New Paradigm (2017 Guidelines) for Blood Pressure Treatment: - PDF document

New Paradigm (2017 Guidelines) for Blood Pressure Treatment: Beyond the Numbers 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 Disclosures • Dr. Lloyd‐Jones has no RWI/COI  Grant funding: NIH, CMS, AHA

Whelton et al. Circulation 2018; JACC 2018 10/1/2019 ACC/AHA Guideline Recommendations • Class (Strength) of Recommendation  I, IIa, IIb, III‐NB, III‐Harm • Level (Quality) of Evidence  A, B‐R, B‐NR, C‐LD, C‐EO 4 10/1/2019

BP Measurement and Classification BP Measurement • Prepare the patient (seated, feet on floor, arm supported) for >5 mins  Avoid caffeine, exercise, smoking for > 30 mins prior • Use appropriate cuff size • Measure in both arms at first visit (use higher value) • Average value of 2 or more readings  On 2 separate occasions • Inform the patient (verbal and written) 6 10/1/2019

Blood Pressure Classification – Updated! BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg • No more “pre‐hypertension” Elevated 120–129 mm Hg and <80 mm Hg Hypertension • Stage 1 & 2 Stage 1 130–139 mm Hg or 80–89 mm Hg thresholds shifted downward Stage 2 ≥140 mm Hg or ≥90 mm Hg *Individuals with SBP and DBP in 2 categories should be designated to the higher BP Why? 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 7 pressure. 10/1/2019 Adjusted HRs for CVD by BP Groups, Age ≥50 y MESA 9.5 Years of Follow‐Up Adjusted Hazard Ratio SBP 120‐139 or SBP ≥140 or <120/<80 mmHg DBP 80‐89 mmHg DBP ≥90 mmHg Endpoint Untreated Treated Untreated Treated Untreated Treated No. Events 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* *P<0.01 compared with referent Liu, JAHA 2015 †P<0.01 compared with treated, same BP

Why? CARDIA BP Levels over 25 Years Liu, JAHA 2015 Adjusted HRs for End Organ Damage by BP CARDIA Y25 Exam Adjusted HR (95% CI) SBP 120‐139 or SBP ≥140 or <120/<80 mmHg DBP 80‐89 mmHg DBP ≥90 mmHg Subclinical Untreated Treated Untreated Treated Untreated Treated Marker Echo g/m 2.7 37.9 (ref) 39.9* 39.2* 42.2* † 43.0* 43.9* LVMI CAC % 5.3 (ref) 10.7* 7.9* 14.8* † 9.9* 12.7* >100 eGFR % 0.8 (ref) 3.9* 0.6 2.1 † 1.4 6.3* † <60 *P<0.01 compared with referent Liu, JAHA 2015 †P<0.01 compared with treated, same BP

Adjusted Relationship (Spline Regression) Between 25‐Year Cumulative SBP and LV Mass Index: CARDIA 3000 mm Hg‐years = 120 mm Hg x 25 years Adjusted for age, sex, race, BMI, smoking, diabetes, LDL-C, and cholesterol medication Liu, JAHA 2015 Implications of these Data • Treatment back down to optimal BP levels does not restore low risk of those with always optimal BP • Individuals exposed to higher BP, even within the “pre‐ hypertensive” range, over time are accruing myocardial and vascular damage that is difficult if not impossible to reverse

Implications of New HTN Thresholds • Prevalence of HTN increases from 32% to 46% among US adults …But not all of these newly HTNsive pts require meds! (~5% more) 13 Lifetime Risk of HTN by Thresholds Chen et al, JAMA Cardiol 2019

Evaluation Home and Ambulatory BP Monitoring Recommendation for Out‐of‐ CO LOE Office and Self‐Monitoring of R BP Out‐of‐office BP measurements are recommended to confirm the diagnosis of hypertension and A SR I for titration of BP‐lowering medication, in conjunction with telehealth counseling or clinical interventions. 16 10/1/2019

Home and Ambulatory BP Monitoring Detecting White Coat and Masked Hypertension Screen for white coat HTN Screen for masked HTN if target organ damage if target organ damage 17 10/1/2019 Basic and Optional Testing for New‐Onset HTN • Basic • Optional  FBG  Echocardiogram  Lipids  Uric acid  SCr with eGFR  UACR  U/A  CBC  TSH  ECG 18 10/1/2019

When to Screen for Secondary HTN • New‐onset or uncontrolled HTN with:  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 19 10/1/2019 Common Causes of Secondary HTN Additional Cause Prevalence Clinical Indicators Screening Tests Tests Renal Abdominal mass; family hx 1‐2% Renal U/S Renal w/u disease PCKD; ↑Cr; abnl U/A Resistant HTN; abrupt onset; Renovascu‐ Renal Duplex, MRA, 5‐34% flash pulmonary edema; Angio lar disease CT abdominal bruit; other bruits Sodium Plasma aldo/renin Primary loading test – 8‐20% Resistant HTN; ↓K ratio (K corrected; hyperaldo aldo; adrenal off ACEi/ARB 4 wks) CT Resistant HTN; obesity; OSA 25‐50% Epworth sleepiness PSG snoring; somnolence Drug/EtOH Caffeine; nicotine; EtOH; History; urinary Withdraw 2‐4% induced NSAIDs; OCPs; illicits drug screen agent

Uncommon Causes of Secondary HTN • Pheochromocytoma/paraganglioma • Cushing’s syndrome • Hypothyroidism • Hyperthyroidism • Aortic coarctation (undiagnosed or repaired) • Primary hyperparathyroidism • Congenital adrenal hyperplasia • Mineralocorticoid excess syndromes other than primary aldosteronism • Acromegaly Treatment

Lifestyle Modification for BP Lowering All IA Recommendations Impact on SBP Intervention Goal HTN NormoTN Ideal body weight; Weight Weight loss ‐5 mm Hg ‐2/3 mm Hg 1 mm Hg/ 1 kg Physical Aerobic 90‐150 min/wk ‐5/8 mm Hg ‐2/4 mm Hg activity exercise Dynamic 90‐150 min/wk ‐4 mm Hg ‐2 mm Hg resistance 6 ex/3 sets/ 10 reps Isometric 4 x 2 min (hand grip) ‐5 mm Hg ‐4 mm Hg resistance EtOH EtOH M: ≤2 drinks/day ‐4 mm Hg ‐3 mm Hg moderation reduction W: ≤1 drink/day Dietary Modification for BP Lowering All IA Recommendations Impact on SBP Intervention Goal HTN NormoTN Focus on DASH eating fruits/veg/whole Healthy diet ‐11 mm Hg ‐3 mm Hg pattern grains/low‐fat dairy, ↓ sat and total fat Dietary Reduced <1500 mg/day; at least ‐5/6 mm Hg ‐2/3 mm Hg sodium intake ↓ 1000 mg/day Dietary Enhanced 3500‐5000mg/day thru ‐4/5 mm Hg ‐2 mm Hg potassium intake dietary sources

Initial Approaches to Therapy 25 10/1/2019 Thresholds for Initiating BP‐Lowering Drug Therapy Recommendations for BP Treatment Threshold and Use of Risk COR LOE Estimation* to Guide Drug Treatment of Hypertension Use of BP‐lowering medications is recommended for secondary SBP: A 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 I Hg or higher, and for primary prevention in adults with an estimated DBP: C‐ 10‐year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or EO higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher. Use of BP‐lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an I C‐LD estimated 10‐year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher. * Using Pooled Cohort Equations

Risk‐Based Approach to HTN Drug Treatment BPLTTC • For the same SBP lowering, higher estimated CVD risk yields more events prevented per 1000 patients treated Risk‐ vs BP‐Based Approach to HTN Drug Treatment BPLTTC Karmali et al. PLoS Med 2018

Risk‐ vs BP‐Based Approach to HTN Drug Treatment BPLTTC Karmali et al. PLoS Med 2018 Risk‐ vs BP‐Based Approach to HTN Drug Treatment BPLTTC But it is not “or”, it is “and”… Karmali et al. PLoS Med 2018

Further Rationale • RCTs have used other RFs to enhance risk of/increase events in eligible ppts and most have had 10‐year ASCVD risk >10% • SPRINT included ppts with SBP >130 mm Hg and used general FRS >15% as inclusion criterion (~7% ASCVD risk) • Meta‐analyses indicate that lowering of BP results in benefit in 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. Principles of Drug Therapy • Primary Agents • Secondary Agents  Thiazide diuretics  Loop diuretics  Potassium sparing diuretics  ACE‐inhibitors  Aldosterone antagonists  ARBs  Beta‐blockers  CCBs  Direct renin inhibitor (aliskiren)  Alpha 1 ‐blockers  Central alpha 2 ‐agonist (clonidine)  Direct vasodilators (hydralazine, minoxidil)