Presented by Summary of Recommendations from the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Jointly provided by: December 20, 2017
Summary of Recommendations from the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Jointly provided by Tulane University Paul K. Whelton, MB, MD, MSc Clinical Professor and Show Chwan Health System Endowed Chair in Global Public Health Tulane University School of Public Health and Tropical Medicine Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA Professor of Medicine Tulane University School of Medicine Tulane Heart and Vascular Institute
Presenters’ Disclosures Keith C. Ferdinand, MD has disclosed the Paul K. Whelton, MB, MD has disclosed following affiliations. Any real or the following affiliations. Any real or apparent COIs related to the presentation apparent COIs related to the presentation have been resolved. have been resolved. Disclosures Disclosures Consultant - Amgen, Sanofi, • Chair, 2017 ACC/AHA BP Guideline • Boehringer Ingelheim, Novartis, Writing Committee Quantum Genomics • Chair, SPRINT, ALLHAT, TOHP and TONE trials
AMA and Tulane University Disclosures The following AMA members have documented that they have nothing to disclose and no COIs to resolve: • Michael Rakotz, MD, FAHA, FAAFP, Activity Director and Moderator; Una Charley; Delane Heldt, PMP; and Alison Smith, MPH, BA, BSN, RN The following Tulane faculty have disclosed/documented the following. Any real or apparent COIs have been resolved: • Chayan Chakraborti, MD, FACP, FHM, Tulane Faculty Liaison – Honorarium: ACP • Myra Kleinpeter, MD, MPH, Chair, Tulane CCE (CME) Advisory Committee – Grants: Amgen, Glaxo Smith Kline, Astra Zeneca; Speakers Bureau: Gilead Sciences, Fresenius Medical Care, OPKO; Stocks: BD, Abbvie, P&G; Board Member: Orleans Parish Medical Society, New Orleans East Hospital • N. Kevin Krane, MD, FACP, Vice Dean of Academic Affairs – Nothing to disclose The following Tulane CCE/CME staff have documented that they have nothing to disclose and no COIs to resolve: • Melinda Epperson, PhD, Director, Tulane CCE ; Caroline Lind, MPH, MBA; Sarah Refvem, MPH; Pamala Schmidt; and Roblynn Sliwinski
Objectives Slide The presenters will: • Define new levels of blood pressure (BP) classification • Describe how to accurately measure BP (office and out-of-office) • Define non-pharmacological treatment for hypertension • Recognize when to use pharmacologic treatment and understand treatment targets • Review BP treatment targets for people with comorbid conditions (diabetes, CKD, CVD, CHF) • Review treatment of special populations with high BP (African Americans, older persons)
Dr. Whelton’s Slides 1. I ntroduction - Background and Science/Evidence of Guideline 2. Classification of Blood Pressure and Impact on Prevalence 3. Blood Pressure Measurement (in and out-of-office) 4. Treatment of Hypertension 5. Special populations: Focus on Older Adults, Diabetes, CKD 6. Importance of Team-Based Care, Plan of Care and shared Decision Making
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ PCNA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Tulane University School of Medicine - December 20, 2017 Paul K. Whelton, MB, MD, MSc Show Chwan Chair of Global Public Health Tulane University School of Public Health and Tropical Medicine Tulane University School of Medicine • Conflicts of interest: None • Disclosures: - Chair, 2017 ACC/AHA BP Guideline Writing Committee - Chair, SPRINT, ALLHAT, TOHP and TONE trials
Guid idelin ines in in C Clin inic ical P Practic ice • ~25 cl clinica cal pract ctice g ce guidel elines es o on reco ecord • Primarily a U US p phenomenon Pre 1 1960s 960s • Stand ndards ba based o on t n traini ning ng pr program and nd credent ntials • Rapid ex expansion of b biomed edica cal res esea earch ch 1960s 960s • RCTs em emer erged ed as g gold s standard f for trea eatmen ent deci ecisions • Sys ystem ematic r c rev eview ews, many y em employi ying m met eta-an anal alysis 1970s 970s • Emer ergen ence ce of ev eviden ence ce based ed m med edici cine e movem emen ent • Early C y CVD g guidel elines es • 1976: JNC 1 1 ( (cons nsens nsus d document nt) • 1980: 980: JNC 2 , 2 , 1 1984: 984: JNC 3 a 3 and 1988: 988: JNC 4 4 1980s 980s • Prolif iferation of clin inic ical practic ice g guid idelin ines ( s (CPGs) s) • Professional societies, government agencies, non-pro rofits • Subs bstant ntial variation n in n the he quality of the he CPGs
Guid idelin ines in in C Clin inic ical P Practic ice Current status • Part of t the routine o of clinical p practice • Structured a d assessment of evide dence • Basis for de determining/m /monitoring standa dards ds of c care • Es Especially h helpful when: • Clini nical cond ndition n common n and nd/or e expe pens nsive • Practice patterns vary substantially • Ev Evide dence of sufficient quality & quantity • US: i increasing reliance o on I IOM CPG r recommendations • 2011 “CPGs We C Can Trust” core elements 1) T Trans nspa parenc ncy 5) E Eviden idence ce founda datio ions 2) A Avoid/m id/manage e COI 6) A Articu iculatio ion of fin indin dings 3) T Team s specs 7) E Extern rnal r review 4) S Systematic r reviews 8) 8) U Updates
BP Clinical Practice Guidelines (CPGs) • Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High BP, 1977 - Consensus report, with six recommendations - Stepped- care treatment for adults with DBP ≥105 mm Hg - No recommendations for lifestyle change or drug treatment based on SBP • Seventh Report of JNC on Prevention, Detection, Evaluation, and Treatment of High BP, 2003 • Structured, comprehensive guideline; recommendations supported by more/better evidence • Detailed BP classification system; focus on SBP but included DBP recommendations • Lifestyle modification recommended as initial treatment for high BP • Antihypertensive drug therapy when SBP/DBP exceeded 140/90 mm Hg (130/80 for DM or CKD) • Several subsequent US BP clinical practice guidelines • Most focused on aspects of antihypertensive drug treatment • In 2013, NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA
2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults • Writing committee • Multidisciplinary (21 members) • Initiative lead by • No relationships with industry • American College of Cardiology • Independent External Review Committee (10 members) • American Heart Association • Systematic review/meta-analyses for selected questions • Processes standardized • Nine additional partners • ACC/AHA Guideline Task Force processes • American Academy of Physician Assistants • American College of Preventive Medicine • 15 easy to navigate self contained sections • American Geriatrics Society • 106 recommendations supported by 448 evidence tables • American Pharmacists Association • American Society of Hypertension • Each recommendation characterized by: • American Society of Preventive Cardiology • Class (strength) of Recommendation (COR) • Level of evidence (LOE) • Association of Black Cardiologists • National Medical Association • Extensive peer review (internal & external) • Preventive Cardiovascular Nurses Association • Approved by 11 partner professional societies
2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Writing Committee Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair Wilbert S. Aronow, MD, FACC, FAHA Bruce Ovbiagele, MD, MSc, MAS, MBA FAHA Donald E. Casey, Jr, MD, MPH, MBA, FAHA Sidney C. Smith, Jr, MD, MACC, FAHA Karen J. Collins, MBA Crystal C. Spencer, JD Cheryl Dennison Himmelfarb, RN, ANP, PhD Randall S. Stafford, MD, PhD Sondra M. DePalma, MHS, PA-C, CLS, AACC Sandra J. Taler, MD, FAHA Samuel Gidding, MD, FACC, FAHA Randal J. Thomas, MD, MS, FACC, FAHA Kenneth A. Jamerson, MD Kim A. Williams, Sr, MD, MACC, FAHA Daniel W. Jones, MD, FAHA Jeff D. Williamson, MD, MHS Eric J. MacLaughlin, PharmD Jackson T. Wright, Jr, MD, PhD Paul Muntner, PhD Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].
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