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Hypertension: what is newand old GREG FOTIEO, MD

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Objectives Background Review JNC 8 Recommendations through clinical cases Discuss concerns about JNC 8 Figure out how to apply JNC 8 to your practice (hopefully)

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Prevalence 1/3 of adults About 60 million hypertensives in the US Most common chronic condition seen in primary care Most common risk factor for heart attack and stroke Prevalence increases with increasing age

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Why worry? There is a strong relationship between blood pressure and the risk of CV events, strokes and kidney disease The risk is lowest at 115/75 and for each increase of 20 mm in SBP or 10 mm in DBP the risk of major CV event or stoke doubles Treatment of hypertension has been shown to reduce risk of adverse CV outcomes by 20-25% and stroke by 30- 40%

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How are we doing? Not so good 2005-8 NHANES survey found only 46-51% of persons with HTN had their blood pressure controlled

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JNC HISTORY JNC 1: published 1976 JNC 2: published 1980 JNC 3: published 1984 JNC 4: published 1988 JNC 5: published 1992 JNC 6: published 1997 JNC 7: published 2003 JNC LATE

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Questions Addressed by the JNC 8 Panel 1. In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Thresholds 2. In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvement in health outcomes? Targets 3. In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? Impact of drugs

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The 9 Recommendations Recommendations 1-5 address thresholds and goals for BP treatment. Recommendations 6-8 address selection of antihypertensive drugs. Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs.

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Case #1 A 72 yo Caucasian man with HTN, COPD, BPH and a history of prostate cancer s/p radical prostatectomy presents for routine f/u. He feels well except for SOB with heavy exertion that responds to his albuterol inhaler. His BP is 118/78. He is currently on albuterol MDI prn, Lisinopril 10 mg qday, and HCTZ 12.5 mg qday. His labs are unremarkable. What should you do with his hypertensive regimen?

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RECOMMENDATION 1 In the general population aged 60 years, initiate pharmacological treatment to lower BP at SBP of 150 mm Hg or DBP of 90mm Hg and treat to a goal SBP < 150 mm Hg and DBP