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IN THE NAME OF GOD

IN THE NAME OF GOD. Hypertension. Mohammad Garakyaraghi,MD Cardiologist Associate Professor. 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. New Guidelines for Hypertension.

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. Hypertension Mohammad Garakyaraghi,MD Cardiologist Associate Professor

  3. 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

  4. New Guidelines for Hypertension • National Institute for Health and Clinical Excellence (NICE), 2011 • Kidney Disease: Improving Global Outcome (KDIGO), 2012 • European Society of Hypertension/European Society of Cardiology, (ESH/ESC), 2013 • American Diabetes Association (ADA), 2014 • American Society of Hypertension and the International Society of Hypertension (ASH/ISH), 2014 • Eighth Joint National Committee (JNC8), 2013

  5. JNC 8: Hypertension ManagementEvidence 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

  6. JNC 8: Hypertension ManagementEvidence Review • RCT’s December 2009 – August 2013 • Major study in hypertension • ACCORD, NEJM 2010 • > 2,000 participants • Multicentered • Met all other inclusion/exclusion criteria

  7. JNC8: Methods • Excluded sample size < 100 and f/up period < 1 year • Only included randomized, controlled trials rated as good or fair • Only included studies reporting effects of interventions on: • MI • Stroke • ESRD, doubling of Scr, or halving of GFR • Heart failure (HF) or hospitalization for HF • Coronary revascularization or other revascularization • Mortality (Overall mortality, CVD-related mortality, CKD-related mortality)

  8. JNC 8: Graded Recommendations A – Strong evidence B – Moderate evidence C – Weak evidence D – Against E – Expert Opinion N – No recommendation

  9. JNC8: Strength of Recommendation

  10. JNC8: Key Questions • In adults with HTN, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? • In adults with HTN, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? • In adults with HTN, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

  11. JNC 8: Drug TreatmentThresholds 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

  12. JNC 8: Drug TreatmentThresholds 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 18-39

  13. JNC 8: Drug TreatmentThresholds 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

  14. 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)

  15. 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

  16. JNC8: Treatment Strategies (Grade E) • If goal BP not met after 1 month of treatment: • Increase dose of initial drug, or • Add a second drug (Thiazide, CCB, ACEi, or ARB) • If goal BP not met with 2 medications: • Add and titrate a third medication (Thiazide, CCB, ACEi, or ARB) • Do not use ACE and ARB together • Other classes may be used in the following scenarios: • Goal BP not met with 3 medications • Contraindication to thiazide, ACE/ARB, or CCB

  17. Strategies to Dose Antihypertensive Drugs • Titrate to max dose, then add a second drug • Add a second drug before achieving max dose of the initial drug • Start with 2 drugs at the same time • If SBP ≥ 160mmHg and/or DBP ≥ 100 mmHg • If SBP ≥ 20mmHg above goal and/or DBP ≥ 10mmHg above goal ***Consider scheduling follow-up with the Enhanced Care Clinic for titration of BP Meds

  18. Comparison of RecentGuideline Statements

  19. Goal BP **KDIGO: <140/90 w/o albuminuria <130/80 if >30 mg/24hr *ADA: < 140/80 or lower

  20. Comparison of JNC Guidelines JNC7 JNC8 Systematic review Randomized, controlled trials (RCT) only Graded recommendations Recommendations: No specific lifestyle recommendations Initial therapy for HTN Racial, CKD, and diabetic subgroups addressed Addressed three key questions • Nonsystematic literature review and expert opinion • Range of study designs • No grading system for recommendations • Recommendations: • Lifestyle modifications • Initial therapy for HTN • Compelling indications • Addressed secondary HTNand resistant HTN

  21. Recommendations for General Population Age ≥ 60 Years JNC 7 JNC8 BP Goal < 150/90 mmHg Rated Grade A Evidence for JNC8 • BP Goal < 140/90 mmHg (No age recommendations) • HYVET Trial • SHEP Trial • JATOS Trial • VALISH Trial

  22. Recommendations for General Population Age < 60 Years JNC 7 JNC8 SBP Goal < 140 mmHg Grade E DBP Goal < 90 mmHg Ages 30-59 years (Grade A) Ages 18-29 years (Grade E) Evidence for JNC8 • BP Goal < 140/90 mmHg • HDFP Trial • Hypertension-Stroke Cooperative Trial • MRC Trial • ANBP Trial • VA Cooperative Trial

  23. Recommendations for General Non-black Population (Including DM) JNC 7 JNC8 First-line Thiazide diuretics CCB ACE inhibitor ARB Grade B Evidence for JNC8 • First-line: Thiazide diuretics (no racial distinction made) • ALLHAT Trial • BP control more important than medication used • Alpha blockers not recommended first-line • LIFE Study • Beta-blockers not recommended first-line • Insufficient evidence to recommend other classes

  24. Recommendations for General Black Population (Including DM) JNC 7 JNC8 Initial treatment for black population (Grade B) with DM (Grade C) Thiazide diuretics CCB ALLHAT Trial • First-line: Thiazide diuretics (no racial distinction made) • Pre-specified subgroup analysis • Thiazide more effective in improving CV outcomes compared to ACEi in black patient subgroup • 51% higher rate of stroke (RR 1.51; 95% CI 1.22-1.86) with use of ACEi as initial therapy in black patients (compared to CCB) • 46% of patients in subgroup analysis had DM

  25. Recommendations for General Population Age ≥ 18 with CKD JNC 7 JNC8 Goal BP: < 140/90 mmHg Grade E Initial or add-on treatment: ACEi or ARB Grade B Regardless of race or DM status Evidence for JNC8 • Goal BP: < 130/80 mmHg • First-line agent: ACEi or ARB • AASK Trial • MDRD Trial • Potential benefit of goal <130/80 for patients with proteinuria (>3g/24 hours) • REIN-2 Trial • No trials showed goal <130/80 mmHg significantly lowered kidney or CV end points compared to 140/90

  26. Recommendations for General Population Age ≥ 18 with DM JNC 7 JNC8 Goal BP: < 140/90 mmHg Grade E Evidence for JNC8 • Goal BP: < 130/80 mmHg • ACCORD-BP Trial • No difference in outcomes with SBP < 140 vs. SBP < 120 • No good or fair quality trials to support DBP < 80

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

  28. Hypertension treatment for people with diabetes SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

  29. Hypertension treatment for people with nephropathy SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

  30. Lifestyle changes for hypertensive patients * Unless contraindicated. BMI, body mass index.

  31. ADA Guidelines for 2014 • Goal BP for patients with DM • Less than 140/80 mmHg • ACCORD-BP trial • HOT Trial • Showed 51% reduction in major CV events in patients with DM • Post-hoc analysis of small subgroup of the study (not pre-specified) • Evidence graded as low quality by JNC8 • Preferred Agents • ACEi or ARB • HOPE Study • Included non-hypertensive patients • Decreased risk of stroke with ACEi • Despite conflicting evidence, continue to recommend ACE/ARB first-line • Cite high CVD risk and high prevalence of undiagnosed CVD in patients with DM

  32. Thank You For Your Attention

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