New Paradigm (2017 Guidelines) for Blood Pressure Treatment: - - PDF document
New Paradigm (2017 Guidelines) for Blood Pressure Treatment: Beyond the Numbers Donald M. LloydJones, MD ScM FACC FAHA Eileen M. Foell Professor Chair, Dept. of Preventive Medicine Senior Associate Dean Director, NUCATS Institute
Donald M. Lloyd‐Jones, MD ScM FACC FAHA Eileen M. Foell Professor Chair, Dept. of Preventive Medicine Senior Associate Dean Director, NUCATS Institute Northwestern Feinberg School of Medicine
10/1/2019
Whelton et al. Circulation 2018; JACC 2018
Recommendation
I, IIa, IIb, III‐NB, III‐Harm
A, B‐R, B‐NR, C‐LD, C‐EO
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Avoid caffeine, exercise, smoking for > 30 mins prior
On 2 separate occasions
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“pre‐hypertension”
thresholds shifted downward
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*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 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.
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
80–89 mm Hg Stage 2 ≥140 mm Hg
≥90 mm Hg
Adjusted Hazard Ratio <120/<80 mmHg SBP 120‐139 or DBP 80‐89 mmHg SBP ≥140 or DBP ≥90 mmHg Endpoint
Untreated Treated Untreated Treated Untreated Treated CVD 603 1.0 (ref) 2.2* 1.4* 2.2*† 2.8* 3.0* CHD 423 1.0 (ref) 2.0* 1.3 2.1*† 2.3* 2.5* HF 226 1.0 (ref) 1.7 1.4 2.4*† 2.4* 3.0* Stroke 171 1.0 (ref) 2.6* 1.8 3.1* 4.2* 4.7* MESA 9.5 Years of Follow‐Up
*P<0.01 compared with referent †P<0.01 compared with treated, same BP
Liu, JAHA 2015
Liu, JAHA 2015
Adjusted HR (95% CI) <120/<80 mmHg SBP 120‐139 or DBP 80‐89 mmHg SBP ≥140 or DBP ≥90 mmHg Subclinical Marker Untreated Treated Untreated Treated Untreated Treated
Echo LVMI
g/m2.7 37.9 (ref) 39.9* 39.2* 42.2*† 43.0* 43.9*
CAC >100
% 5.3 (ref) 10.7* 7.9* 14.8*† 9.9* 12.7*
eGFR <60
% 0.8 (ref) 3.9* 0.6 2.1† 1.4 6.3*† CARDIA Y25 Exam
*P<0.01 compared with referent †P<0.01 compared with treated, same BP
Liu, JAHA 2015
Adjusted for age, sex, race, BMI, smoking, diabetes, LDL-C, and cholesterol medication
Liu, JAHA 2015
3000 mm Hg‐years = 120 mm Hg x 25 years
risk of those with always optimal BP
hypertensive” range, over time are accruing myocardial and vascular damage that is difficult if not impossible to reverse
increases from 32% to 46% among US adults
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…But not all of these newly HTNsive pts require meds! (~5% more)
Chen et al, JAMA Cardiol 2019
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CO R 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, in conjunction with telehealth counseling or clinical interventions.
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Detecting White Coat and Masked Hypertension
Screen for masked HTN if target organ damage Screen for white coat HTN if target organ damage
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Abrupt onset Early onset (<30 yo) Onset of diastolic HTN in older adult Unprovoked or excessive hypoK Accelerated/malignant HTN Exacerbation of previously controlled HTN Drug‐resistance Disproportionate TOD
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Cause Prevalence Clinical Indicators Screening Tests Additional Tests Renal disease 1‐2% Abdominal mass; family hx PCKD; ↑Cr; abnl U/A Renal U/S Renal w/u Renovascu‐ lar disease 5‐34% Resistant HTN; abrupt onset; flash pulmonary edema; abdominal bruit; other bruits Renal Duplex, MRA, CT Angio Primary hyperaldo 8‐20% Resistant HTN; ↓K Plasma aldo/renin ratio (K corrected;
Sodium loading test – aldo; adrenal CT OSA 25‐50% Resistant HTN; obesity; snoring; somnolence Epworth sleepiness PSG Drug/EtOH induced 2‐4% Caffeine; nicotine; EtOH; NSAIDs; OCPs; illicits History; urinary drug screen Withdraw agent
Intervention Goal Impact on SBP HTN NormoTN Weight Weight loss Ideal body weight; 1 mm Hg/ 1 kg ‐5 mm Hg ‐2/3 mm Hg Physical activity Aerobic exercise 90‐150 min/wk ‐5/8 mm Hg ‐2/4 mm Hg Dynamic resistance 90‐150 min/wk 6 ex/3 sets/ 10 reps ‐4 mm Hg ‐2 mm Hg Isometric resistance 4 x 2 min (hand grip) ‐5 mm Hg ‐4 mm Hg EtOH moderation EtOH reduction M: ≤2 drinks/day W: ≤1 drink/day ‐4 mm Hg ‐3 mm Hg All IA Recommendations
Intervention Goal Impact on SBP HTN NormoTN Healthy diet DASH eating pattern Focus on fruits/veg/whole grains/low‐fat dairy, ↓ sat and total fat ‐11 mm Hg ‐3 mm Hg Dietary sodium Reduced intake <1500 mg/day; at least ↓ 1000 mg/day ‐5/6 mm Hg ‐2/3 mm Hg Dietary potassium Enhanced intake 3500‐5000mg/day thru dietary sources ‐4/5 mm Hg ‐2 mm Hg All IA Recommendations
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* Using Pooled Cohort Equations COR LOE Recommendations for BP Treatment Threshold and Use of Risk Estimation* to Guide Drug Treatment of Hypertension I SBP: A Use of BP‐lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10‐year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher. DBP: C‐ EO I C‐LD Use of BP‐lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10‐year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.
higher estimated CVD risk yields more events prevented per 1000 patients treated
BPLTTC
BPLTTC
Karmali et al. PLoS Med 2018
BPLTTC
Karmali et al. PLoS Med 2018
BPLTTC
Karmali et al. PLoS Med 2018
eligible ppts and most have had 10‐year ASCVD risk >10%
>15% as inclusion criterion (~7% ASCVD risk)
higher‐risk individuals, regardless of their baseline treated or untreated BP ≥130/80 mm Hg and irrespective of the specific cause of their elevated risk
These analyses indicate that the benefit of treatment outweighs the potential harm at threshold BP ≥130/80 mm Hg.
Loop diuretics Potassium sparing diuretics Aldosterone antagonists Beta‐blockers Direct renin inhibitor (aliskiren) Alpha1‐blockers Central alpha2‐agonist (clonidine) Direct vasodilators (hydralazine, minoxidil)
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COR LOE Recommendation for General Principle of Drug Therapy III: Harm A Simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension. 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
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.
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COR LOE Recommendations for Follow‐Up After Initiating Antihypertensive Drug Therapy I B‐R Adults initiating a new or adjusted drug regimen for hypertension should have a follow‐up evaluation
treatment at monthly intervals until control is achieved.
COR LOE Recommendations for BP Goal for Patients With Hypertension I SBP: B‐RSR For adults with confirmed hypertension and known CVD or 10‐ year ASCVD event risk of 10% or higher a BP target of less than 130/80 mm Hg is recommended. DBP: C‐ EO IIb SBP: B‐NR For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable. DBP: C‐ EO
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risk of CVD.
guidelines target SBP <140 mm Hg based on limited evidence.
diabetics showed null effect, less stroke, more harm.
pressure to a target of less than 120 mm Hg with treatment to a target
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Participants: Age 50+, SBP 130‐180, and ↑ risk for CVD
‐ Clinical or subclinical CVD (not stroke or active CHF); CKD; 10‐year CVD risk ≥15%; or age 75+; excluded those with DM
Intervention: Target SBP <120 mm Hg Comparator: Target SBP <140 mm Hg Outcomes: 1o: Composite of MI, ACS, Stroke, Acute decompensated HF, CVD death; 2o: Primary components, total mortality Time Course: Planned 5‐year average follow up; stopped early after 3.3 years for total mortality benefit Setting: 102 centers in US and Puerto Rico Funded by NIH
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Intensive (N=4678) Standard (N=4683) Age, years (SD) 67.9 (9.4) 67.9 (9.5) Women, % 36.0% 35.2% Black race, % 31.1% 31.9% SBP, mean (SD) 139.7 (15.8) 139.7 (15.4) Clinical CVD, % 16.7% 16.7% FRS 10‐y CVD risk, mean (SD) 20.1 (10.9) 20.1 (10.8) Creatinine, mean (SD) 1.07 (0.34) 1.08 (0.34) BP‐lowering drug use, % 90.8% 90.4%
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Mean SBP 136.2 mm Hg Mean SBP 121.4 mm Hg
Year 1
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Number needed to treat to prevent 1 outcome / 3.3 years = 60 Number needed to treat to prevent 1 death / 3.3 years = 83
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Intensive vs Standard BP Lowering Goal for High‐Risk HTN
Intensive (<120 mmHg) Standard (<140 mm Hg)
Events Rate, %/year
Events Rate, %/year HR (95% CI) P Primary Outcome 243 1.65 319 2.19 0.75 (0.64, 0.89) <0.001 All MI 97 0.65 116 0.78 0.83 (0.64, 1.09) 0.19 Non‐MI ACS 40 0.27 40 0.27 1.00 (0.64, 1.55) 0.99 All Stroke 62 0.41 70 0.47 0.89 (0.63, 1.25) 0.50 All HF 62 0.41 100 0.67 0.62 (0.45, 0.84) 0.002 CVD Death 37 0.25 65 0.43 0.57 (0.38, 0.85) 0.005
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Strengths: Large, diverse sample; achieved SBP separation. Limitations: No DM or stroke pts; method of BP measurement not usual for clinical practice. Conclusions: Targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, in patients at high risk for cardiovascular events but without diabetes resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any
frequently with the lower target.
Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General No clinical CVD and 10‐year ASCVD risk <10% ≥140/90 <130/80 Clinical CVD or 10‐year ASCVD risk ≥10% ≥130/80 <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 With or at risk for heart failure (HFrEF or HFpEF) ≥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
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COR LOE Recommendations for Treatment of Hypertension in Patients With DM I SBP: B‐RSR In adults with DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal of less than 130/80 mm Hg. DBP: C‐ EO I ASR In adults with DM and hypertension, all first‐line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. IIb B‐NR In adults with DM and hypertension, ACE inhibitors or ARBs may be considered in the presence of albuminuria.
COR LOE Recommendations for Race and Ethnicity I B‐R In black adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide‐type diuretic or CCB. I C‐LD Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.
COR LOE Recommendations for Treatment of Hypertension in Pregnancy I C‐LD Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy. III: Harm C‐LD Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors.
COR LOE Recommendations for Treatment of Hypertension in Older Persons I A Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community‐dwelling adults (≥65 years of age) with an average SBP
IIa C‐EO For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team‐based approach to assess risk/benefit is reasonable for decisions regarding intensity
COR LOE Recommendations for Antihypertensive Medication Adherence Strategies I B‐R In adults with hypertension, dosing of antihypertensive medication
adherence. IIa B‐NR Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive therapy.
COR LOE Recommendation for Structured, Team‐Based Care Interventions for Hypertension Control I C‐EO Every adult with hypertension should have a clear, detailed, and current evidence‐based plan of care that ensures the achievement of treatment and self‐management goals, encourages effective management of comorbid conditions, prompts timely follow‐up with the healthcare team, and adheres to CVD GDMT. I A A team‐based care approach is recommended for adults with hypertension.
lowering while minimizing side effects, esp. for Stage 2 HTN (≥140/90 mm Hg)