hypertension 2014

Asso: Professor Kyaw Soe WinMBBS, MMedSc (Int Med), MRCPUK, FRCP (Edin), FAsCC, FAPSIC

New 2014 Hypertension GuidelinesEvidence Based Confusion?

6th July 2014

Published online December 18, 2013

Davidson’s Principles and Practice of Medicine 22nd edition

2011 BHS/NICE Guidelines

2011 BHS/NICE Guidelines

Davidson’s Principles and Practice of Medicine 22nd edition

Goals People with diabetes and hypertension

should be treated to a systolic blood pressure goal of <140 mmHg

Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden

Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg

Recommendations: Hypertension/Blood Pressure Control

ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S36

ADA 2014ADA 2014

Step 1 Step 2

JNC-1 (1977)Stepped Care

Diuretic Add methyldopa, reserpine, or propranolol


Diuretic Adrenergic-inhibiting agents (clonidine, methyldopa, beta blocker, alpha blocker, )


Less than full dose of diuretic or beta blocker

Add small dose of adrenergic-inhibiting agent or thiazide-type diuretic

JNC-4 (1988)Individualized Stepped

Care

Diuretic, beta blocker, calcium channel blocker, or ACE inhibitor

Add second drug of another class, increase dose of first drug, or substitute drug of different class

JNC-5 (1993) Diuretic or beta blockerAlternative therapy: ACE inhibitor, CCB, beta blocker, alpha blocker

Increase dose or substitute another drug, or add a second agent from a different class

JNC-6 (1997) Uncomplicated hypertension: diuretic, beta blocker

Specific indications for ACE inhibitor, ARB, alpha-beta blocker, beta-blocker, CCB, and diureticSubstitute another drug or add second agentLow-dose combination therapy may be appropriate initial therapy

ACE= angiotensin-converting enzyme; ARB= angiotensin II receptor blocker; CCB= calcium channel blockerSOURCE: MOSER 2002

Blood Pressure Classification JNC 7 2003

BP Classification SBP mmHg* DBP mmHg Lifestyle Modification

Drug Therapy**

Normal <120 and <80 Encourage No

Prehypertension 120-139 or 80-89 Yes No

Stage 1 Hypertension 140-159 or 90-99 Yes Single

Agent

Stage 2 Hypertension ≥ 160 or ≥ 100 Yes Combo

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 *Treatment determined by highest BP category; **Consider treatment for compelling indications regardless of BP

Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

Stage 2 HTN (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic

and ACEI, or ARB, or BB, or CCB)

Stage 1 HTN (SBP 140–159 or DBP 90–99 mmHg)

Thiazide-type diuretics for most. May consider ACEI, ARB, BB,

CCB, or combination.

Without Compelling Indications

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

What to choose first?

Initial antihypertensive therapy without compelling indicationsJNC 6: Diuretic or a beta-blockerJNC 7: Thiazide-type diuretics

Most outcome trials base antihypertensive therapy on thiazides

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

"The Goal!”

Hypertension-PLUS-

Diabetes or Renal Disease

< 140/90 mmHg < 130/80 mmHg

Changes in 2014 Hypertension Guidelines

This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults.

Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness.

Evidence quality and recommendations were graded based on their effect on important outcomes.

Questions Guiding the Evidence Review

This evidence-based hypertension guideline focuses on the panel’s 3 highest-Ranked questions related to high BP management .

1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? (how low should you go)

2. In adults with hypertension, does treatment with antihypertensivepharmacologic therapy to a specified BP goal lead to improvementsin health outcomes? (when to initiate drug treatment)

3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? (How do we get there?)

Nine recommendations are made reflecting these questions.

Recommendation 1In the general population aged 60 years or older, initiate

pharmacologic treatment to lower BP at systolic blood pressure (SBP) of 150 mmHg or higher or diastolic blood pressure (DBP) of 90mmHg or higher and treat to a goal SBP lower than 150mmHg and goal DBP lower than 90mmHg.

Recommendation 2In the general population <60 years, initiate

pharmacologic treatment to lower BP at DBP 90mmHg and treat to a goal DBP <90mmHg.

Recommendation 3In the general population <60 years, initiate

pharmacologic treatment to lower BP at SBP 140mmHg and treat to a goal SBP <140mmHg.

2014 Evidence Based Guideline for management of High Blood Pressure in Adults (JNC 8)

Recommendation 4

In the population aged 18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP 140mmHg or DBP 90mmHg and treat to goal SBP<140mmHg and goal DBP<90mmHg.

Recommendation 5

In the population aged 18years with diabetes, initiate pharmacologic treatment to lower BP at SBP 140mmHg or DBP 90mmHg and treat to a goal SBP <140mmHg and goal DBP <90mmHg.


Recommendation 6In the general non-black population, including those with

diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor(ACEI), or angiotensin receptor blocker (ARB).

Recommendation 7In the general black population, including those with

diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.

Recommendation 8In the population aged 18 years with CKD, initial (or add-

on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.


Recommendation 9The main objective of hypertension treatment is to attain

and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes.

If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient.

If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used.

Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.


This evidence-based guideline for the management of high BP in adults is not a comprehensive guideline and is limited in scope because of the focused evidence review to address the 3 specific questions .

Clinicians often provide care for patients with numerous comorbidities or other important issues related to hypertension, but the decision was made to focus on 3 questions considered to be relevant to most physicians and patients.

Limitations

Limitations

Treatment adherence and medication costs were thought to be beyond the scope of this review, but the panel acknowledges the importance of both issues.

The evidence review did not include observational studies, systematic reviews, or meta-analyses, and the panel did not conduct its own meta-analysis based on prespecified inclusion criteria.

Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes.

these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

the algorithm will facilitate implementation and be useful to busy clinicians

Limitations

Comparison of Current Recommendations With JNC 7 Guidelines

Topic JNC 7 2014 Hypertension guideline

Methodology Nonsystematic literature review by expert committee including a range of study designs Recommendations based on consensus

Initial systematic review by methodologists restricted to RCT evidenceSubsequent review of RCT evidence and recommendations by the panel according to a standardized protocol

Definitions Defined hypertension and prehypertension

Definitions of hypertension and prehypertension not addressed, but thresholds for pharmacologic treatment were defined

Treatmentgoals

Separate treatment goals defined for “uncomplicated” hypertension and for subsets with various comorbid conditions (diabetes and CKD)

Similar treatment goals defined for all hypertensive populations except when evidence review supports different goals for a particular subpopulation



Drug therapy

Recommended 5 classes to be considered as initial therapy but recommended thiazide-type diuretics as initial therapy for most patients without compelling indication for another class Specified particular antihypertensive medication classes for patients with compelling indications, ie, diabetes, CKD, heart failure, myocardial infarction, stroke, and high CVD risk Included a comprehensive table of oral antihypertensive drugs including names and usual dose ranges

Recommended selection among 4 specific medication classes (ACEIor ARB, CCB or diuretics) and doses based on RCT evidenceRecommended specific medication classes based on evidence reviewfor racial, CKD, and diabetic subgroupsPanel created a table of drugs and doses used in the outcome trials



Scope of topics

Addressed multiple issues (blood pressure measurement methods,patient evaluation components, secondary hypertension, adherenceto regimens, resistant hypertension, and hypertension in specialpopulations) based on literature review and expert opinion

Evidence review of RCTs addressed a limited number of questions, those judged by the panel to be of highest priority.

Review processprior topublication

Reviewed by the National High Blood Pressure Education ProgramCoordinating Committee, a coalition of 39 major professional, public,and voluntary organizations and 7 federal agencies

Reviewed by experts including those affiliated with professional and public organizations and federal agencies; no official sponsorship by any organization should be inferred

Conclusion (my opinion)

•The BP for everyone will be <140/90 mmHg

• BP for those >60- <150/90 mmHg

• Combinations of RAS blockers with thiazidediuretics or RAS blockers and dihydropyridine CCBs are acceptable first line combos to get BP to goal, if >20/10mmHg above goal

Thank You

hypertension 2014

Health & Medicine

alphabeta blocker

management of hypertension

uncomplicated hypertension

dose of diuretic

receptor blocker ccb

treatment thresholds

drug treatment3

goal blood pressure