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Hypertension Treatment 2019: ACC /AHA Guidelines and Goals

Hypertension Treatment 2019: ACC /AHA Guidelines and Goals. Sidney C. Smith Jr, MD MACC FAHA FESC Professor of Medicine University of North Carolina Past President, American Heart Association Past President, World Heart Federation No Conflicts or Relationships with Industry. Outline.

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Hypertension Treatment 2019: ACC /AHA Guidelines and Goals

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  1. Hypertension Treatment 2019: ACC/AHA Guidelines and Goals Sidney C. Smith Jr, MD MACC FAHA FESC Professor of Medicine University of North Carolina Past President, American Heart Association Past President, World Heart Federation No Conflicts or Relationships with Industry

  2. Outline • Evolution of Guidelines and New Evidence • Blood Pressure Goals and Risk • Lifestyle Recommendations • Racial and Ethnic Considerations • Monotherapy versus Combination Therapy • Treatment of Hypertension in Pregnancy • Treatment of Hypertension in Diabetes • Out of office Blood Pressure Evaluation

  3. BP Clinical Practice Guidelines (CPGs) • Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High BP, 1977 - Consensus report, with six recommendations - Stepped-care treatment for adults with DBP ≥105 mm Hg - No recommendations for lifestyle change or drug treatment based on SBP • Seventh Report of JNC on Prevention, Detection, Evaluation, and Treatment of High BP, 2003 • Structured, comprehensive guideline; recommendations supported by more/better evidence • Detailed BP classification system; focus on SBP but included DBP recommendations • Lifestyle modification recommended as initial treatment for high BP • Antihypertensive drug therapy when SBP/DBP exceeded 140/90 mm Hg (130/80 for DM or CKD) • In 2013, NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA

  4. Does Hypertension Treatment Effect In RCTs Mirror Observational Data? Observational Data Incidence of cardiovascular disease Treatment Effect 120 140 160 180 200 220 Systolic blood pressure (mmHg)

  5. Achieved BP and Benefit in Hypertension Trials J Hypertension 2009 25

  6. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, Lefevre ML, Mackenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E 13 Pages, 9 Recommendations

  7. 2014 Hypertension Guideline Management Algorithm Adult aged ≥18 years with hypertension Implement lifestyle interventions (continue throughout management). Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD). General population (no diabetes or CKD) Diabetes or CKD present Age ≥60 years Age <60 years All ages Diabetes present No CKD All ages CKD present with or without diabetes Blood pressure goal SBP <150 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Nonblack Black All races Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination.a Initiate thiazide-type diuretic or CCB, alone or in combination. Initiate ACEI or ARB, alone or in combination with other drug class.a Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dose combination.

  8. Recommendation 1 • In the general population ≥60 years of age, initiate pharmacologic treatment to lower BP at SBP ≥150 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. • Strong Recommendation – Grade A • Corollary Recommendation: In the general population ≥60 years of age, if pharmacological treatment for high BP results in lower achieved SBPs (for example, <140 mm Hg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted. • Expert Opinion – Grade E

  9. SystolicBlood Pressure Intervention Trial (SPRINT) • Multicenter, RCT compares Rx <120 vs. <140 BP • Inclusion: 1) age > 50, 2) BP > 130 < 180 • and 3) CVD, CKD, 10 y FR>15%, or age > 75 • Exclusion: DM, Stroke, PCKD, HFrEF <0.35 or Sx, Prot> 1G/d, CKD eGFR < 60 , Adherence Issues • 9361 pts 102 clinics USA, PR; 30%B 36%W 28%>75, 28%CKD, 20%CVD • Results: -30% CV Events -25% Mortality -all cause

  10. 283 Pages, 106 Recommendations JACC doi:10.1016/j.jacc.2017.11.006 *American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ║American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ║║Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative. 2017 High Blood Pressure Guideline Writing Committee

  11. 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults BP Classification (JNC 7 and ACC/AHA+ Guidelines) • Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions • Adults with SBP or DBP in two categories should be designated to the higher BP category

  12. CVD EVENTS AVOIDED BY BASELINE RISK AND MAGNITUDE OF SBP LOWERING Sundstrom et al. Lancet. 2014;384:591–598 69 54 57 44 37 Cardiovascular events avoided per 1000 36 31 19 28 >21 16 20 16-21 18 10 11-15 14 5-year risk of CVD (%) 10 16 <11 12 5 8 4 Systolic blood pressure reduction (mm Hg)

  13. RISK-BASED TREATMENT OF HYPERTENSION Blood Pressure Lowering Treatment Trialists. Lancet.2014;384;591-598.

  14. BP THRESHOLDS AND RECOMMENDATIONS FOR TREATMENT AND FOLLOW UP BP thresholds and recommendations for treatment and follow-up Normal BP (BP <120/80 mm Hg) Elevated BP (BP 120-129/<80 mm Hg) Stage 1 Hypertension(BP 130-139/80-89 mmHg) Stage 2 Hypertension (BP >140/90 mm Hg) Clinical CVD or estimated 10 y ASCVD risk ≥ 10% Promote optimal lifestyle habits (Class I) Non-pharm-acologic therapy (Class I) Yes No Non-pharmacologic therapy and BP lowering medication (Class I) Non-pharmacologic therapy and BP lowering medication (Class I) Reassess in 1 y (Class IIa) Reassess in 3-6 mo (Class I) Non-pharmacologic therapy (Class I) Reassess in 1 mo (Class 1) Reassess in 3-6 mo (Class I)

  15. After Muntner ACC NY Symposium 2019

  16. *Factors that can be changed and, if changed, may reduce CVD risk. †Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress). CKD indicates chronic kidney disease; and CVD, cardiovascular disease.

  17. JNC VII Guidelines: Lifestyle Modifications for BP Control BMI=Body mass index, BP=Blood pressure, SBP=Systolic blood pressure Source: Chobanian AV et al. JAMA 2003;289:2560-2572

  18. Choice of Initial Medication SR indicates systematic review.

  19. Racial and Ethnic Differences in Treatment

  20. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy

  21. Pregnancy

  22. General Principles of Drug Therapy

  23. Patients Undergoing Surgical Procedures (cont.)

  24. Recommendations for Treatment of Hypertension in Patients with Diabetes Mellitus

  25. Significance of Out of Office BP Readings • A major reason is to identify patients on no antihypertensive medication with: • Guideline calls for greater use of out of office BP measurements (ABPM or HBPM) for both the diagnosis and management of hypertension. • White Coat Hypertension (WCH) with elevated office BPs who may not require drug treatment and • Masked Hypertension (MH) with normal office readings who should be considered for drug treatment • In addition, in those on antihypertensive medications, to identify • White Coat Effect (WCE) – where office BPs are significantly higher than out of office readings • Masked Uncontrolled Hypertension (MUCH) –office readings indicate adequate BP control but out of office readings elevated

  26. Masked and White Coat Hypertension

  27. 2017 ACC/AHA/+ Hypertension Guidelines Diagnosis • New BP Categories: <120/80, 120-129/<80 HBP, 130-139/80-89 S1, >140/90 S2 • Out of Office BP measurement and Telehealth counseling recommended Therapy • Lifestyle modification recommended for HBP, S1 and S2 with meds based on risk/ASCVD • Meds recommended when BP > 130/80 with clinical CVD or ASCVD 10 yr Risk > 10% • If no clinical CVD and ASCVD 10 yr Risk < 10 % Meds recommended when BP > 140/90 Management • Target <130/80 for ASCVD or 10 yr Risk > 10%. (<130/80 target may be useful for lower risk) • First line agents for treating BP are Thiazide diuretics, CCB, ACEI and ARBs (BB for CI) • For Stage 2 HTN when BP > 20/10 above target use 2 first line agents After Cifu and Davis, JAMA 2017; 318 2132

  28. Measure office BP accurately • Detect white coat hypertension or masked hypertension by using ABPM and HBPM • Evaluate for secondary hypertension • Identify target organ damage • Introduce lifestyle interventions • Identify and discuss treatment goals • Use ASCVD risk estimation to guide BP threshold for drug therapy • Align treatment options with comorbidities • Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment • Initiate antihypertensive pharmacological therapy • Insure appropriate follow-up • Use team-based care • Connect patient to clinician via telehealth • Detect and reverse nonadherence • Detect white coat effect or masked uncontrolled hypertension • Use health information technology for remote monitoring and self-monitoring of BP • (ABPM = ambulatory blood pressure monitoring; • HBPM = Home Blood Pressure monitoring) Plan of Care for Hypertension

  29. Muchas Gracias!

  30. Patient Question - Hypertension 38 yo AA M BP= 138/82, Non- Smoker BMI =31, type 2 DM, no Albuminuria, 10 yr Risk 8.5% Which is correct? A- Patient should be treated with lifestyle modification with major focus on weight loss, follow BP and Risk to be certain BP remains < 140 systolic and risk remains < 10% B – Start HCTZ with target systolic BP < 130 mm Hg

  31. LIFE: Individual Endpoint Results Cardiovascular Death Stroke Myocardial Infarction P=0.001 P=0.206 P=0.491 Adjusted HR 0.75 Adjusted HR 0.89 Adjusted HR 1.07 Losartan Atenolol Losartan Losartan Atenolol Atenolol

  32. LIFE: New-onset diabetes P=0.001 Adjusted Hazard Ratio = 0.75 Rate 13.0/1,000 patient yrs Rate 17.4/1,000 patient yrs n=241 n=319 Losartan Atenolol

  33. ALLHAT Only Subgroup Differences:Lisinopril vs Chlorthalidone in Blacks/Non-Blacks for CVD & Stroke Non-Blacks Blacks CHD 1.10 (0.94 - 1.28) 0.94 (0.85 - 1.05) Mortality 1.06 (0.95 - 1.18) 0.97 (0.89 - 1.06) Combined CVD 1.19 (1.09 - 1.30) 1.06 (1.00 - 1.13) Stroke 1.40 (1.17 - 1.68) 1.00 (0.85 - 1.17) Heart Failure 1.32 (1.11 - 1.58) 1.15 (1.01 - 1.30) ESRD 1.29 (0.94 - 1.75) 0.93 (0.67 - 1.30) 0.50 1 2 0.50 1 2 Favors Favors Lisinopril Chlorthalidone Favors Favors Lisinopril Chlorthalidone

  34. Initial Combinations of Medications(LIFE) Diuretics b-blockers should be included in the regimen if there is a compelling indication for a b-blocker Calciumantagonists ACE inhibitors or ARBs* * Combining ACEI with ARB discouraged

  35. Association between SBP/DBP and CVD risk • Several meta-analyses have reported a gradient of progressively higher CVD risk going from normal BP to elevated BP to hypertension. Guo et. al. PLoS One, 2013; 8e61796. Huang et. al. Neurology, 2014; 82: 1153-1161. Huang et. al. American Journal of Kidney Diseases, 2014; 63: 76-83. Lee et. al., Neurology 2011; 77: 1330-1337. Shen, American Journal of Cardiology, 2013; 112: 266-271. Guo et. al. Current Hypertension Reports 2013; 15: 703-716.

  36. 80-89 years 70-79 years 60-69 years 50-59 years 40-49 years Blood Pressure (BP) and Cardiovascular Disease (CVD) Risk • Log-linear increase in risk starting at 115/75 • Risk of stroke and CHD mortality doubles for every 20/10 mm Hg increase Diastolic Blood Pressure (DBP) Systolic Blood Pressure (SBP) Age at risk: Age at risk: 80-89 years 256 256 70-79 years 128 128 60-69 years 64 64 50-59 years 32 32 16 16 (Floating Absolute Risk and 95% CI) (Floating Absolute Risk and 95% CI) IHD Mortality IHD Mortality 40-49 years 8 8 4 4 Lewington et al. Lancet. 2002;360:1903-1913. 2 2 Lewington et al. Lancet. 2002;360:1903-1913. 1 1 70 80 90 100 110 120 140 160 180 Usual SBP (mm Hg) Usual DBP (mm Hg)

  37. BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

  38. If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts, he shall end in certainties.” “— —Francis Bacon, The Advancement of Learning, year 1605”

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