Hypertension Update: Navigating the New Guidelines Shawna D. - - PowerPoint PPT Presentation

Shawna D. Nesbitt, MD, MS Professor of Medicine Associate Dean UT Southwestern Medical School

“Hypertension Update: Navigating the New Guidelines”

SPEAKER DISCLOSURE

• Dr. Nesbitt has disclosed that she has received grant

support from Quantum Genomics, she is a consultant for Relypsa, and she is on the advisory board for Quantum Genomics and Reylpsa.

EDUCATIONAL OBJECTIVES

By completing this educational activity, the participant should be better able to:

• 1. Discuss the significance of early detection and effective

treatment of hypertension.

• 2. Address barriers to care among patients with hypertension and

assess treatment barriers in the elderly.

• 3. Discuss the recommendations of the JNC8.
• 4. Construct a management plan for patients with hypertension

and discuss methods for treating for resistant hypertension.

BASELINE BP PREDICTS PROGRESSION TO HYPERTENSION

Age 35-64

5.3 17.6 37.3 10 20 30 40 50 60

Optimal Normal High Normal

4 Year Hypertension Incidence %

Age 65-94

16 25.5 49.5 10 20 30 40 50 60

Optimal Normal High Normal

4 year Hypertension Incidence rates

Optimal = <120/80 mm Hg Normal = 120‐130/80‐85 mm Hg High Normal = 130‐139/85‐89 mm Hg Adjusted for sex, age, BMI, and baseline BP Vasan RS. Lancet. 2001;358:1682

KAPLAN‐MEIER CURVES OF CLINICAL HYPERTENSION IN THE TWO GROUPS

1 2 3 4 Years in study 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 % Cumulative incidence Candesartan Placebo Candesartan 391 356 309 191 128 Placebo 381 269 184 118 85 Numbers under the graph refer to hypertension‐free individuals 2 Years RR ↓66% AR ↓ 26% 4 Years RR ↓15.8 AR ↓ 9.6

Julius S, Nesbitt SD, et al. NEJM. 2006;354

Lancet, 2002; 360:1903‐1913

CORONARY ARTERY DISEASE MORTALITY STROKE MORTALITY

Risk of CAD and Stroke Mortality by SBP

Lewington S, et.al. Lancet. 2002;360:1903‐1913

MORTALITY FROM HIGH BLOOD PRESSURE HIGHER IN AFRICAN AMERICANS

Age‐adjusted Mortality Rates Attributable to Hypertension, 2014

Mortality Rate per 100,000 African American Women Men Women 20 10 30 40 50

50.1 19.3 35.6 15.8

60 Men White Adapted from Benjamin EJ, et al. Circulation. 2017.

ADULT BLOOD PRESSURE CATEGORIES

BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg

• r

80–89 mm Hg Stage 2 ≥140 mm Hg

• r

≥90 mm Hg

• *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.
• BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2
• ccasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.

Whelton PK, et.al. ACC/AHA/AAPA/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; Nov 13

PREVALENCE OF HYPERTENSION BASED ON 2 SBP/DBP THRESHOLDS*†

SBP/DBP ≥130/80 mm Hg or Self-Reported Antihypertensive Medication† SBP/DBP ≥140/90 mm Hg or Self- Reported Antihypertensive Medication‡ Overall, crude 46% 32% Men (n=4717) Women (n=4906) Men (n=4717) Women (n=4906) Overall, age-sex adjusted 48% 43% 31% 32% Age group, y 20–44 30% 19% 11% 10% 45–54 50% 44% 33% 27% 55–64 70% 63% 53% 52% 65–74 77% 75% 64% 63% 75+ 79% 85% 71% 78% Race-ethnicity§ Non-Hispanic White 47% 41% 31% 30% Non-Hispanic Black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32%

• The prevalence estimates have been rounded to the nearest full percentage.
• *130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.
• †BP cut points for definion of hypertension in the present guideline.
• ‡BP cut points for definion of hypertension in JNC 7.
• §Adjusted to the 2010 age‐sex distribution of the U.S. adult population.
• BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.

Whelton PK, et al. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; Nov 13

Muntner, P et al. “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.” Circulation. 2017.

42% 46% 31% 30%

59% 56% 47% 41% 0% 10% 20% 30% 40% 50% 60% 70% Black men Black women White men White women

Prevalence of Hypertension Based on BP Thresholds (NHANES)

JNC 7‐‐140/90 mmHg 2017 ACC/AHA‐‐130/80 mmHg

LANGUAGE AS A BARRIER TO HEALTHCARE

“Triple Threat”

• 1. Language differences
• 2. Cultural differences

associated with language

• 3. Low health literacy

Schyve PM. J Gen Intern Med. 2007;22(suppl2);360

5 AREAS OF SOCIAL DETERMINANTS OF HEALTH (SDOH)

Education

• High School Graduation
• Enrollment in Higher Education
• Language and Literacy
• Early Childhood Education and Development

Neighborhood and Built Environment

• Access to foods that support healthy Eating Patterns
• Quality of Housing
• Crime and Violence
• Environmental Conditions

Social and Community Context

• Social Cohesion
• Civic Participation
• Discrimination
• Incarceration

Health and Health Care

• Access to Health Care
• Access to Primary Care
• Health Literacy
• Provider Bias
• Cultural Competency

Economic Stability

• Poverty
• Employment
• Food Insecurity
• Housing Instability

Social Determinants Of Health

Healthy People 2020; Healthy People.Gov

RECOMMENDATION FOR ACCURATE MEASUREMENT OF BP IN THE OFFICE

COR LOE Recommendation for Accurate Measurement

• f BP in the Office

I C‐EO For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP.

What’s wrong with this picture?

Abbasi J. Medical Students Fall Short on Blood Pressure Check Challenge. JAMA 2017

OUT‐OF‐OFFICE AND SELF‐MONITORING OF BP

COR LOE Recommendation for Out‐of‐Office and Self‐ Monitoring of BP I ASR Out‐of‐office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP‐lowering medication

Home BP monitoring 24 hr. ambulatory BP monitoring

Siu et al. Ann Intern Med. 2015;163:1‐10

“The USPSTF recommends obtaining measurements outside of the clinical setting (Ambulatory or Home BP) for diagnostic confirmation before starting treatment. (Grade A)”

BP mm Hg

                        

50 100 150 200 250 16:00 24:00 16:00

Sleep

hr:min

Normal

                        

15:00 24:00

Office visits

White Coat Effect

White Coat Hypertension White Coat Hypertension

24 Hour Ambulatory BP Monitoring

24 Hour Ambulatory BP Monitoring 24 Hour Ambulatory BP Monitoring

60 100 140 180 Blood Pressure mm Hg

4 pm midnight 4 pm

Asleep Awake

Dow Jones Down

Masked HTN and White Coat HTN in Dallas Heart Study

Population‐based probability sample (n =3,027 50% African Americans 49% female) Median follow up 9.5 years

WCH 3% Masked HTN 18% Sustained HTN 12%

Tientcheu, et al. J Am Coll Cardiol. 201517;66(20):2159‐69.

Increased CV Complications in WCH and MH

Sustained HTN Masked HTN White coat HTN Normotensives

Tientcheu, et al. J Am Coll Cardiol. 2015 17;66(20):2159‐69

HOW ACCURATE ARE HOME BP MONITORS ? A CROSS‐SECTIONAL STUDY IN 210 PATIENTS

Ruzicka, et al. PLOS ONE. June 2016

• Patients at increased cardiovascular risk but without

diabetes were assigned to intensive treatment of systolic BP (target, <120 mm hg) or standard treatment (target, <140 mm hg).

• After a median of 3.26 years, the rate of cardiovascular

events was significantly lower with intensive treatment.

SPRINT TRIAL: Systolic Blood Pressure Intervention Trial

A Randomized Trial of Intensive versus Standard Blood-Pressure Control

JT Wright, et al. A Randomized Trial of Intensive versus Standard Blood‐Pressure Control. N Engl J Med. Nov 26; 2015 373(22):2103‐2116

SPRINT TRIAL: Systolic Blood Pressure Trend

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT Trial: Primary Outcome and Death from Any Cause

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT Study Primary Outcome According to Subgroups

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL: Primary and Secondary Outcomes and Renal Outcomes.

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL: Primary and Secondary Outcomes and Renal Outcomes.

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL CONCLUSION

Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm hg, as compared with less than 140 mm hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive‐treatment group.

The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

PERKOVIC V, RODGERS A. N ENGL J MED. 2015;373:2175‐2178.

Outcomes Data from SPRINT and the ACCORD Trial and Combined Data from Both Trials

RECOMMENDATIONS FOR TREATMENT AND FOLLOW‐UP OF ELEVATED BP

Whelton PK, et.al. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2017; Nov 13

Color coded by the class of

• f recommendation using

the ACC/AHA equations.

• Sex: Male
• Age
• Race
• Diabetes
• Systolic BP
• Treatment of HTN
• Total Cholesterol
• HDL‐Cholesterol
• Smoking

ASCVD Risk: Pooled Cohort Equation

BP Thresholds for and Goals of Pharmacological Therapy in Patients with Hypertension According to Clinical Conditions

Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10‐year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10‐year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ambulatory, community‐living adults) ≥130 (SBP) <130 (SBP) Specific comorbidities Diabetes mellitus ≥130/80 <130/80 Chronic kidney disease ≥130/80 <130/80 Chronic kidney disease after renal transplantation ≥130/80 <130/80 Heart failure ≥130/80 <130/80 Stable ischemic heart disease ≥130/80 <130/80 Secondary stroke prevention ≥140/90 <130/80 Secondary stroke prevention (lacunar) ≥130/80 <130/80 Peripheral arterial disease ≥130/80 <130/80

Whelton PK, et.al. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2017; Nov 13

CHOICE OF INITIAL MEDICATION

COR LOE Recommendation for Choice of Initial Medication

I

ASR For initiation of antihypertensive drug therapy, first‐ line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs. SR indicates systematic review.

Beta Blockers are NOT first line Drug therapy

Whelton PK, et.al. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2017; Nov 13

CHOICE OF INITIAL MONOTHERAPY VERSUS INITIAL COMBINATION DRUG THERAPY

COR LOE Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy* I C‐EO Initiation of antihypertensive drug therapy with 2 first‐line agents of different classes, either as separate agents or in a fixed‐dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target. IIa C‐EO Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.

Whelton PK, et.al. Guideline for the prevention, Detection, Evaluation, and Management of High BP in Adults. Hypertension 2017; Nov 13

PART 1 SUMMARY

• BP threshold and goal generally lower to 130/80 mmHg

(though not SPRINT level)

• However, drug Rx not recommended for low risk patients with

BP 130‐139/80‐89 mmHg

• ASCVD risk assessment is recommended in conjunction with BP

to guide HTN Rx

• Beta blocker is not first line Rx for HTN without other indication
• For patients with stage II HTN BP >= 140/90 mmHg 2 drug

combination preferred (2‐in1 combo pill, if possible)

BP Measurement in SPRINT: Does automated Office BP measurement matter ?

• Automated BP monitors (OMRON) by research nurses
• Monitor is programmed to have delay start after 5 min rest
• 3 measurements separated by 1 min with all 3 average
• Research personnel encourage to leave the room but not a must

Always Alone (4,082 participants at 38 sites): Alone for both 5 min rest and 3 BP readings Never Alone (2,247 participants at 25 sites): Personnel in the room the entire time Alone for Rest (1746 participants at 19 sites): Alone for 5 min rest but not during 3 BP readings Alone for BP Measurement (570 participants at 6 sites): Alone only during 3 BP readings but not during rest

CV Outcome by Method of BP Measurement in SPRINT

Johnson et al. Abstract AHA LBCT Meeting. 2017.

Stroke CHD Total –6 –4 –3 –8 –5 –4 –14 –9 –7 Reduction in BP

Population‐Based Strategy

SBP Distributions Before Intervention After Intervention

% Reduction in Mortality Reduction in SBP mmHg 2 3 5 SBP<140 SBP<135

CASE 1

• A 78 yo woman with HTN presents for follow up. She lives alone, but is

quite active.

• Taking amlodipine 10mg daily and chlorthalidone 25mg daily for several
• years. Brings home blood pressure logs for past 3 days showing values

ranging 138/68‐149/75 mm Hg. She is concerned about lowering her BP too much as she is worried about falling.

• BP is 146/68 R arm, Height 5’1’’, Weight 109lbs, BMI‐ 20.6 kg/m2
• Exam otherwise unremarkable
• ECG – normal sinus rhythm, no LVH
• Labs – Cr‐0.7mg/dL
• What do you recommend?

SPRINT STUDY: AGE ≥75

Overall Age≥75 HR NNT* HR NNT* Primary Outcome 0.75 (0.64–0.89) 61 0.66 (0.51‐0.85) 27 CV Death 0.57 (0.38–0.85) 172 0.60 (0.33‐1.09) 116 All Cause Mortality 0.73 (0.60–0.90) 90 0.67 (0.49‐0.91) 41

* ~3.2 years f/u 1°outcome= myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes

SPRINT Investigators NEJM 2015;373:2103‐2116 Williamson J et al. 2016 JAMA;315:2673‐2682.

SPRINT SENIOR Sub Study Benefit of Intensive BP Reduction in Frail Elderly

• Williamson. JAMA. 2016;315(24):2673‐2682

Cardiovascular Outcome in SPRINT Participants with CKD at Baseline

HR (95% CI) 0.81 (0.63‐1.05)

Cheung, et al. JASN, June 2017

Intensive Standard

HR (95% CI) 0.90 (0.44‐1.83) Cheung, et al. JASN, June 2017

RENAL OUTCOME IN SPRINT PARTICIPANTS WITH CKD AT BASELINE (EGFR < 60 ML/MIN/1.73 M2)

Outcome: decrease. in eGFR > 50% or ESRD

All Cause Mortality in SPRINT Participants with CKD at Baseline

Standard Intensive

Cheung et al. J Am Soc Nephrol. Jun 22 2017

Intensive Standard

SPRINT: Patient Reported Outcomes

• Berlowitz. NEJM. 2017;377:8

Physical Health Depression Scale Mental Health

Effect of Intensive vs. Standard Blood Pressure Control on Probable Dementia

• SPRINT. Mind. JAMA 2019;32:553‐561

Shaded regions indicate 95% CI. Median follow‐up time 5.14 years

• vs. 5.07 years. Hazard Ratio 0.83 95% CI 0.67‐1.04 P=0.1

Effect of Intensive vs. Standard Blood Pressure Control on Probable Dementia

• SPRINT. Mind. JAMA

2019;32:553‐561

OUTCOMES OF INTENSIVE BLOOD PRESSURE LOWERING IN OLDER HYPERTENSIVE PATIENTS

Bavishi C. JACC. 2017;69:486‐493

CASE 2

• 66 yo African‐American man is being seen for a recent gout flare.

He has T2DM and hyperlipidemia.

• He takes HCTZ 25mg and amlodipine 10mg.
• His blood pressure in the office is 138/94 mm Hg which is similar

to home readings.

• Labs show eGFR of 40 with a positive urine dipstick for protein.
• What’s his goal and what are his options?

Muntner, P et al. “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.” Circulation 2017.

42% 46% 31% 30%

59% 56% 47% 41% 0% 10% 20% 30% 40% 50% 60% 70% Black men Black women White men White women

Prevalence of Hypertension Based on BP Thresholds (NHANES)

JNC 7‐‐140/90 mmHg 2017 ACC/AHA‐‐130/80 mmHg

• DM or CKD patients are automatically placed in the high‐risk category. For initiation of

RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy.

• †Consider iniaon of pharmacological therapy for stage 2 hypertension with 2

antihypertensive agents of different classes.

• Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated,

carefully monitored, and have medication dose adjustment as necessary to control BP.

• Reassessment includes
• BP measurement
• Detection of orthostatic hypotension in selected patients (e.g., older or with

postural symptoms)

• Identification of white coat hypertension/effect
• Documentation of adherence
• Monitoring of the response to therapy
• Reinforcement of the importance of adherence, the importance of treatment, and

assistance with treatment to achieve BP target

Special Considerations in Treatment Recommendations

IMPORTANT POINTS

• New guideline emphasize proper BP measurement and out‐of‐office BP

measurement to confirm Dx

• Home BP monitors for most but may not be accurate for some patients
• Consider 24‐ABP if data inconsistent
• Risk vs. benefit of intensive BP reduction should be individualized

Initial therapy includes:

• CCB, ACE/ARB, Thiazide Diuretics

Add‐on therapy:

• Beta Blockers, Alpha Blockers
• Mineralocorticoid Blockers, Direct vasodilators
• Central acting drugs