hypertension guidelines 1

Hypertension Guidelines 2014Jason A. Smith, DOAssociated Cardiovascular Consultants atLourdes Cardiology Services

Disclosures No disclosures

HypertensionHypertension 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

CaseA 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 micro-albumin is mildly elevated.

Case Question 1What goal BP is most appropriate for this patient?

Case Question 2What is the drug of choice to start?HCTZNorvascLisinoprilLosartanBystolicCombination therapy

Classification of BP JNC 7

CategorySystolic (mmHg)Diastolic (mmHg)Normal< 120and< 80Pre-HTN120-139or80-89HypertensionStage I140-159or90-99Stage II> 160or> 100

Medical Education & Information for all Media, all Disciplines, from all over the WorldPowered by2013 ESH/ESC Guidelines for the management of arterial hypertensionThe 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

Denitions and classication of office BP levels (mmHg)* * 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.Hypertension:SBP >140 mmHg DBP >90 mmHg

CategorySystolicDiastolicOptimal

JNC 82014 Evidence-Based Guidelines for the Management of High Blood Pressure in AdultsJAMA. 2014;311(5):507-520December 18, 2013

JNC 8: Hypertension ManagementQuestions Guiding ReviewIn adults with HTN:Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?Does treatment with antihypertensive pharmacologic therapy to a specified goal lead to improvements in health outcomes?Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

JNC 8: Hypertension ManagementEvidence ReviewLimited to RCTsHypertensive adults > 18 years oldSample size > 100Follow-up > 1 yearReported effect of treatment on important health outcomes (mortality, MI, HF, CVA, ESRD)January 1966 to December 2009Separate criteria used of RCTs published after December 2009

JNC 8: Hypertension ManagementEvidence ReviewRCTs December 2009 August 2013Major study in hypertensionACCORD, NEJM 2010> 2,000 participantsMulticenteredMet all other inclusion/exclusion criteria

JNC 8: Graded RecommendationsA Strong evidenceB Moderate evidenceC Weak evidenceD AgainstE Expert OpinionN No recommendation

JNC 8: Drug TreatmentThresholds and GoalsAge > 60 yoSystolic:Threshold > 150 mmHgGoal < 150 mmHgLOE: Grade A

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A

JNC 8: Drug TreatmentThresholds and GoalsAge < 60 yoSystolic:Threshold > 140 mmHgGoal < 140 mmHgLOE: Grade E

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A for ages 40-59; Grade E for ages 18-39

JNC 8: Drug TreatmentThresholds and GoalsAge > 18 yo with CKD or DMJNC 7: < 130/80 (MDRD NEJM 1994)Systolic:Threshold > 140 mmHgGoal < 140 mmHgLOE: Grade E

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade E

JNC 8: Initial Drug ChoiceNonblack, including DMThiazide diuretic, CCB, ACEI, ARBLOE: Grade B

Black, including DMThiazide diuretic, CCBLOE: Grade B (Grade C for diabetics)

JNC 8: Initial Drug ChoiceAge > 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 outcomesLOE: Grade BBlacks w/ or w/o proteinuriaACEI or ARB as initial therapy (LOE: Grade E)No evidence for RAS-blockers > 75 yoDiuretic is an option for initial therapy

JNC 8: Subsequent ManagementReassess treatment monthlyAvoid ACEI/ARB combinationConsider 2-drug initial therapy for Stage 2 HTN (> 160/100)Goal BP not reached with 3 drugs, use drugs from other classesConsider referral to HTN specialistLOE: Grade E

Dissenting EditorialAnn Intern Med. January 14, 2014

5/17 authors (29%)

Insufficient evidence to increase target SBP to 150 mmHg.

Expertise vs. Scientific Evidence

Recent HTN Guideline Statements2013 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


Blood pressure goals in hypertensive patientsSBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure.

RecommendationsSBP goal for mostPatients at lowmoderate CV riskPatients with diabetesConsider with previous stroke or TIAConsider with CHDConsider with diabetic or non-diabetic CKD

BP goal in the elderly


Hypertension treatment for people with diabetesSBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.

RecommendationsAdditonal considerationsMandatory: initiate drug treatment in patients with SBP 160 mmHgStrongly recommended: start drug treatment when SBP 140 mmHgSBP goals for patients with diabetes:

What is the goal BP?

Comparison of RecentGuideline Statements

JNC 8ESH/ESCAHA/ACCASH/ISH>140/90Threshold>140/90 < 60 yrEldery SBP >160>140/90 150/90 >60 yrConsider SBP>140/90>150/90 >80 yr140-150 if 160/100"Markedly>160/100>160/100w/ 2 drugselevated BP"

Goal BP*ADA: < 140/80 or lower**KDIGO:

Thank you for your attention!

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hypertension guidelines 1

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