Blueprint for Change: Defining and Promoting a Single, Effective System of

Care for Patients with Hypertension

Robert M. Carey, MD, MACP, FRCP, FRCPI, FAHADean, Emeritus, and Professor of Medicine

University of Virginia School of MedicineCharlottesville, VA

AMERICAN COLLEGE OF MEDICAL QUALITY

Bethesda, MD12 April 2019

I have nothing to disclose.

HYPERTENSION

• World’s leading risk factor for morbidity and mortality.

• Ranks first worldwide in disability-adjusted life years (7%).

• Affects 27% of the world’s adult population –approximately one-billion people.

• Prevalence 34.0% in U.S. (2011-2014 NHANES data; 85.7 million adults).

• The most common reason for visiting a physician for ongoing care in the U.S.

Recent BP Guidelines

KDIGO JNC 8 Panel ACP/AAFP ADA

2012 2014 2017 2017

Kidney Int (Supp) JAMA Ann Intern Med Diabetes Care (2003 GL Update)

Areas of Focus

Renal disease(Adults & children)

≥ 18 y Older adults (≥ 60 y)

Diabetes Mellitus(Adults)

Treatment(Lifestyle & Drug)

Treatment (Drug)Limited to:1) BP threshold2) BP goal3) Drug class diffs.

Treatment (Drug)Limited to: 1) BP goal

Diagnosis and Treatment(Lifestyle & Drug)

JNC 7 Australia Canada ACC/AHA ESC/ESH

2003 2016 2016 2017 2018

Hypertens/JAMA AHF website Can J Cardiol Hypertens/JACC J Hypertens/EHJ

≥18 y ≥18 y Adults Adults Adults

Update (1997 JNC VI) Update (2010 GL) Update (Annual) Update (JNC 7) Update (2013 GL)

Focused

Comprehensive

DiagnosisJNC 7 Australia Canada ACC/AHA ESC/ESH

Office SBP ≥ 140 DBP ≥ 90

OfficeSBP ≥ 140DBP ≥ 90

Office (Non AOBP)SBP ≥ 140DBP ≥ 90

OfficeSBP ≥130DBP ≥80

OfficeSBP ≥140DBP≥90

Office (AOBP) PreferredSBP ≥135/DBP ≥85SBP ≥130/DBP ≥80 in DM

ABPM Day:≥ SBP 135 or DBP ≥ 8524 hrs:≥ SBP 130 or DBP ≥ 80

HBPM≥ SBP 135 or DBP ≥ 85

5

KDIGO JNC 8 Panel ACP/AAFP ADA

Not defined(Focus on BP)

Not defined Presumably assumes:

SBP ≥140DBP ≥90

Not definedPresumably assumes:

SBP ≥140DBP ≥90

OfficeSBP ≥140DBP ≥90

Focused Guidelines

Comprehensive Guidelines

Threshold

JNC 7 Australia Canada ACC/AHA ESC/ESH

LifestyleSBP ≥120DBP ≥80

LifestyleAll adults

Lifestyle Lifestyle Lifestyle

DrugsSBP≥140DBP ≥90

DrugsSBP ≥140DBP ≥90

(Consider CVD risk)

DrugsNon-AOBPSBP ≥140DBP ≥ 90

DrugsBP ≥140/90for all adults;BP ≥130/80 for those with CVD or high ASCVD risk

DrugsAdd drugs if;

SBP ≥140DBP ≥90

Comprehensive Guidelines

KDIGO JNC 8 Panel ACP/AAFP ADA

Office BPSBP≥140DBP ≥90

Drug therapy (only)<60y: SBP ≥140/DBP ≥90>60y: SBP ≥150/DBP ≥90

Drug therapy ≥60YAll: SBP ≥150Stroke/TIA: SBP ≥140High CVD risk: SBP ≥140

Not specifically stated

Presumably office BPSBP ≥140/DBP ≥90

Focused Guidelines

TargetJNC 7 Australia Canada ACC/AHA ESC/ESH

SBP <140DBP <90

SBP <140DBP <90High CVD risk: SBP <120

SBP <140DBP <90

High CVD risk:SBP <120

SBP <130DBP <80

COR higher forhigh ASCVD risk

SBP ≤130 but not less than 120 in adults 18-65 years; <140 - 130 if tolerated.

7

Not based CVD risk Treatment target influenced by CVD risk

KDIGO JNC 8 Panel ACP/AAFP ADA

SBP ≤140DBP ≤90

≥60 ySBP/DBP <150*/90

≥60 ySBP <150

SBP <140DBP <90

Albuminuria

>300 mg/24 hr>30 mg/24 hr in DM

30 – 59 y<DBP 90 mm Hg

High CVD risk(not defined)

SBP <140

High CVD risk (not defined)

SBP <130/DBP <80

*Minority report favoring SBP <140

H/O stroke or TIASBP < 140(moderate evidence forSBP 130-139)

Comprehensive Guidelines

Focused Guidelines

No explicit influence by CVD risk Treatment target influenced by CVD risk

Not based CVD risk

ACCURACY OF BP MEASUREMENT

• Statement calls for greater use of out-of-office BP measurements (ABPM or HBPM) for both the diagnosis and management of hypertension.

• AOBP devices (attended or unattended) should be considered for use in measuring office BP.

• Office BP should be measured ≥2 times at each clinic visit.

• Training of personnel is crucial for BP measurement, even when AOBP is employed.

• HBPM by itself is ineffective in BP control but is effective when used in combination with supportive interventions (eg. web-based/telephone feedback).

• The main indications for ABPM are to detect white coat and masked hypertension.

• HBPM can be employed to assess out-of-office BP when ABPM is unavailable or unaccepted by the patient and can be used to detect WCH and MH.

Muntner P et al. Hypertension. 2019;73: DOI:10.1161/HYP.0000000000000087

BP MEASUREMENT BY AOBP

• Automated oscillometric device records multiple BP readings automatically.

• Allows the patient to have BP measured alone without talking in absence of a health care provider, improving the quality of the readings.

• Meta-analysis of 31 studies comprising 9,279 participants demonstrated that research/office SBP readings were 14.5 mmHg higher than AOBP readings.

• AOBP readings were demonstrated to be equivalent to daytime ABPM readings and essentially eliminating the white coat effect.

• The data suggest that unattended AOBP readings are more accurate than office BP readings and are devoid of any white coat effect.

Roerecke M et al. JAMA Intern Med. 2019;179:351-362.

BP CLASSIFICATION (JNC 7 and ACC/AHA Guidelines)

SBP DBP

<120 and <80

120–129 and <80

130–139 or 80–89

140–159 or 90-99

≥160 or ≥100

2003 JNC7

Normal BP

Prehypertension

Stage 1 hypertension

Stage 2 hypertension

2017 ACC/AHA

Normal BP

Elevated BP

Stage 1 hypertension

Stage 2 hypertension

Stage 2 hypertension

• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions• Adults with SBP or DBP in two categories should be designated to the higher BP category

Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.

Area ofdifference

11

Estimated Risk of BP-related Coronary Heart Disease by Level of Systolic Blood Pressure

Experience during an average of 11.6 years of follow-up in 347,978 adults

screened for entry into the Multiple Risk Factor Intervention Trial

Adapted from Stamler J et al. Arch Intern Med. 1993;153:598-615.

130-139 category> 20% of BP-related risk

130-139 categoryalmost double riskof CHD (and stroke)vs. normal BP

130-139 categoryhigh prevalence

2017 ACC/AHA BP Guideline: Thresholds for Treatment

CVD Risk/other

circumstances

N/A

N/A

- No CVD- 10-yr ASCVD risk <10%*

- CVD, or- 10-year ASCVD risk ≥ 10%

Diabetes or CKD

Age ≥65 years

N/A

Recommended Treatment

Healthy Lifestyle

Nonpharmacological therapy

Nonpharmacological therapy

Nonpharmacological therapy

and

Antihypertensive drug therapy

* AHA/ACC 2013 Pooled Cohort CVD Risk Equations

Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.

+

SBP DBP

<120 and <80(Normal)

120–129 and <80(Elevated)

130-139 or 80-89(Stage 1 Hypertension)

130-139(Stage 1 Hypertension)

≥140 or ≥90(Stage 2 Hypertension)

http://tools.acc.org/ASCVD-Risk-Estimator/APP Store: ASCVD Risk Estimator Plus

ACC/AHA POOLED COHORT EQUATIONS

To estimate the 10-year risk of ASCVD

Based on age, race, sex, total cholesterol, LDL cholesterol, HDL cholesterol, treatment with a statin, systolic BP, treatment for hypertension, history of diabetes, current smoker, aspirin therapy

Validated for adults 40-79 years of age.

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r 1

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0

0

10

20

30

40

50

60

70

1

2

3

4

1612

84

Systolic blood pressure reduction (mm Hg)

<11

11-15

16-21

>21

18

69

54

37

19

57

44

31

16

36

28

20

1014

10

5

CVD EVENTS AVOIDED BY BASELINE RISK AND MAGNITUDE OF SBP LOWERING

Sundstrom et al. Lancet. 2014;384:591–598

Lifestyle

Intervention Dose

Impact on SBP

Hypertension Normotension

Weight loss Best goal is ideal body weight, but aim

for at least a 1-kg reduction in body

weight for most adults who are

overweight. Expect about 1 mm Hg for

every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet Consume a diet rich in fruits,

vegetables, whole grains, and low-fat

dairy products, with reduced content

of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced intake

of dietary

sodium

Optimal goal is <1500 mg/d, but aim

for at least a 1000-mg/d reduction in

most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced intake

of dietary

potassium

Aim for 3500–5000 mg/d, preferably

by consumption of a diet rich in

potassium.

-4/5 mm Hg -2 mm Hg

LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND TREATMENT OF HYPERTENSION

All 4 Recommendations COR:1; LOE:A

Nonpharmacological

Intervention Dose

Effect on SBP

Hypertension Normotension

Physical

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

-5/8 mm Hg -2/4 mm Hg

Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10

repetitions/set

-4 mm Hg -2 mm Hg

Isometric

resistance

● 4 × 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction,

3 sessions/wk

● 8–10 wk

-5 mm Hg -4 mm Hg

Moderation

in alcohol

intake

Alcohol

consumption

In individuals who drink alcohol,

reduce alcohol to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

-4 mm Hg -3 mm

LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND

TREATMENT OF HYPERTENSION

Both Recommendations COR:1; LOE:A

0

20

40

60

80

45.6%

13.7%

31.9%

36.2%1.9%

34.3%

53.4%

14.4%

39.0%

0

20

40

60

80

100

120

140

Hypertension Recommended

pharmacological

treatment

Blood pressure

above goal among

pharmacologically

treated US adults

103.3

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72.2

81.94.2

77.7 29.2

7.9

21.3

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2017 ACC/AHA guideline but not JNC7

2017 ACC/AHA guideline and JNC7

PREVALENCE OF HYPERTENSION, RECOMMENDATIONS FOR ANTIHYPERTENSIVE DRUG TREATMENT AND BP ABOVE GOAL

Muntner et al. Circulation. November, 2017

2017 ACC/AHA BP Guideline: Treatment Targets

SBP DBP

<120 and <80

120–129 and <80

130-139 or 80-89

130–139 or 80–89

≥130 or ≥80

≥140 or ≥90

≥130

CVD Risk

N/A

N/A

No CVD and 10-yearASCVD risk <10%

Clinical CVD or 10-year ASCVD risk ≥ 10%

Diabetes or CKD

N/A

Age ≥65 years

Recommended BP Target

N/A

N/A

SBP <130 (DBP <80 mm Hg)

SBP <130 mm Hg

Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.

ASSOCIATION OF HYPERTENSION GUIDELINES WITH CVD EVENTS AND DEATH IN THE US

Bundy JD et al. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.1240

Characteristic 2014 Evidence-Based Guideline

2017 ACC/AHA Guideline

BP threshold for definition of hypertension

≥140/90 ≥130/80

BP threshold for initiation of antihypertensive drugs

≥140/90 (<age 60)≥150/90 (≥age 60)

≥140/90 (gen. population)≥130/80 (high CVD risk)

BP goal of treatment <140/90 (<age 60)<150/90 (≥age 60)

<130/80

Annual CVD event reduction (adults ≥age 40)

270,000 610,000 (NNT=70)

Annual reduction in death(adults ≥age 40)

177,000 334,000 (NNT=129)

(1) Incidence of major CVD events & all-cause mortality by modeling 4 community-based cohort studies

(2) Network meta-analysis (42 RCTs) to estimate HRs for outcomes and determine population-attributable risks and events reduced.

SUMMARY

• Hypertension is, arguably, the most significant medical and public health problem in the United States today.

• Evidence-based clinical practice guidelines from several organizations have appeared during the past 2 years.

• Although recommendation differences do exist, these are relatively minor compared with the overall similarities of the guidelines.

• Although we may not be able to reach complete consensus on the guideline recommendations, the hope is that we can reach conclusions about the way BP is controlled that will benefit our patients and communities.

Thank you for your kind attention!