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Hypertension 2014

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Hypertension 2014

  1. 1. Current major guidelines to future guidelines
  2. 2. WHY DO WE NEED GUIDELINES ? Physicians are continuously flooded with studies. Guidelines should help to find the right way through this jungle of information. Experts should review existing data to provide clear recommendations based on evidence. Guidelines are increasingly used by healthcare providers and politicians to assess the “appropriate use” and develop disease management programs.
  3. 3. Proportion of deaths attributable to leading risk factors worldwide High mortality, developing region Lower mortality, developing region Developed region 0 8000 7000 6000 5000 4000 3000 2000 1000 Attributable Mortality (In thousands; total 55,861,000) Ezzati et al. WHO 2000 Report. Lancet.2002;360:1347-1360
  4. 4. BP(mmHg) WHO(1970) JNC V(1991) JNC VI (1997) WHO/ISH 1999 ESH.ESC 2003 -2013 JNC VII (2003) JNC VIII (2014) < 120 & < 80 Normal Optimal Optimal Normal < 130 & < 85 Normal Normal Pre-hypertension 130-139 or 85-89 High-Normal High-Normal 140-159 or 90-99 Borderline Stage 1 Stage 1 160-179 or 100-109 Hypertension SBP >160 or DBP >95 Stage 2 Stage 2 180-199 or 110-119 Stage 3 Stage 3 ≥ 200 or ≥ 120 Stage 4 Classifications of Blood Pressure
  5. 5. 2013 ESH/ESC
  6. 6. Definitions Stage 1 hypertension: •Clinic blood pressure (BP) is 140/90mmHg orhigher and •ABPM or HBPM average is 135/85mmHg or higher. Stage 2 hypertension: •Clinic BP 160/100mmHg is or higher and •ABPM or HBPM daytime average is 150/95mmHgor higher. Severe hypertension: •Clinic BP is 180mmHg or higher or •Clinic diastolic BP is 110mmHg or higher. 2013
  7. 7. NATIONAL HEALTH & NUTRITION EXAMINATION, PERCENT NHANES II (1976-80) NHANES III (Phase1 88-91) NHANES III (Phase 2 91-94) 1999-2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 M Wolt, National Heart, Lung, and Blood Institute; JNC 6
  8. 8. Triple paradox 1.Easy to diagnose often remains undetected 2.Simple to treat often remains untreated 3.Despite availability of potent drugs, treatment all too often is ineffective
  9. 9. Cardiovascular Risk Factors Hypertension Cigarette smoking Obesity ( BMI ≥ 30 ) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimate GFR <60 mL/min Age (older than 55 for men , 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65) JNC VII EXPRESS
  10. 10. DMsmoking agegenetics/sex obesity HTN DYS Global Risk: Overlapping CV Risk Factors
  11. 11. Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy JNC VII EXPRESS
  12. 12. Identifiable causes of hypertension Sleep apnea Drug –induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy & Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease JNC VII EXPRESS
  13. 13. Laboratory Tests & Other Diagnostic Procedures JNC VII EXPRESS Electrocardiogram Urinalysis Blood glucose & hematocrit Serum potassium & calcium Creatinine Lipid profile
  14. 14. * Individuals, 40-69 years, beginning at 115/75 mm Hg. Lewington S, et al. Lancet. 2002; 60:1903-1913. The JNC 7 Report. JAMA.2003 Risk of mortality SBP (mm Hg) / DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75 135/85 155/95 175/105
  15. 15. WHITE COAT HYPERTENSION BP recording in office or clinic is high while at home is normotensive "white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology )
  16. 16. HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSMASKED HYPERTENSION
  17. 17. 135/85 Ambulatory Pressure 140/90 Clinic PressureSustained Hypertension White Coat Hypertension True Normotension Masked Hypertension
  18. 18. 2013 ESH/ESC
  19. 19. 2013 ESH/ESC
  20. 20. 2013 ESH/ESC
  21. 21. 2013 ESH/ESC
  22. 22. 2013 ESH/ESC
  23. 23. Care pathway CBPM ≥160/100 mmHg & ABPM/HBPM ≥150/95mmHg Stage 2 hypertension Consider specialist referral Offer antihypertensive drug treatment Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication Offer patient education and interventions to support adherence to treatment CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension 2013
  24. 24. Step 4 Summary of antihypertensive drug treatment Aged over 55 years or black person of African or Caribbean family origin of any age Aged under55 years C2 A A + C2 A + C + D Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha-or beta-blocker5 Consider seeking expert advice Step 1Step 2Step 3KeyA –ACE inhibitor or low-cost angiotensinII receptor blocker (ARB)1C –Calcium-channel blocker (CCB) D –Thiazide-like diuretic See slide notes for details of footnotes 1-5 2013
  25. 25. 2013 ESH/ESC
  26. 26. BP thresholds for drug treatment* General population (including CKD) (CHEP 2011**) 140/90 Very elderly (>80) (CHEP 2013**) 150 Diabetes (CHEP2000**) 130/80 Very lowCV risk (CHEP 2000**) 160/100 * lifestyle modification is recommended for all regardless of BP ** Year of incorporation into CHEP recommendations 2013
  27. 27. III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents New Recommendation for 2013 B) Recommendations for Individuals with Isolated Systolic Hypertension ADD: In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmHg (Grade C). CHEP Recommendation: the very elderly 2013
  28. 28. Summary of evidence in patients with diabetes and hypertension •SBP lowering below 140 mmHg appears beneficial with respect to all cause mortality and stroke •SBP lowering below 135mmHg or 130 mmHg appears to confer significant benefit with respect to stroke •As SBP decreases below 140 mmHg, the risk of SAEs increasesbut the absolute number of these events is low 2013
  29. 29. III. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling IndicationsTARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY *BBs are not indicated as first line therapy for age 60 and above Beta- blocker* Long- acting CCB Thiazide ACEI ARB Lifestyle modification therapyACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potentialA combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target 2013
  30. 30. III. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling IndicationsCONSIDER •Nonadherence •Secondary HTN •Interfering drugs or lifestyle •White coat effect Dual Combination Triple or Quadruple Therapy Lifestyle modification Thiazide diuretic ACEILong-actingCCBTARGET <140/90 mmHg ARB *Not indicated as first line therapy over 60 yInitial therapy A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target Beta- blocker*
  31. 31. III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications INITIAL TREATMENT AND MONOTHERAPY Thiazide diuretic Long-acting DHP CCBLifestyle modificationtherapyARBTARGET <140 mmHg (< 150 mmHg if age >80 years) 2013
  32. 32. III. Add-on therapy for Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER •Nonadherence •Secondary HTN •Interfering drugs or lifestyle •White coat effect If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). If partial response to monotherapy Long-acting DHP CCB Triple therapy Thiazide diuretic ARB Dual combination Combine first line agents2013
  33. 33. III. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER •Nonadherence •Secondary HTN •Interfering drugs or lifestyle •White coat effect Thiazide diuretic Long-acting DHP CCB Dual therapy Triple therapy Lifestyle modification therapy ARB TARGET <140 mmHg, < 150 mmHg for age >80 years *If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). 2013
  34. 34. 39Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmHg Isolated systolic hypertension Age >80 years <140 < 150 Systolic/Diastolic Hypertension • Systolic BP • Diastolic BP <140 <90 Diabetes • Systolic • Diastolic <130 <80 V. Goals of Therapy
  35. 35. 2013 ESH/ESC
  36. 36. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2013;():. doi:10.1001/jama.2013.284427 JNC VIII
  37. 37. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2013;():. doi:10.1001/jama.2013.284427 JNC VIII
  38. 38. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2013;():. doi:10.1001/jama.2013.284427 Strategies to Dose Antihypertensive DrugsJNC VIII
  39. 39. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2013;():. doi:10.1001/jama.2013.284427 Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With HypertensionJNC VIII
  40. 40. Recurrent stroke Diuretic Recurrent stroke ACE inhibitor + diuretic CEREBROVASCULAR DISEASE Cardiovascular morbidity and mortality ARB Left ventricular hypertrophy Mortality Spironolactone Mortality Beta-blocker CHF (diuretics almost always included) Mortality ACE inhibitor Heart failure ACE inhibitor Mortality Beta-blocker Left ventricular dysfunction Mortality ACE inhibitor Post MI CARDIAC DISEASE Progression of renal failure ACE inhibitor Nondiabetic nephropathy Progression of renal failure ARB Diabetic nephropathy type 2 Progression of renal failure ACE inhibitor Diabetic nephropathy type 1 RENAL DISEASE Stroke DHCCB Stroke Diuretic ELDERLY WITH ISOLATED SYSTOLIC HYPERTENSION PRIMARY ENDPOINT PREFERRED DRUG COMPELLING INDICATION Compelling Indications for Specific Antihypertensive Drugs ISH/WHO
  41. 41. Indications for the Major Classes of Antihypertensive Drugs BPH; hyperlipidemia Alpha-blockers type 2 nephropathy; diabetic microalbuminuria; proteinuria; LV hypertrophy; ACE inhibitor cough ARBs CHF; LV dysfunction; post MI; nondiabetic nephropathy; type 1 diabetic nephropathy; proteinuria ACE inhibitors Angina pectoris, carotid atherosclerosis; supraventricular tachycardia CCBs (verapamil, diltiazem) Elderly; ISH; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy CCBs (DHP) Angina pectoris; post MI; CHF (up-titration); pregnancy; tachyarrhythmias Beta-blockers CHF; post MI Diuretics (antialdosterone) Renal insufficiency; CHF Diuretics (loop) CHF; elderly; ISH; hypertensives of African origin Diuretics (Thiazide) Conditions Favoring Use Drug
  42. 42. -Chobanian AV et al. JNC 7. JAMA 2003 ; 289 : 2560-2572 -ESH Guidelines Committee. J Hypertens 2003 ; 21 : 1011-1053 Compelling indications for beta-blockade Hypertension /Heart Failure Hypertension /post MI Hypertension /high CAD risk Hypertension /Diabetes Mellitus Hypertension /arrhythmias Hypertension /angina pectoris
  43. 43. Choice of anti-hypertensive drugs in patient with concomitant disease Concomitant disease Diuretics B-Blockers ACEI Ca channel blocker Alpha blocker ARB Diabetes Careful Careful Yes Yes Yes Yes Gout No Yes Yes Yes Yes Yes/No Hyperlipidemia Careful Careful Yes Yes Yes Yes IHD Yes Yes Yes Yes Yes Yes Heart Failure Yes Careful Yes Careful Yes Yes Asthma Yes No Yes Yes Yes Yes PVD Yes Careful Yes Yes Yes Yes Renal impairment Yes Yes Careful Yes Yes Careful Renal A Stenosis Yes Yes Careful Yes Yes Careful Elderly with no co morbid cond. Yes Yes Yes Yes Yes Yes
  44. 44. Group Effective Agents Ineffective Agents Young white ACE inhibitors, beta blocker Diuretic Older white CCB, beta-blocker Young black CCB ACE inhibitors, beta-blocker Other black Diuretic ACE inhibitors, beta-blocker Isolated systolic hypertension Diuretic ACE inhibitors CurrentDiagnosis&TreatmentinCardiology Response by demographic group
  45. 45. Stratification and Management Blood pressure (mmHg) Other risk factors & disease history No other risk factors 1-2 risk factors ≥ 3 risk factors or TOD or ACC Pre-hypertension 120-139 or 80-89 Lifestyle modification Lifestyle modification Drug for the compelling indications Grade I: SBP 140-159 or DBP 90-99 Lifestyle modification 6 months One drug therapy Drug combination Grade II & III: SBP ≥160 or DBP ≥ 100 Drug combination Drug combination Drug combination
  46. 46. Renin-angiotensin system Sympathetic nervous system Vasoconstriction/ Renal Retention of Excess Sodium Vascular Hypertrophy Hypertension: a multifactorial entity Patient 1Patient 2Patient 3
  47. 47. Renin-angiotensin system Sympathetic nervous system Vasoconstriction/ Diuretic Vascular Hypertrophy Renal Retention of Excess Sodium Hypertension: a multifactorial entity
  48. 48. MDs have not been aggressive enough in controlling hypertension in their patients Patients w/ DM & CKD require more aggressive BP control Most patients with hypertension will require two or more antihypertensive medications to control blood pressure The use of combination therapy is appropriate as initial treatment Sustained antihypertensive efficacy may protect against the early morning rise in blood pressure that leads to heightened risk of cardiovascular events Summary

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