trials, nearly 1

million people, age bands from 40 to 89Examined relationship between blood

pressure level and 12,000 strokes, 34,000 heart disease events over an average of 13.2 years follow-up

Reductions in systolic of 20mmHg and diastolic 10mmHg was associated with reductions in death from stroke and ischemic heart disease of about one half (~50%)

Importance of lowering blood pressure A similar analysis of 9 observational studies

looking at relationship between BP level and strokes/coronary events found:Reductions in diastolic BP of 5, 7.5, and 10

was associated with reductions in stroke of 34%, 46%, and 56%, and coronary heart disease of 21%, 29%, and 37%, respectively

Cardiovascular risk assessmentImportant to determine presence of CV disease

or high CV risk states (diabetes or CKD).Risk models have been developed for doctors

to assess likelihood of patients developing cardiovascular disease. (10 year risk).

Factors involved in risk assessment include:Gender, age, diabetic status, smoking status,

total cholesterol, HDL cholesterol, and blood pressure.

Allows for identification of patients under greatest overall risk and treatment of modifiable risk factors.

Target Organ Damage

Medscape Cardiology. 2008 Medscape. http://www.medscape.org/viewarticle/577753

Target Organ DamageAnother important objective in assessing

people with suspected hypertension is:To document presence of absence of target

organ damage.Examples include:

Left ventricular hypertrophy, hypertensive retinopathy, and increased albumin:creatinine ratio (kidney damage)

Clinical TestsImportant to perform full CV assessment in

patients with persistently high BP that do not have established CV disease.May detect diabetes and signs of developing

target organ damage (damage to heart and kidneys)

These include: urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total and HDL cholesterol, and 12 lead electrocardiogram

Diagnosis of HypertensionIf clinic blood pressure is >140/90, offer

AMBULATORY BLOOD PRESSURE MONITORING to confirm diagnosis.When ABPM is used, at least two

measurements per hour should be taken during person’s waking hours.

Use the average value of at least 14 measurements taken during person’s waking hours to confirm diagnosis of hypertension.

The Oscar 2 monitor. The ambulatory blood pressure monitor. 2007. gizmag.com

Diagnosis Another option is Home

Blood Pressure Monitoring (HBPM). When this is used:For each blood pressure

recording, two consecutive measurements are taken, at least 1 minute apart and with person seated,

Blood pressure is recorded twice daily, in morning and evening,

Blood pressure recording continues for at least 4 days, ideally for 7 days.

Measurements on first day are discarded

Average of remaining measurements are used to confirm diagnosis

Omron blood pressure monitor. BP monitor ratings. 2011. effectsofhighbloodpressure.com

DiagnosisABPM/HBPM

<135/85 mmHg = Normal>135/85 mmHg = Stage 1 Hypertension>150/95 mmHg = Stage 2 Hypertension

Treatment algorithm

Lifestyle ModificationsDietary modifications and exercise

Low calorie diets have modest effect on BP in overweight individuals (avg. 5-6 mm Hg).

Aerobic exercise (brisk walking, jogging, or cycling) for 30-60 min., 3-5 times/week, had small effect on BP (2-3 mm Hg).

Relaxation therapiesThese activities (stress management,

meditation, cognitive therapy, muscle relaxation) reduce by average of 3-4 mm Hg.

Lifestyle ModificationsLimit alcohol consumption

Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health.

Reducing alcohol can lower BP 3-4 mm Hg.Limiting excessive consumption of

coffee/caffeine (small benefit).Limit dietary sodium intake

< 6 g/day, modest reduction of 2-3 mm Hg.Encourage smoking cessation (reduce risk

of CV/pulmonary disease).

Initiating TreatmentOffer antihypertensive drug treatment to

people aged under 80 years with Stage 1 hypertension who have one or more of the following:Target organ damage, established

cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater.

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

Initiating TreatmentFor people aged under 40 years with stage

1 hypertension and no evidence of target organ damage, CV disease, renal disease or diabetes, consider specialist evaluation of secondary causes of hypertension and more detailed assessment of potential target organ damage.

Step 1 Treatment> 55 yearsCALCIUM CHANNEL BLOCKER

Offer to people aged over 55 years and to black people of African or Caribbean family origin of any age.

If CCB is not suitable (i.e. edema, intolerance, evidence of heart failure or risk of heart failure), offer a thiazide-like diuretic over conventional thiazide diureticsChlorthalidone 12.5-25 mg daily; indapamide 1.5-2.5

mg once dailyCalcium Channel Blockers examples—

amlodipine, nifedipine, felodipine, verapamil, diltiazem.

Step 1 Treatment< 55 yearsACE INHIBITOR or ARB

Offer people aged under 55 years an ACE inhibitor or a low-cost ARB.

If ACE inhibitor is prescribed and is not tolerated (i.e. because of cough), offer a low-cost ARB.

ACE inhibitor examples—benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Zestril), quinapril (Accupril), ramipril (Altace)

ARB examples—candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)

Step 2 TreatmentACE inhibitor/ARB + Calcium Channel

BlockerFor those intolerant to CCBs or at high risk of

heart failure: ACE inhibitor/ARB + Thiazide-like diuretic.

ACCOMPLISH trial and updated cost-effectiveness analysis both favored A + C over A + D

Step 3 TreatmentACEi/ARB + CCB + Thiazide-like

diureticBased on the recommendations and analyses

performed in the first two steps.Thiazide diuretic examples: chlorthalidone

(Hygroton), indapamide (Lozol), hydrochlorothiazide (Hydrodiuril), metolazone (Zaroxolyn)

Resistant Hypertension: Step 4 treatmentPerson with confirmed hypertension in

whom blood pressure is not controlled (<140/90mmHg) despite treatment with combination of optimum or best tolerated doses of three antihypertensive drugs (generally A+C+D).

Recommendations for Step 4Addition of low-dose Spironolactone

Considered when potassium level is <4.5 mmol/LPotassium, sodium, creatinine: checked 2 weeks

after initiation and periodically thereafter.

Higher-dose thiazide-like diuretic treatmentConsidered when potassium level is >4.5

mmol/LOther options for add-on therapy: alpha

blockers or beta blockers

Blood Pressure GoalsPeople aged < 80 years with treated

hypertension: <140/90 (home: 135/85)

People aged > 80 years with treated hypertension: <150/90 (home: 145/85)

For people with “white coat effect”—difference of 20/10 mmHg between clinic and average daily reading—consider adjunt ambulatory or home BP measurement to monitor BP.

Comparing NICE with JNC7 (U.S.): DiagnosisNICE

Hypertension signaled from clinic reading (>140/90 mm Hg).

Officially diagnosed using Ambulatory Blood Pressure Monitoring (>135/85 mm Hg)

JNC 7 (U.S.)Mainly based on

office BP reading (>140/90)

Ambulatory or Home Blood Pressure Monitoring mainly used for self-monitoring.

Comparing NICE with JNC7: Initiation of Medication TherapyNICE:

Stage 1 (>135/85mmHg Ambulatory or Home BP)Offer antihypertensive to

patients under 80 years if the patient has: Target organ damage, established cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater.

Stage 2 (150/95 mmHg ABPM). Offer antihypertensive

therapy to patients of any age with Stage 2 hypertension

JNC7:After attempt of

lifestyle modifications to lower BP, if still not at goal:Stage 1: diuretic or

medication for compelling indication

Stage 2: diuretic + additional medication considering compelling indication.

Comparing NICE with JNC7 (U.S.): First Medication Therapy Used.NICE:

< 55 years: ACE inhibitor or ARB

> 55 years: Calcium Channel BlockerIf CCB not tolerated

or contraindicated, use diuretic.

JNC 7:Thiazide diuretic

for mostUnless diuretic

cannot be used or if compelling indication requires use of another class of antihypertensive.

Comparing NICE with JNC7: Additional medication treatmentNICE:

Step 2: ACEi/ARB + Calcium Channel Blocker

Step 3: ACEi/ARB + Calcium Channel Blocker + diuretic

Step 4: add spironolactone if K < 4.5 mmol/L or increase doses of diuretic if K > 4.5 mmol/L. Also can add alpha

blocker or beta blocker

JNC 7:Stage 2 (>160/100

mmHg):Thiazide diuretic +

ACEi or ARB or CCB or BB.

Level of Evidence: Class I, Level A

ReferencesChobanian AV, Bakris GL, Black HR, Cushman WC, Green

LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Rocella EJ, and National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2003. Amer Heart Assoc

National Institute for Health and Clinical Excellence. Hypertension: clinical management of primary hypertension in adults. CG127. 2011. http://guidance.nice.org.uk/CG127/Guidance/pdf/English

Medscape Cardiology. New Approaches to Managing Dyslipidemia: Risk Reduction Beyond LDL-C (Slides with Transcript). 2008. Available at: http://www.medscape.org/viewarticle/577753. Accessed on April 12, 2012.