Download Hypertension Guidelines 2014

Hypertension Guidelines 2014
Jason A. Smith, DO
Associated Cardiovascular Consultants at
Lourdes Cardiology Services
Disclosures
No disclosures
Hypertension
• Hypertension 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
Case
• A 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 microalbumin is mildly elevated.
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg
Case Question 2
• What is the drug of choice to start?
1.
2.
3.
4.
5.
6.
HCTZ
Norvasc
Lisinopril
Losartan
Bystolic
Combination therapy
Classification of BP – JNC 7
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Normal
< 120
and
< 80
Pre-HTN
120-139
or
80-89
Stage I
140-159
or
90-99
Stage II
> 160
or
> 100
Hypertension
2013 ESH/ESC Guidelines for the management of arterial hypertension
Definitions and classification of office BP levels (mmHg)*
Hypertension:
SBP >140 mmHg ± DBP >90 mmHg
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120–129
and/or
80–84
High normal
130–139
and/or
85–89
Grade 1 hypertension
140–159
and/or
90–99
Grade 2 hypertension
160–179
and/or
100–109
Grade 3 hypertension
≥180
and/or
≥110
Isolated systolic hypertension
≥140
and
<90
* 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.
The 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
Medical Education & Information – for all Media, all Disciplines, from all over the World
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JNC 8
• 2014 Evidence-Based Guidelines for
the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
– December 18, 2013
JNC 8: Hypertension Management
Questions Guiding Review
• In adults with HTN:
1. Does initiating antihypertensive
pharmacologic therapy at specific BP
thresholds improve health outcomes?
2. Does treatment with antihypertensive
pharmacologic therapy to a specified goal
lead to improvements in health outcomes?
3. Do various antihypertensive drugs or drug
classes differ in comparative benefits and
harms on specific health outcomes?
JNC 8: Hypertension Management
Evidence Review
• Limited to RCT’s
– Hypertensive adults > 18 years old
– Sample size > 100
– Follow-up > 1 year
– Reported effect of treatment on important
health outcomes (mortality, MI, HF, CVA,
ESRD)
• January 1966 to December 2009
– Separate criteria used of RCT’s published
after December 2009
JNC 8: Hypertension Management
Evidence Review
• RCT’s December 2009 – August 2013
1. Major study in hypertension
•
ACCORD, NEJM 2010
2. > 2,000 participants
3. Multicentered
4. Met all other inclusion/exclusion criteria
JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
JNC 8: Drug Treatment
Thresholds and Goals
• Age > 60 yo
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A
JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yo
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for ages 40-59; Grade E for ages 1839
JNC 8: Drug Treatment
Thresholds and Goals
• Age > 18 yo with CKD or DM
– JNC 7: < 130/80 (MDRD NEJM 1994)
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade E
JNC 8: Initial Drug Choice
• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B
• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
JNC 8: Initial Drug Choice
• Age > 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
outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria
• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo
• Diuretic is an option for initial therapy
JNC 8: Subsequent Management
• Reassess treatment monthly
• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
– Consider referral to HTN specialist
– LOE: Grade E
Dissenting Editorial
• Ann 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 Statements
• 2013 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
2013 ESH/ESC Guidelines for the management of arterial hypertension
Blood pressure goals in hypertensive patients
Recommendations
SBP goal for “most”
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD
<140 mmHg
SBP goal for elderly
•Ages <80 years
•Initial SBP ≥160 mmHg
140-150 mmHg
SBP goal for fit elderly
Aged <80 years
<140 mmHg
SBP goal for elderly >80 years with SBP
•≥160 mmHg
140-150 mmHg
DBP goal for “most”
<90 mmHg
DB goal for patients with diabetes
<85 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The 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
Medical Education & Information – for all Media, all Disciplines, from all over the World
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BP goal in the elderly
2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with diabetes
Recommendations
Additonal considerations
Mandatory: initiate drug treatment in patients
with SBP ≥160 mmHg
• Strongly recommended: start drug treatment
when SBP ≥140 mmHg
SBP goals for patients with diabetes: <140 mmHg
DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes
• RAS blockers may be preferred
• Especially in presence of preoteinuria or
microalbuminuria
Choice of hypertension treatment must take comorbidities into account
• Avoid in patients with diabetes
Coadministration of RAS blockers not
recommended
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.
The 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
Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with nephropathy
Recommendations
Additonal considerations
Consider lowering SBP to <140 mmHg
Consider SBP <130 mmHg with overt proteinuria
• Monitor changes in eGFR
RAS blockers more effective to reduce
albuminuria than other agents
• Indicated in presence of microalbuminuria or
overt proteinuria
Combination therapy usually required to reach BP
goals
• Combine RAS blockers with other agents
Combination of two RAS blockers
• Not recommended
Aldosterone antagonist not recommended in CKD
• Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.
The 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
Medical Education & Information – for all Media, all Disciplines, from all over the World
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What is the goal BP?
Comparison of Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
>140/90 <80 yr
>150/90 >80 yr
>140/90
Threshold
for Drug Rx
>140/90 < 60 yr Eldery SBP >160
>150/90 >60 yr Consider SBP
140-150 if <80 yr
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
w/ 2 drugs
>160/100
"Markedly
elevated BP"
>160/100
>160/100
Goal BP
Group
BP Goal (mm Hg)
General
DM*
CKD**
JNC 8:
<60 yr: <140/90
>60 yr: <150/90
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
*ADA: < 140/80 or lower
(SBP < 130 if proteinuria)
< 140/90
< 140/90
(Consider < 130/80 if proteinuria)
< 140/90
< 140/90
**KDIGO: <140/90 w/o albuminuria
<130/80 if >30 mg/24hr
2013 ESH/ESC Guidelines for the management of arterial hypertension
Lifestyle changes for hypertensive patients
Recommendations to reduce BP and/or CV risk factors
Salt intake
Restrict 5-6 g/day
Moderate alcohol intake
Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
25 kg/m2
BMI goal
Waist circumference goal
Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Exercise goals
Quit smoking
* Unless contraindicated. BMI, body mass index.
The 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
Medical Education & Information – for all Media, all Disciplines, from all over the World
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Thank you for your attention!
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