lawrence fine-recent htn guidelines
TRANSCRIPT
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Recent Hypertension Guidelines
Lawrence J. Fine, MD, DrPH, FAHADivision of Cardiovascular Sciences
NHLBI/NIH
February 19, 2014
Disclosures: Member of Panel Appointedto the Eighth Joint National Committee
(JNC 8)
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Million Heart Campaign wants to build on
the accelerating progress of the last
twenty years
The Million Heart
Campaign is building onthe accelerating
progress of the last
twenty years
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Getting warm . warmer.
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Look at CVD mortality for those < 75 yearsold.
Nearly one fourth of all CVD death avoidable.
56% of the avoidable deaths in those < 65(important target for primary prevention).
Some of these avoidable deaths are likely
due to lack of preventive health care or timelyand effective medical care.
vo a e ea s rom ear sease,Stroke, and Hypertensive DiseaseUnited
States, 2001 - 2010 MMWR September 6, 2013
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AgeGroups
CVDDeath
s in
2001
CVDDeath
s in
2010
PercentDecline in
Death Rate(p < .05)
35-54 46,426 43,884 -6%
55-64 61,105 65,680 -27%
65-74 117,66
2
87,741 -37%
Number of Avoidable Deaths from CVD
United States, 2001 -2010
MMWR 9/26/2013Schieb LJ
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Race/Ethnicity and sex
2001Rates
per
100,000
2010 (%Decline over 10
years p < .05)
Asian
Females
36 22 (-39%)
White Men 112 81 (-28%)
Hispanic
Men
93 63 (-28%)
a es o vo a e ea s a a us ra esMurrays Eight Americas: New perspectives
on U.S. health disparities
Asian men
47
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sen ang ng omp ex y s a eng ngWhy did CVD decrease and how can we
make additional progress?
http://www.smallmanart.com/2012/07/05/disentangling-complexity.html -
Stefano Masini 2012
http://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.html -
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146
133
122139
108100
110
120
130
140
150
160
1988-1994 1999-2002 2007-2010
Age Specific LDL mg/dL in Adults60-69
Carroll et al. 2012 JAMA
Wom
en
A Partial Answer: Trends in LDL 1988-2010
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Disentangling Complexity is ChallengingMany
new guidelines?
http://www.smallmanart.com/2012/07/05/disentangling-complexity.html -
Stefano Masini 2012
http://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.htmlhttp://www.smallmanart.com/2012/07/05/disentangling-complexity.html -
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2014 Evidence-Based Guideline for theManagement of High Blood Pressure in Adults:
Report from the Panel Members Appointed to
the Eighth Joint National Committee (JNC 8)
American Society of Hypertension and the
International Society of Hypertension Clinical
Practice Guidelines for the Management of
Hypertension in the Community
2013 European Society of
Hypertension/European Society of Cardiology
Guidelines
Four New Guidelines
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Each set of these guidelines wasindependently developed. They used
different methodologies and criteria for
reaching their conclusions and varied inhow comprehensive their
recommendations were.
All acknowledged that many key questionsremained unanswered and called for
greater research.
Four New Guidelines
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Areas of agreement - 140/90 for both goaland threshold
Individuals younger than 60
Individuals with diabetes Individuals with chronic kidney disease (CKD)
without significant proteinuria
Systolic Blood Pressure Treatment Goals
and Thresholds
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2014 Evidence-Based Guideline for the Management ofHigh Blood Pressure in Adults Report From the PanelMembers Appointed to the Eighth Joint NationalCommittee (JNC 8)
Paul A. James, MD1; Suzanne Oparil, MD2; Barry
L. Carter, PharmD
1
; William C. Cushman, MD
3
;Cheryl Dennison-Himmelfarb, RN, ANP, PhD4;Joel Handler, MD5; Daniel T. Lackland, DrPH6; MichaelL. LeFevre, MD, MSPH7; Thomas D. MacKenzie, MD,MSPH8; Olugbenga Ogedegbe, MD, MPH, MS9; SidneyC. Smith Jr, MD10; Laura P. Svetkey, MD, MHS11; Sandra
J. Taler, MD12
; Raymond R. Townsend, MD13
; JacksonT. Wright Jr, MD, PhD14; Andrew S. Narva, MD15;Eduardo Ortiz, MD, MPH16,17
The JAMA Report in December 2013
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Date of download: 2/11/2014 Copyright 2014 American MedicalAssociation. All rights reserved.
2014 Evidence-Based Guideline for the Management of HighBlood Pressure in Adults: Report From the Panel MembersAppointed to the Eighth Joint National Committee (JNC 8)
Guideline Goal BP and Initial Drug Therapy for Adults With Hypertension
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
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Corollary Recommendation -ifpharmacologic treatment for high BP
results in lower achieved SBP (e.g.,
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Other Views
http://www.ash-us.org/documents/ASH_ISH-
Guidelines_2013.pdf
http://www.ash-/http://www.ash-/http://www.ash-/ -
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Where ASH and the JAMA JNC Paper
Agreed
http://www.ash-us.org/documents/ASH_ISH-
Guidelines_2013.pdf
The treatment goal for systolic bloodpressure is usually
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Where Do ASH and the JAMA JNC 8 Diverge
on SBP Thresholds and Goals?
http://www.ash-us.org/documents/ASH_ISH-
Guidelines_2013.pdf
For patients older than 80 years, thesuggested threshold for starting
treatment is at levels 150/90 mm Hg.
Thus, the target of treatment should be
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Biggest area of diversion is between 60 and 79years old.
There is more general agreement for thoseindividuals 80 years old and older, particularly if
they are fragile, that the treatment goal shouldbe 150/90 rather than 140/90. This includes the expert opinion that if an individual is
doing well on treatment there is no compelling reasonto reduce the intensity of treatment at a specific age.
Other guidelines (Canadian, UK and ESH/ESC)all support the 150/90 goal for those 80 yearsold and older.
Treatment Goals and Thresholds in Older
Individuals
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Initial Drug ChoicesGeneral Population
and Diabetes
JNC 8 Panel Nonblack: Thiazide-type
diuretic, ACEI, ARB, or CCB
Black Patients - Thiazide-
type diuretic, or CCB
Patients with Diabetes:
Thiazide-type diuretic,ACEI, ARB, or CCB
Both agree on ACEI and
ARB for CKD patients
ASH
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Minority View from JNC 8 Panel Members on
Only One Recommendation
Wright was frank: "Thisarticle is not intended as anattack on the 2014hypertension guidelines. . . .The purpose of
thisAnnals
commentarywas to clarify the rationalebehind the defense ofkeeping the 140 mm Hgtarget, rather than raising itto 150 mm Hg.
Lot of dialogue and mutualrespect on the Panel.
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Differing Perspectives on Whether There Was
Evidence of Benefits
Majority Perspective
HYVET, Syst-Eur andSHEP showed benefit buthad average SBP in the
active arm of between143 and 150 mm Hg.
Only two other goal trials(JATOS and VALISH),while having limitations,provided no evidence ofbenefit of 145 vs. 135 mmHg.
Minority Perspective
Evidence from trials andobservational studies thatthe panel did not use as
part of its review supportsthe lower goal, especially inhigh-risk patients.
Two large meta-analysessupported the < 140 mm Hg
goal. Inconsistency on lower goal
ok for diabetes but not otherhigh risk groups.
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These Differing Perspectives Were
Reflected within the Appointed JNC 8 Panel
Majority Perspective No. 1, it's going to simplify the
goals (of treatment because) thereare only two goals to remember. No.2, I do think a lot of physicians whotake care of the elderly have beenconcerned over the years about thepotential for causing harm byovertreating blood pressure." It'scertainly not uncommon for elderlypatients to become dizzy onstanding because of theantihypertensive medication ormedications they take. Such
patients, James noted, are at anincreased risk for falls and theirsequelae.
Minority Perspective
What is the trial
evidence of increase
risk of serious adverse
events with treatment to
< 140 mm Hg.
JATOS, VALISH, and
SPS3 all concluded that
the lower goal was
safe.
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HYVET - Blood Pressure, Measured byStudy Group
Beckett NS et al. N Engl J Med 2008;358:1887-1898
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Main Fatal and Nonfatal End Points
Beckett NS et al. N Engl J Med 2008;358:1887-1898
O f th R f Diff i
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Table 2 Trials Comparing SBP < 140 mmHg vs. Higher
SBP Goal
TRIAL(N)TOTAL
ENDPTSCOMPOSITE
CVD STROKEJATOS(21)(n=4,418) N= 172
Rate per 1000
py: 22.6 vs
22.7P=0.99
Rate per 1000
py: 13.7 vs.
12.9 P=0.77
VALISH(17)(N = 3,260) N= 99
HR: 0.89p = 0.383 HR: 0.68p = 0.237
FEVER(16) N = 575 HR: 0.73 HR: 0.73
One of the Reasons for Differing
Conclusions
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Increasing the systolic BP target in those 60 yearsor older will have the effect of reducing the intensityof antihypertensive treatment among patientsalready being treated, among them a large
population with established CVD or at high risk forCVD (including African Americans and patients withmultiple CVD risk factors other than chronic kidneydisease).
Raising the target may have the unintended effect ofreversing decades of declining CVD rates,especially stroke mortality.
Possible Consequences of the Higher Goal
US CVD D th R t f I di id l d
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Condition(Cause ofdeath by
underlying
Cause)
Age < 65or 65 years
1999-2010Yearly
Average
Death Rate
per 100,000
1989-1998
Averageannual %
change in
age-
adjusted
death rates
1999-2010
Averageannual %
change in
age-
adjusted
death ratesCoronar
y
Disease < 65 30 -3.6 -3.4Coronar
y
Disease 65 1038 -2.7 -5.6
Stroke < 65 7 -1.3 -2.3Stroke 65 356 -0.9 -5.3
US CVD Death Rates for Individuals < and >
than 65 years
Aft th JAMA P bli ti
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The American Heart Association and the American Collegeof Cardiology released four cardiovascular treatmentguidelines for healthcare providers in November, and nextyear they will be updating their high blood pressureguidelines as well. The new report that was published inJAMA will be taken into consideration for those
guidelines, which will be the national standard for treatinghypertension.
Until then, the AHA/ACC recognize the most recenthypertension guidelines, published in 2004 by the JointNational Committee on Prevention, Detection, Evaluation,and Treatment of High Blood Pressure, as the nationalstandard.
After the JAMA Publication:
American Heart Association Stays with JNC 7
http://hyper.ahajournals.org/content/42/6/1206.fullhttp://hyper.ahajournals.org/content/42/6/1206.full -
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WWhat will resolve the
controversy ?w
More data
Jackson Wright
Th k Y (I l t Li t) Alth h Wh t
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Thank You (Incomplete List) - Although What
I Say May Not Reflect Their Views
Jackson WrightDaniel Lackland
Gbenga Ogedeghe
Cheryl Dennison
Michael Mussolino
Joni Snyder
Paul Sorlie
Stefano MasiniOther Member of the JNC 8
Panel
Authors of the articles that I
cited32