hypertension mohammad garakyaraghi,md cardiologist associate professor

IN THE NAME OF GOD

Hypertension

Mohammad Garakyaraghi,MDCardiologistAssociate Professor

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

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

New Guidelines for Hypertension

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 ManagementEvidence Review

RCT’s December 2009 – August 20131. Major study in hypertension

ACCORD, NEJM 20102. > 2,000 participants3. Multicentered4. Met all other inclusion/exclusion criteria

JNC 8: Hypertension ManagementEvidence Review

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)

JNC8: Methods

A – Strong evidenceB – Moderate evidenceC – Weak evidenceD – AgainstE – Expert OpinionN – No recommendation

JNC 8: Graded Recommendations

JNC8: Strength of RecommendationGrade Strength of Recommendation

A Strong: High certainty net benefit is substantial

BModerate• Moderate certainty net benefit is moderate to substantial,

or• High certainty that net benefit is moderate

C Weak: At least moderate certainty of small net benefit

EExpert Opinion• Insufficient evidence, or • Evidence is unclear or conflicting• Further research is recommended in this area

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?

JNC8: Key Questions

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 TreatmentThresholds and Goals

Age < 60 yo◦ Systolic:


LOE: Grade E


LOE: Grade A for ages 40-59; Grade E for ages 18-39


Age > 18 yo with CKD or DM◦ JNC 7: < 130/80 (MDRD NEJM 1994)◦ Systolic:


LOE: Grade E


LOE: Grade E


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: Initial Drug Choice

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

JNC8: Treatment Strategies (Grade E)

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

Strategies to Dose Antihypertensive Drugs

Comparison of RecentGuideline Statements

JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90

Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr

for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr

140-150 if <80 yr

B-blocker No Yes No NoFirst line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100

w/ 2 drugs elevated BP"

Goal BPGroup BP Goal (mm Hg)

General DM* CKD**JNC 8: <60 yr: <140/90 < 140/90 < 140/90

>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)(<80 yr: SBP<140)

ASH/ISH < 140/90 < 140/90 < 140/90>80 yr: <150/90 (Consider < 130/80 if proteinuria)

AHA/ACC < 140/90 < 140/90 < 140/90

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

Comparison of JNC Guidelines

JNC7• 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 HTN and

resistant HTN

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

Recommendations for General Population Age ≥ 60 Years

JNC 7

• BP Goal < 140/90 mmHg(No age recommendations)

JNC8• BP Goal < 150/90 mmHg

– Rated Grade A

Evidence for JNC8

• HYVET Trial• SHEP Trial• JATOS Trial• VALISH Trial

Recommendations for General Population Age < 60 Years

JNC 7

• BP Goal < 140/90 mmHg

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

• HDFP Trial• Hypertension-Stroke

Cooperative Trial• MRC Trial• ANBP Trial• VA Cooperative Trial

Recommendations for General Non-black Population (Including DM)

JNC 7

• First-line: Thiazide diuretics (no racial distinction made)

JNC8• First-line

– Thiazide diuretics– CCB– ACE inhibitor– ARB

• Grade B

Evidence for JNC8

• 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

Recommendations for General Black Population (Including DM)

JNC 7

• First-line: Thiazide diuretics(no racial distinction made)

JNC8• Initial treatment for black

population (Grade B) with DM (Grade C)– Thiazide diuretics– CCB

ALLHAT Trial• 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

Recommendations for General Population Age ≥ 18 with CKD

JNC 7

• Goal BP: < 130/80 mmHg• First-line agent: ACEi or ARB

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• 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

Recommendations for General Population Age ≥ 18 with DM

JNC 7

• Goal BP: < 130/80 mmHg

JNC8• Goal BP: < 140/90 mmHg

– Grade E

Evidence for JNC8• ACCORD-BP Trial

• No difference in outcomes with SBP < 140 vs. SBP < 120

• No good or fair quality trials to support DBP < 80

Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by

2013 ESH/ESC Guidelines for the management of arterial hypertension

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

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.

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 elderlyAged <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




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

Coadministration of RAS blockers not recommended

• Avoid in patients with diabetes

Hypertension treatment for people with diabetes

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.




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

Hypertension treatment for people with nephropathy

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.




Lifestyle changes for hypertensive patients

* Unless contraindicated. BMI, body mass index.

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

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week(moderate, dynamic exercise)

Quit smoking

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

ADA Guidelines for 2014

Thank You For Your Attention

hypertension mohammad garakyaraghi,md cardiologist associate professor

Documents

specific health outcomes

high certainty net benefit

ckdrelated mortality

jnc8 panel

rctshypertensive adults

hypertension algorithm

orhigh certainty

observational studies