Copyofhtn3-140829102059-phpapp01.pdf

I am a gentle killer

All over the world, I am called HYPERTENSION

World Hypertension Day, annually celebrated on May 17th

Statement of Need Please write down your answer to the following:

“My greatest challenge as a doctor in the management of patients with hypertension is……………” When to begin treatment, How low to aim for, and Which antihypertensive medications to use.

Evidence-Based Cardiology Consult

OE Hi gh es tL

LO E st Lo we

Levels Of Evidence Pyramid

oct 2011

oct 2013 Nov 2013

2013

2012

2010

JuN 2013

Dec 2013

Dec 2013

Definitions and classification of office BP levels (mmHg) Category

Systolic

Diastolic

Optimal

<120

and

80>

Normal

120-129

and/or

84–80

High normal

130-139

and/or

89–85

Grade 1 hypertension

140-159

and/or

90-99

Grade 2 hypertension

160-179

and/or

100-109

Grade 3 hypertension

180≤

and/or

110≤

Isolated systolic hypertension

140≤

and

90>

The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated

Risk FactoRs • •

Male sex Age (men ≥55 years; women ≥65 years) • Smoking • Dyslipidaemia TC > 190 mg/dL, and/or LDL >115 mg/dL, and/or HDL: men <40 mg/dL, women < 46 mg/dL, and/or Triglycerides >150 mg/dL

• Fasting plasma glucose 102– 125 mg/dL • Abnormal glucose tolerance test • Obesity [BMI ≥30 kg/m² (height²)] • Abdominal obesity (waist circumference: men ≥102 cm;women ≥88 cm) • Family history of premature CVD (men aged <55 years; women aged <65 years)

asymptomatic oRgan damage • Pulse pressure (in the elderly) ≥60 mmHg • ECG :LVH (Sokolow–Lyon index >3.5 mV;RaVL >1.1 mV; Cornell voltage duration product >244 mV x ms), or • Echo: LVH [LVM index: men >115 g/m²;women >95 g/m² (BSA)]

• Carotid wall thickening (IMT >0.9 mm) or plaque • Carotid–femoral PWV >10 m/s • Ankle-brachial index <0.9 • CKD with eGFR 30–60 ml/min/1.73 m² (BSA) • Microalbuminuria (30–300 mg/24 h), or albumin– creatinine ratio 30–300 mg/g; (preferentially on morning spot urine)

diabetes mellitus • Fasting plasma glucose ≥126 mg/dL on two repeated measurements, and/or • HbA1c >7% , and/or • Post-load plasma glucose >198 mg/dL

established cV or Renal disease • • • • •

Cerebrovascular disease: stroke; TIA CHD:MI; angina; revascularization with PCI or CABG HF, including HF with preserved EF Symptomatic lower extremities PAD CKD with eGFR <30 mL/min/1.73m²(BSA); proteinuria (>300 mg/24 h). • Advanced retinopathy: haemorrhages or exudates, papilledema

,Other risk factors asymptomatic organ damage or disease

(Blood Pressure (mmHg High normal SBP 130–139 or DBP 85–89

Grade 1 HT SBP 140–159 or DBP 90–99

Grade 2 HT Grade 3 HT SBP 160–179 SBP ≥180 or DBP 100–109 or DBP ≥110

No other RF RF 1-2 RF 3≤ OD, CKD stage 3 or diabetes ,Symptomatic CVD CKD stage ≥4 or diabetes with OD/RFs

Total CV RISK

BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; DBP = diastolic blood pressure; HT = hypertension; OD = organ damage; RF = risk factor; SBP = systolic blood pressure

High risk Moderate risk Low risk

Stratification of total CV risk in categories of low, moderate, high and very high risk according to SBP and DBP and prevalence of RFs , asymptomatic OD , diabetes , CKD stage or symptomatic CVD.

Initiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated(<140/90). (in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)

,Other risk factors asymptomatic organ damage or disease

(Blood Pressure (mmHg High normal SBP 130–139 or DBP 85–89

Grade 1 HT SBP 140–159 or DBP 90–99

Grade 2 HT Grade 3 HT SBP 160–179 SBP ≥180 or DBP 100–109 or DBP ≥110

No other RF RF 1-2 RF 3≤ OD, CKD stage 3 or diabetes ,Symptomatic CVD CKD stage ≥4 or diabetes with OD/RFs

m o C

g n i ll e p

s n io t ca i d in

N

p m o C o

g n i ell

a c i ind

s n tio

Any Body Can Dance 2

Any Body Can Dance

2013

2014

 

Any

Body

A

B

Can Dance

C

D

The A,B,C,D drug classes

Choice of drug treatment No suggestion, all 5 classes

AA BB CC DD

No ranking or classification of preferred drugs

Diuretics (thiazides,chlorthalidone and indapamide), beta-blockers,calcium antagonists, ACE inhibitors, and ARBs are all suitable and recommended for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations with each other

Possible combinations of classes of antihypertensive drugs DD BB

AA CC AA

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 .

The Joint National Committee (JNC )

This JNC 8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from JNC 7 reasonable. SBP (mm Hg)

DBP (mm Hg)

< 120

< 80

120-139

80-90

Stage 1

140 – 159

90 – 99

Stage 2

160 and above

100 and above

Category Normal Pre – hypertension

Hypertension

Hypertension

Coronary Heart Disease

Diabetes Chronic Kidney Disease Heart Failure

JNC 7 Compelling Indications

† ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.

Compelling Indicator: Heart Failure ACE-I (or ARB) is indicated in nearly all patients with LV systolic dysfunction. ACE-I (or ARB) should be titrated to target HF doses, even if BP is low, as long as the patient does not become symptomatic or develop impaired renal perfusion.

Beta Blockers in nearly all patients with LV systolic dysfunction .Titrate to target HF doses.

Consider spironolactone after the patient is placed on the maximum doses of ACE-I and beta-blocker,especially if Class III or IV

Diuretics (usually loop) are often required for fluid management

Compelling Indicator : Chronic Kidney Disease ACE-I and ARB’s can slow progression of kidney disease. AA limited limited increase increase in in serum serum creatinine creatinine of of as as much much as as 30% 30% above above baseline baseline with with ACE-I ACE-I or or ARB ARB isis acceptable acceptable and and not not aa reason reason to to withhold withhold treatment, treatment, unless unless hyperkalemia hyperkalemia develops. develops. In In CKD CKD stages stages 44 and and 55 (eGFR<30 (eGFR<30 mL/min/per mL/min/per 1.73m²) 1.73m²) higher higher doses doses of of loop loop diuretics diuretics may may be be needed needed in in combination combination with with other other drug drug classes. classes.

Stages of Chronic Kidney Disease Two Screening Tests

• eGFR • ACR –Albumin/ Creatinine ratio

Questions guiding the JNC 8 review This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management. They address thresholds, goals for pharmacologic treatment, and whether particular antihypertensive drugs or drug classes improve important health outcomes compared to others.

1.In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? 2.In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? 3.In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?  The answers to these three questions are reflected in 9 recommendations

Recommendations Recommendation 1

BP thresholds

Goals

SBP ≥150 mm Hg or DBP ≥90 mm Hg

SBP <150 mm Hg and DBP <90 mm Hg

DBP ≥90 mm Hg

DBP <90 mm Hg

SBP ≥140 mm Hg

SBP <140 mm Hg

(Strong recommendation)

General population

≥60 years

Recommendation 2 (Strong recommendation)

General population

<60 years

Recommendation 3 (Expert opinion)

General population

<60 years

Recommendations Recommendation 4

BP thresholds

Goals

SBP ≥140 mm Hg or DBP ≥90 mm Hg

SBP <140 mm Hg and DBP <90 mm Hg

SBP ≥140 mm Hg or DBP ≥90 mm Hg

SBP <140 mm Hg and DBP <90 mm Hg

(Expert opinion)

Population with CKD ≥18 years

Recommendation 5 (Expert opinion)

Population with diabetes ≥18 years

Initial treatment

Recommendation 6 (Moderate recommendation)

General nonblack population ( ± diabetes )

AA

or

CC

or

DD

Recommendations Recommendation 7

Initial treatments

(Moderate recommendation)

General ( ± diabetes )

black population

Recommendation 8 (Moderate recommendation)

Population with CKD ≥18 years(irrespective of race or diabetes)

Recommendation 9 (Expert opinion)

Goal BP not reached within a month of treatment Goal BP not reached

with 2 drugs

CC

or

Black CD

DD

Initial or add-on treatments

AA Non control strategies Increase the dose of the initial drug, or add a second drug (from the list provided) Add and titrate a third drug (from the list provided) Do not use an ACEI and an ARB together in the same patient

CKD

DM

AA CC

DD

CC

Alone or in combination

DD

AA

Alone or in combination with other drug class

BB

Major changes from JNC 7  Focus on evidence based recommendations  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 choices

AA

CC

DD

JNC 8 :Relaxing blood pressure goals

Higher real-world blood pressures This is akin to the “speed limit rule”— people are more likely to hover above target,no matter what the target is.

Recommendation in patients with grade I hypertension (BP 140–159 mm Hg systolic or 90–99 mm Hg diastolic)

ESH/ESC BP-lowering drugs recommended when total cardiovascular risk is high because of organ damage, diabetes, cardiovascular disease, or chronic kidney disease JNC 8 BP-lowering drugs recommended to lower BP <140 mm Hg systolic and 90 mm Hg diastolic in patients aged <60 years ,and <150 mm Hg systolic and 90 mm Hg diastolic in patients aged >60 years

Guidelines are meant to “guide” and not to “mandate”

One Size Does Not Fit All.

?

New New hypertension hypertension guidelines: guidelines: One One size size fits fits most? most?

Lo we r yo ur Lo num we b r y er ou rr isk

,Goal BP mm Hg

General nonelderly

140/90>

General elderly <80 y General ≥80 y

150/90>

Diabetes

140/85>

CKD

140/90>

CKD + proteinuria

130/90>

General <60 y

140/90>

General ≥60 y

150/90>

JNC

8

ES H/ ES C

Population

Initial Drug Treatment Options

AA

140/90>

CKD

140/90

CC

DD

CC CC

DD DD

AA Nonblack Black

Diabetes

BB

AA

AA

CC DD AA

The JNC 8 : Nine recommendations

Initial Drug Choices

AA

AA CC

DD

Replaces

As first line drug 2013

”ESH/ESC“ Beta-blockers

Yes

BB CC

DD

JNC 8 “ 2014 ” (No (Step 4

Possible combinations of ABCD classes

DD

CC

AA ß-blocker should be included in the regimen if there a compelling indication for a ß-blocker

BB

Angina Pectoris Post-MI Heart Failure Atrial Fib. Aortic Aneurysm