1 / 36

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressu

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) A Review of the Guidelines and Controversies Baylor College of Medicine Med-Peds Continuity Clinic. Statistics.

zuwena
Download Presentation

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressu

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) A Review of the Guidelines and Controversies Baylor College of Medicine Med-Peds Continuity Clinic

  2. Statistics • HTN affects approximately 50 million individuals in the US and • 1 billion people worldwide. • HTN is the most common primary diagnosis in the USA with • 35 million office visits per year. • Framingham Heart Study—Individuals who are normotensive at • 55 years of age have a 90% lifetime risk of developing HTN • Relationship between BP and risk of CVD is continuous, • consistent, and independent of other risk factors • Only 35% of hypertensive patients on treatment are under control. • For those age 40-70, each increased increment of 20 mmHg in • systolic BP or 10 mmHg in diastolic BP doubles the risk • of CVD across the entire BP range of 115/75 to 185/115.

  3. Benefits of Lowering BP • Anti-HTN Therapy associated with: • 35 – 40% mean decrease in stroke • 20 – 25% decrease in MI • More than 50% decrease in HF • Patients with Stage 1 HTN/Additional Risk Factors: • Achieving a sustained 12 mmHg decrease in systolic BP • for 10 years will prevent 1 death for every 11 pts treated • The majority of Patients will require 2 or more anti-HTN • drugs.

  4. JNC: The Past • First JNC report published in 1977 by NIH (NHLBI). Since that time, JNC has repeatedly recommended the use of diuretics. • In JNC 5, ACE-I and beta-blockers were added as first-line therapy. • In JNC 6, these two classes were removed, and diuretics remained as the sole first-line agent.

  5. JNC: The Present • What’s new in JNC-7? • 1. New disease classification of ‘pre-hypertension’ • 2. Start with 2 drug combo therapy for BP ≥ 160/100, i.e. Stage 2. • 3. Simpler approach to risk stratification - deletion of Stage 3 HTN • 4. Committee’s fine print comment on choosing first line agent: choice can be based on patient’s co-morbid conditions, i.e.‘compelling indication’ • (JNC-7 published Dec 2003)

  6. New BP Classification • Based on the Mean of 2 or more properly measured, seated BP readings. • On each of 2 or more office visits • New category of pre-hypertension has been added: • Identifies patients with increased risk of progression to HTN. • Those with BP 130/80 – 139/89 are at twice the risk • Prior Stage 2 and 3 have been combined.

  7. New BP Classification BP ClassificationSystolic BP/Diastolic BP Lifestyle Drug Therapy Modifiation Without With Compelling Ind.Compelling Ind. Normal < 120 and < 80 Encourage Pre Hypertension120 – 139 or 80 – 89 Yes No Drug Indicated Drugs for the Compelling Ind. Stage 1 HTN 140 – 159 or 90 – 99 Yes Thiazide for most; Drugs for the may consider ACEI, comp ind. ARB, BB, or CCB as Others as needed first line Stage 2 HTN > 160 or > 100 Yes 2-Drug Combo for Drugs for the most- Usually compelling ind. thiazides AND Other drugs as ACEI, ARB, BB needed or CCB * Compelling Indications: Chronic Kidney Disease and Diabetes

  8. JNC 7: Controversies • Some clinicians are critical of the new recommendations. • Not in favor of creating the new disease ‘pre-hypertension’ - feel it will cause more anxiety than aid • What do you do for someone who is lean and living a healthy lifestyle and has ‘prehypertension’? • No evidence that lifestyle interventions in this population prevents CV disease, though it may slow progression to hypertension.

  9. JNC 7: Controversies cont. • Minor concerns regarding combination therapy: • If side effects occur, then it may not be clear which agent is responsible and how to adjust therapy. • The subset of patients with Stage 2 HTN whose BP could be controlled with monotherapy will not be afforded the opportunity for simpler therapy.

  10. JNC 7: Controversies • Diuretics overemphasized as first line agent. • Guidelines too dependent on the ALLHAT trial. • ALLHAT had shown no difference in primary end points of coronary events between diuretics, CCB or ACE-I, but also claimed fewer coronary events in some subsets of patients. Hence, concluding diuretics are the best for everyone as first line. • ALLHAT not without flaws: patients were randomized to treatment with a diuretic, CCB or ACE-I without regard for comorbid conditions (i.e., ACE for DM, BB for MI patients) • Also, guidelines seem to have ignored trials with evidence of ACE-I superiority in younger patients. Thus, not accounting for the theory of high plasma renin levels as a cause of HTN in this population. • To recommend a single drug across-the-board as first line for all patients promotes the absurdity that all hypertension is the same.

  11. JNC 7: The Fine Print • Cracking open the door beyond diuretics for first line in a patient without co-morbid conditions • Along with promoting a thiazide diuretic for Stage 1 HTN, the committee added this suprising sentence:“May consider ACE-I, ARB, BB, CCB.” • The ‘Compelling Indication’ Category - JNC put emphasis on evidence showing benefits with specific antihypertensive agents for certain medical conditions. Again, taking a small sidestep from the NHLBI dictum of diuretics first.

  12. Treatment Algorithm Lifestyle Modification Not at Goal BP Initial Drug Choices HTN without Compelling Factors HTN with Compelling Indications Stage 2 HTN 2-drug combo for most Usually Thiazide and ACEI Or ARB or BB or CCB Drugs for the Compelling Indications Diuretics, ACEI, ARB, BB, CCB as appropriate Stage 1 HTN Thiazides for Most Consider ACEI, ARB, BB, CCB or Combo Not at Goal BP Optimize Dosages or Add Additional Drugs Until Goal BP is Achieved. Consider Consult with HTN Specialist

  13. Lifestyle Modifications to Manage HTN ModificationRecommendationApproximate SBP Reduction, Range Weight Reduction Maintain normal body wt 5-20 mmHg/10 kg wt loss (BMI 18.5 – 24.9) Adopt DASH eating Consume a balanced diet with reduced 8 – 14 mm Hg Plan content of saturated and total fat Dietary sodium Reduce dietary sodium intake to no 2 – 8 mmHg Restriction more than 100 mEq/L ( 2.4 sodium or 6 sodium chloride) Physical Activity Regular aerobic activity such as 4 – 9 mm Hg brisk walking at least 30 min/day most days a week EtOH in Moderation Limit consumption to no more than 2 2 – 4 mmHg drinks per day in men and 1 drink per day in women and smaller people

  14. Treatment • Goals of therapy: • Decrease risk of CVD and Renal morbidity and • mortality • Primary Focus should be achieving the systolic BP goal • Target for Normal Patients: < 140/90 • Target in DM/Renal Disease: < 130/80 • Combination Therapy - The 20/10 mm Hg rule: • If BP exceeds either of the above targets by at least 20/10 (i.e, 160/100 or 150/90), then 2 drugs should be started • Committee recommends a diuretic be one of the agents • Diuretics provide a synergistic antihypertensive effect with many other agents • Second agent can be ACE, ARB, CCB or BB

  15. Treatment: Choosing an agent • Role of age and race • Younger patients’ HTN related more frequently to higher plasma renin levels - ACE-I • Older patients’ HTN related to salt - Diuretics • African Americans and CCBs • Consideration of co-morbid conditions or ‘compelling indications’ • Side Effect profiles • i.e., HCTZ - has high incidence of causing impotence

  16. African Americans with HTN • Minority Populations: • Elderly African-Americans (>60 yo) show best responses to monotherapy with Diuretics or CCB, and decreased response with B-Blockers, ACE-Inhibitors, or ARBs compared. • Angioedema from ACE-I occurs 2 – 4 times more frequently in the African-American population

  17. Pharmacological Therapy Clinical trials show several drugs decrease complications in HTN: - ACE inhibitors - CCB - ARBs - Thiazide Diuretics - B-Blockers Thiazides - Unsurpassed in preventing CV complications of HTN (as per ALLHAT) -- Enhance anti-HTN efficacy of multi-drug regimens -- More affordable -- Should be initial therapy in most older patients BP > 20/10 mmHg above goal should consider starting therapy with 2 drugs. Use caution in those at risk for orthostatic hypotension: -- DM, autonomic dysfunction, older persons

  18. Drug Treatment Guidelines High-Risk Aldosterone Conditions Diuretic B-Blocker ACEI ARB CCB Antagonist Heart Failure * * * * * Post-MI * * * High Coronary Disease Risk * * * * Diabetes * * * * * Chronic Kidney Disease * * Recurrent Stroke * * Prevention

  19. Chronic Kidney Disease • Goals: 1) Slow deterioration of renal function • 2) Prevent CVD • Often need 3 or more drugs • Target < 130/80 • Drugs: ACE-Inhibitors/ARBs—Favorable effects on progression • -- Increase in Creatinine of 35% is acceptable • Advanced Renal Disease: • GFR < 30, CR 2.5 – 3.0 mg/dl • Increased dose of loop diuretics usually needed in • combo with other drugs

  20. Special Situations LVH: Independent risk factor for subsequent CVD Regression occurs with aggressive BP management -- Weight loss -- Decrease Sodium -- Treat with all classes of anti-hypertensives except direct vasodialators, hydralazine, minoxidil PVD: Equivalent in risk to ischemic heart disease Treatment: Any class of anti-hypertensives, ASA

  21. Special Situations Continued HTN in Women OCPs may increase BP --Risks increase with duration of use --Check BPs regularly --Development of HTN—Sufficient reason to consider other forms of contraception Pregnancy—Methyldopa, B-Blockers, Vasodialators are preferred ACE-Inhibitors/ARBs are contra-indicated in pregnancy and should be avoided in women likely to become pregnant Children—HTN defined as BP at 95th percentile or greater when adjusted for age, height, sex -R/O Causes: Kidney Disease, Coarction of the aorta Tx: Lifestyle, reserve drug therapy for higher BP or HTN resistant to lifestyle modification. Drug choice similar for kids but with decreased dose

  22. Additional Considerations: Thiazide Diuretics—Slow demineralization in osteoporosis --Use with caution in patients with gout, or h/o significant hyponatremia B-Blockers—Treat Atrial Tachycardia/Fibrilation, migraine, thyrotoxicosis (short-term), essential tremor, peri- operative HTN --Avoid in asthma, reactive airway disease, 2nd/3rd degree heart block CCB—Treats Raynaud’s syndrome, certain arrhythmias Alpha Blockers—Treats benign prostatic hypertrophy Aldosterone Antagonists/K-sparing diuretics: Can cause hyperkalemia and should be avoided in patients with K > 5.0 while not on meds

  23. Beta-blockers out of favor • Classic beta-blockers are no longer popular choice due to results of Anglo-Scandanavian Cardiac Outcomes Trial (ASCOT) published in 2005. • Found that regimen of ACE-I/CCB superior to BB/diuretic in cardiovascular mortality and all-cause mortality.

  24. Meta-Analysis of Beta-blocker trials No study has shown reduction in M&M with beta-blocker monotherapy in HTN patients compared to placebo. Bangalore S, et al, Journal of the American College of Cardiology, 2007;50:563-72

  25. Beta-blockers • Consider their side effects: • Metabolic effects: worsen insulin resistance, dyslipidemia • Increased erectile dysfunction • In antihypertensive trials, the atenolol arm has consistently seen increased incidence of new diabetes in the range of 30-40% of patients. • This may explain why BBs do not actually decrease CV events and stroke.

  26. Beta Blockers • Compared with other antihypertensive agents, including classic beta-blockers, vasodilatory beta-blockers (carvedilol and nebivolol) are associated with all of the following, except: • A. Increase in erectile dysfunction • B. Similar or better response rates to therapy • C. Fewer adverse effects • D. Minimal or no dysmetabolic effects • E. Reduce resting heart rate

  27. Beta Blockers • Compared with other antihypertensive agents, including classic beta-blockers, vasodilatory beta-blockers (carvedilol and nebivolol) are associated with all of the following, except: • A. Increase in erectile dysfunction • B. Similar or better response rates to therapy • C. Fewer adverse effects • D. Minimal or no dysmetabolic effects • E. Reduce resting heart rate

  28. ‘3G’ Beta blockers • carvedilol – nonselective B-blocking with alpha-1-blocking • nebivolol (Bystolic)- highly selective B1 blocker • COMET (Carvedilol Or Metoprolol European Trial): after 5 years of tx, pts on carvedilol had lower rate of onset of DM • This study also showed carvedilol was superior to metoprolol in heart failure.

  29. All of the following statements regarding combination antihypertensive therapies are true, except: • A. When BP is > 20 mm Hg above systolic goal or 10 mm Hg above diastolic goal, initiation with 2 drugs should be considered • B. Addition of a drug from a second drug class should be initiated when use of a single agent in adequate doses fails to achieve target BP levels • C. The combination of an ACE inhibitor and CCB lowers the risk of cardiovascular events compared with the combination of a beta-blocker and diuretic. • D. The starting dose of most fixed-dose combinations is typically the same as those used in clinical outcome trials

  30. All of the following statements regarding combination antihypertensive therapies are true, except: • A. When BP is > 20 mm Hg above systolic goal or 10 mm Hg above diastolic goal, initiation with 2 drugs should be considered • B. Addition of a drug from a second drug class should be initiated when use of a single agent in adequate doses fails to achieve target BP levels • C. The combination of an ACE inhibitor and CCB lowers the risk of cardiovascular events compared with the combination of a beta-blocker and diuretic. • D. The starting dose of most fixed-dose combinations is typically the same as those used in clinical outcome trials

  31. When the first drug doesn’t work • JNC 7 pushes for rapid progression to combination therapy before fully exploring monotherapy. • This approach is not an issue for those with Stage 2, but for Stage 1. They seem to ignore the understanding that different mechanisms cause HTN in different patients. Others argue it is because of the heterogeneous mechanisms that multiple class of agents are necessary. • Alternative approach: if there is a partial response, then increase the dose or add a second agent. If there is no response at all, then try an alternate class. The goal here being to find the simplest way to control BP.

  32. Causes of Resistant HTN Improper Measurement Volume Overload and Pseudotolerance Excess Sodium Volume retention from Renal Disease Inadequate Diuretic Therapy Drug-Induced/Other Causes Noncompliance Licorice Inadequate Doses Ephedra Inappropriate Combos ma haung NSAIDS; COX 2 inhibitors Bitter Orange Cocaine, amphetamines, other illicits Obesity Sympathomimetics (decongestants etc.) EtOH OCPs Steroids Erythropoietin Cyclosporine and tacrolimus

  33. Noncompliance • Estimates of noncompliance with medical treatment in general: • Noncompliance causes 125,000 deaths a year - twice the mortality rate from MVAs • 30% of hospital admissions for people over the age of 65 are directly caused by noncompliance. • Half of all prescriptions are taken incorrectly, contributing to prolonged or additional illnesses. • Noncompliance increases with the number of meds and doses per day; at 4 times a day, only 40% get it right.

  34. Improving Hypertension Control • Models suggest that even the most effective therapy will only • control HTN if the patient is motivated to take meds and to establish and maintain a healthy lifestyle. • Motivation improves when patients have positive experiences with their physicians and develop a trusting relationship • HTN treatment must be patient centered. • Drug selection to take into account patient’s age, race and special circumstances. • Physicians must be willing to try different drugs and aim for monotherapy before adding on a second agent.

  35. Summary • New guidelines are more conservative - new category of ‘prehypertension’ • Require more aggressive treatment tailored to particular medical • condition - encourages starting with 2 drug therapy for BPs over 160/90 • Effective therapy combines lifestyle modifications, exercise, and drug therapy • Must maintain an open relationship with the patient in order to provide effective therapy

  36. References • Chobanion AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. • Weber, MA. The JNC 7 Report: Challenges and Dilemmas in Writing Guidelines. Journal of Clinical Hypertension. 2003;5(4):282-286. • Bakris, G. The Implications of JNC 7 for Antihypertensive Treatment Protocols. Medscape. June 30, 2003.

More Related