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Update In Hypertension Management
Dr.Tarek Khalil, M.D., FESC, EAPCIProf. of Cardiology, Menoufiya University
Interventional Cardiology Consultant, Arrawdha general hospital
Dammam23/03/2016
I am a gentle killer All over the world, I am called HYPERTENSION
World Hypertension Day, annually celebrated on May 17th
Statement of Need
“My greatest challenge as a doctor in the management
of patients with hypertension is……………”
Please write down your answer to the following:
1-When to begin treatment?2-How low should I go? and 3-What drug do I use?To Improve CV Outcomes
Scope of the Problem
Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide1
Number of people with HTN
worldwide in 20001
972 million
Increase in the number of adults with HTN globally by 20251
60%
Percent of all global healthcare spending
attributable to high blood pressure2
10%
Annual worldwide cost of hypertension2
$370 billion
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.
1.6 Billion HTN patients estimated
by 2025
Residual Lifetime Risk for Developing Hypertension
• a cohort from the Framingham data, 1298 participants free of hypertension in 1975, and aged either 55 or 65 at baseline.
• Lifetime risk for hypertension for these subjects, defined as BP > 140/90 mm Hg or the use of antihypertensive medications, based on data gathered between 1976 and 1998.
Vasan et al. JAMA 2002;287(8):1003-10
Scope of the problem
Residual lifetime risk of hypertension for men and women, aged 55 and 65 at baseline
Results
By age group By sex0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%90% 90%90% 90%
Life
time
Ris
k fo
r H
yper
tens
ion
Vasan et al. JAMA 2002;287(8):1003-10
Scope of the problem
These high numbers mean strategies to prevent, detect, and treat Hypertension become even more critical.
BP Control RatesTrends in awareness, treatment, and control of high
blood pressure in adults ages 18–74National Health and Nutrition Examination Survey, Percent
NHANESII
1976–80
NHANES III
1988–91
NHANES III
1991–94
NHANES
1999–2000
NHANES
2007-2008
NHANES
2011-2012
Awareness 51 73 68 70 81 82
Treatment 31 55 54 59 72 75
Control* 10 29 27 34 50 51
Sources: Unpublished data for 2011–2012 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 8.
*SBP <140 mmHg, DBP <90 mmHg
Scope of the problem
USA53.1
Canada41.0
Mexico21.8
Germany33.6
Greece49.5
England29.2
Egypt8
South Africa*47.6
Japan*55.7
Taiwan18.0
China28.8
Turkey19.8
*Data for men only
Worldwide Blood Pressure Control in Treated Hypertensive Patients
Updated from Kearney et al. J Hypertens 2004; 22: 11–19
The blood pressure of treated patients is far from being normotensive.
Factors of Suboptimal Hypertension Control
1. Inadequate access to health care2. Cost of therapy3. Poor compliance and persistence with medications4. Drug adverse effects5. Clinician inertia6. Disregard of treatment guidelines7. Inadequate education of clinicians and patients8. Unhealthy lifestyles.
Chobanian AV; JAMA 2010;303(20):2082-2083
HTN leads to an increased risk of death from stroke and heart diseaseC
V m
orta
lity
risk
SBP/DBP (mm Hg)
0123456
115/75 135/85 155/95 175/105
*Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure
Lewington S et al. Lancet 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572
78 8x
4x
2x
CV mortality risk doubles for every 20/10 mmHg increase in systolic and diastolic blood pressure.
Time to take some serious action
Benefits of Lowering BP
Series1
-60
-40
-20
0
>50
35-40
20-25
CHF MIStroke Incidence
All reductions are statistically significant
Average reduction in events
(%)
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.
Evidence-Based Cardiology Consult
Hypertension Guidelines
•2013ESH/ESCASH/ISH
•2014JNC 8
•2015CHEP
Blood Pressure Classification JNC-VII
Normal <120 and <80
Prehypertension 120–139 or 80–89Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160 or >100
BP Classification SBP mmHg DBP mmHg
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) JAMA 21; 289(19):2560-71. 2003
JNC 8 (2014 Hypertension Guideline)
• Definitions of hypertension and prehypertension not addressed
• But thresholds for pharmacologic treatment were defined
When to begin treatment?
What drug do I use?
How low should I go?
Questions Guiding The JNC 8 Review
The answers to these three questions are reflected in 9 recommendations
James PA et al. JAMA 2014;311:507-20.
When to begin treatment?How low should I go?
Questions guiding the JNC 8 review
James PA et al. JAMA 2014;311:507-20.
JNC 8 Recommendations
Recommendation 1(Strong recommendation)
Recommendation 2(Strong recommendation)
Recommendation 3 (Expert opinion)
General population ≥60 years
SBP ≥150 mm Hgor DBP ≥90 mm Hg
SBP <150 mm Hgand DBP <90 mm Hg
General population <60 years
SBP ≥140 mm Hg SBP <140 mm Hg
GoalsBP thresholds
General population <60 years
DBP ≥90 mm Hg DBP <90 mm Hg
Consequence Recommendation: (Expert Opinion) If pharmacologic treatment achieves lower SBP (e.g. <140) & no adverse
events, treatment adjustment not required
Based on high-quality evidence from 5 DBP trials (HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA Cooperative)
Based on results from JATOS Trial, and Valsartan Study group
Based on HYVET, Syst-Eur, SHEP, JATOS, VALISH, and CARDIO-SIS
JNC 8 Recommendations
GoalsBP thresholds
Which drug do I use ?
Population with CKD ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
Population with diabetes ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
Recommendation 4 (Expert opinion)
Recommendation 5 (Expert opinion)
Based on results of trials such as AASK, MDRD & REIN- 2 (<70 yrs with eGFR <60ml or any age with albuminuria >30mg albumin/g at any level of GFR)
Based on results from Trials such as SHEP, Syst-Eur, UKPDS, ACCORD-BP trial, ADVANCE trial, HOT trial
The A,B,C,D drug classes
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Beta-blockers
Calcium channel blockers
Diuretics
JNC 8 Recommendations: Which Drug Do I Use ?
General nonblack population ( ± diabetes ) orA C Dor
Recommendation 6(Moderate recommendation) Initial treatments
What happened to the beta-blockers (BB)? Most evidence for BB is from atenolol
• Does not meet current FDA criteria for a once-daily drug
LIFE Study BB still recommended for many patients with comorbid
conditions (CHF, CAD, etc.)
•Losartan Intervention For Endpoint reduction in hypertension (n=9193)–Previously treated or untreated hypertension–Systolic BP 160-200 mmHg or diastolic BP 95-115 mmHg–ECG LVH when the blood pressure is lowered with an ARB to the same degree as it is with the comparative agent, the ARB will offer better protection against hypertension-related hard end points.
Primary composite endpoint of cardiovascular morbidity and mortality, defined as stroke, MI or cardiovascular death
Losartan vs atenolol2002
Insights Gained From Clinical Trials In Hypertension
20
4060
80100
120140
160180
LIFE Study Blood Pressure During Follow-up
Study Month
Systolic
Diastolic
Mean Arterial
mm
Hg
AtenololLosartan
6 5412 3018 24 36 42 480
Dahlof B, et al. Lancet. 2002;359:995-1003.Reprinted with permission from Elsevier Science.
Insights Gained From Clinical Trials In Hypertension
LIFE: Event rate
0%
2%
4%
6%
8%
10%
12%
14%
Composite Stroke MI Death
Losartan Atenolol
11%
13%
4% 4%5%
7%
4% 5%
Dahlof B, et al. Lancet. 2002;359:995-1003.Presented by B Dahlof at the American College of Cardiology Scientific Sessions Late-Breaking Clinical Trials III, 2002.
13% RR p=0.021
7% RR p=0.491
25% RR p=0.001 11% RR
p=0.206
JNC 8 Recommendations: Which Drug Do I Use ?
General nonblack population ( ± diabetes ) orA C Dor
Recommendation 6(Moderate recommendation) Initial treatments
What happened to the beta-blockers (BB)? Most evidence for BB is from atenolol
• Does not meet current FDA criteria for a once-daily drug
LIFE Study BB still recommended for many patients with comorbid
conditions (CHF, CAD, etc.)
JNC 8 Recommendations: Which Drug Do I Use ?
General nonblack population ( ± diabetes ) orA C Dor
Recommendation 6(Moderate recommendation)
Initial treatments
Initial or add-on treatments
General ( ± diabetes ) black population orC D
Population with CKD ≥18 years(irrespective
of race or diabetes)A
Recommendation 7(Moderate recommendation)
Initial treatments
Recommendation 8(Moderate recommendation)
In single large trial (ALLHAT) , a thiazide-type diuretic was shown to be more effective in improving stroke, HF, & combined CV outcomes compared to an ACEI in the black patient subgroup
based primarily on kidney outcomes because there is less evidence favouring ACEI or ARB for cardiovascular outcomes in patients with CKD
Use of renin-angiotensin system inhibitors in CKD population requires monitoring of electrolyte & serum creatinine levels
Start one drug, titrate to maximum dose, and then add a second drug
Start one drug and then add a second drug before achieving maximum dose of the initial drug
Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination
A
C
B
Recommendation 9: Strategies to Dose of Antihypertensive Drugs To Achieve Goal BP
James PA et al. JAMA 2014;311:507-20.
Multiple Antihypertensive Agents Are Needed to Achieve Target BP
DBP = diastolic blood pressure; MAP = mean arterial pressure.Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
Trial Target BP (mm Hg)
UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
AASK MAP <92
No. of Antihypertensive Agents0 1 2 3 4
Possible combinations of classes of antihypertensive drugs
Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination.
D
A
A
C
B
DM CKD
C D A
B
A C DAlone or in combination
Alone or in combination with other drug class
Comparisons to Other Guidelines
BP Goal JNC-7 JNC-8 ASH/ISH ESC/ESH CHEP
Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90
Age 60-79
<140/90 <150/90 <140/90 <140/90 <140/90
Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90
Diabetes <130/80 <140/90 <140/90 <140/85 <130/80
CKD <130/80 <140/90 <140/90 <130/90 <140/90
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
Comparisons to Other GuidelinesJNC-7 JNC-8 ASH/ISH ESC/ESH CHEP
Non-black (no DM or CKD)
Thiazide Thiazide, ACEI, ARB, CCB
<60:ACEI,ARB>60:CCB, thiazide
Thiazide, ACEI, ARB, CCB, BB
Thiazide, ACEI, ARB (BB if <60)
Black (no DM or CKD)
Thiazide Thiazide, CCB
Thiazide, CCB
Thiazide, ACEI, ARB, CCB, BB
Thiazide, ARB (BB if <60)
Diabetes ACEI, ARB, CCB, BB, thiazide
CCB, thiazide
ACEI, ARB, CCB, thiazide
ACEI, ARB ACEI, ARB, CCB, thiazide
CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
Major changes from JNC 7
Higher target SBP for patients over 60 y/o Limited data to support either 150 or 140 mmHg Removed special lower target BP for those
with CKD or DM Liberalized initial drug choicesA C D
Conclusion• HTN is a widespread and treatable condition, but
• BP control in the community continues to be suboptimal,
• leading to increased rates of MI, stroke and other serious comorbid conditions.
• JNC8 Guidelines are fairly simple to understand and use in general practice,
• But not a substitute for good clinical judgment.
It’s easy to get good players.
Getting’ `em to play together …
That’s the hard part.
Thank You