HYPERTENSION UPDATE: NEW JNC 8 Guideline vs OLD Federal ...€¦ · Hypertension Lead Southern...

Joel Handler, MDKaiser Permanente Care Management InstituteHypertension LeadSouthern California Permanente Group

HYPERTENSION UPDATE: NEW JNC8 Guideline vs OLD Federal Motor

Carrier Safety RegulationsJoint NationJlJ COmmittee

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Conflict of Interest Disclosure

Content Attestation

I, Joel Handler, hereby declare that thecontent for this activity, including anypresentation of therapeutic options, iswell balanced, unbiased, and to theextent possible, evidence-based.

Joint National Committee onPrevention, Detection,

Evaluation, & Treatment of HighBlood Pressure (JNC)

JNC 7: 2003 JNC 6: 1997 JNC 5: 1992 JNC 4: 1988 JNC 3: 1984 JNC 2: 1980 JNC 1: 1976

Detection, Evaluation, &Treatment of High Blood

Cholesterol in Adults (ATP, AdultTreatment Panel)

ATP III Update: 2004 ATP III: 2002 ATP II: 1993 ATP I: 1988

Clinical Guidelines on theIdentification, Evaluation, &

Treatment of Overweight andObesity in Adults

Obesity 1: 1998

4

History ofNHLBI CVD Adult Clinical Guidelines

Objectives

• Recognize the JNC 8 recommendations forthe treatment of hypertension

• Have a plan for addressing thehypertension patient adequately treatedper JNC 8, but whose blood pressure doesnot satisfy the current DOT regulation

• Identify and avoid common errors in bloodpressure measurement

Trials Included inESH 2013 NOT included in JNC 8

Trial Comparator Trial Comparator Trial Comparator

PROGRESS Placebo SystEur Placebo Coope & WarrenderPlaceboADVANCE Placebo SystChina Placebo SHEP PlaceboHYVET Placebo NORDIL BB + D STOP PlaceboCAPP BB + D INVEST BB + D STOP 2 ACE-I or CA

ASCOT BB + D CAPPP ACE-I + DACCOMPLISH ACE-I + D LIFE ARB + D

SCOPE D + placebo ALLHAT ACE-I + BBLIFE BB + D ALLHAT CA + BB

CONVINCE CA + DFEVER D + placebo ONTARGET ACE-I or ARB NORDIL ACE-I + CAELSA BB + D ALTITUDE ACE-I or ARB INVEST ACE-I + CACONVINCE BB + D ASCOT ACE-I + CAVALUE ARB + D

BB and diuretic combinationACE-I and diuretic combination ACE-I and calcium antagonist combination

Combination of two renin-angiotensin-system blockers / ACE-I +ARB or RAS

blocker + renin inhibitor

Angiotensin receptor blocker and diuretic combination

Calcium antagonist and diuretic combination

Trials in JNC 8 NOT included in ESH2013 Survey

MRC REIN-2

ANBP 2 INSIGHT

HDFP KYOTO

UKDPS CASE-J

HOT JATOS

AASK VALISH

MDRD VAH

Table 14. Compelling and possible contra-indications to the use ofantihypertensive drugs

Drug Compelling Possible

Diuretics(thiazides)

Gout Metabolic syndrome

Glucose intolerance

Pregnancy

Hypercalcemia

Hypokalemia

Beta-blockers Asthma Metabolic syndrome

A-V block (grade 2 or 3) Glucose intolerance

Athletes and physically activepatientsChronic obstructive pulmonarydisease(except for vasodilator beta-blockers)Calcium antagonist

(dihydropyridines) Tachyarrhythmia

Heart failure

Calcium antagonist A-V block (grade 2 or 3, trifascicular block)

(verapamil, diltiazem) Severe LV dysfunction

Heart failure

ACE inhibitors Pregnancy Women with child bearing potential

Angioneurotic edema

Hyperkalemia

Bilateral renal artery stenosis

Angiotensin receptor blockers Pregnancy Women with child bearing potential

Hyperkalemia

Bilateral renal artery stenosis

Mineralocorticoid receptorantagonists

Acute or severe renal failure (eGFR <30ml/min)

Hyperkalemia

Gout and Thiazide: NEJM Case Vignette

A 54 year old male with crystal-proven gout hashad 4 attacks during the previous year. Onallopurinol 300 mg daily, his serum urate is 7.2mg/dl. His BP is controlled on HCTZ. How shouldhis case be managed?

1. Increase allopurinol to 400 mg2. Stop HCTZ3. Increase allopurinol to 400 mg and stop HCTZ

Neoghi T. NEJM 2011; 364: 443-452

Table 15. Drugs to be preferred in specific conditionsCondition DrugAsymptomatic organ damage

LVH ACE inhibitor, calcium antagonist, ARB

Asymptomatic atherosclerosis Calcium antagonist, ACE inhibitor

Microalbuminuria ACE inhibitor, ARB

Renal dysfunction ACE inhibitor, ARB

Clinical CV event

Previous stroke Any agent effectively lowering BP

Previous myocardial infarction BB, ACE inhibitor, ARB

Angina pectoris BB, calcium antagonist

Heart failureDiuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptorantagonist

Aortic aneurysm BB

Atrial fibrillation, preventionConsider ARB, ACE inhibitor, BB, or mineralocorticoidreceptor antagonist

Atrial fibrillation, ventricular ratecontrol BB, non-dihydropyridine calcium antagonist

ESRD/proteinuria ACE inhibitor, ARB

Peripheral artery disease ACE inhibitor, calcium antagonist

Other

ISH (elderly) Diuretic, calcium antagonist

Metabolic syndrome ACE inhibitor, ARB, calcium antagonist

Diabetes mellitus ACE inhibitor, ARB

Pregnancy Methyldopa, BB, calcium antagonist

Blacks Diuretic, calcium antagonist

Topic: Beta-blockers for prevention of progression if CVD in patientswith AAA

Recommendation

For patients with unrepaired abdominal aorticaneurysm (AAA),there is no recommendation for or against the use ofbetablockers to reduce the risk of cardiovascular diseaseprogression

Basis ofThere is only low quality evidence that suggest nobenefit of beta-

recommendation

blockers in reducing AAA expansion or all-causemorality. Theevidence so of insufficient quality and applicabilityto draw any

meaningfully conclusions

effects mortality; harms not reported. The balance between desirable and

undesirable effects cannot be detrmined.

Quality of Evidence Low (risk of bias, imprecision, indirectness)

Values and This recommendation places a high value on preventing cardiovascular

Preferences morbidity and mortality, and a low value on rare serious adverse effects

associated with treatment. Variability of values and preferences is

estimated to be low

Resource From the perspective of the health care delivery system, resource

implications implication for this recommendation are insignificant. Beta-blockers

are widely available at low cost, and would represent an insignificant

additional burden to the health care delivery team

Key Findings

• Among ACC/AHA GLs updated by Sept. 2008 48% (1330 to 1973) increase in recommendations

occurred, the largest number being Class II

• Of 16 current GL with Level Of Evidencerecommendations 11% (314/2711) are A 48% (1246/2711) are C

• Only 9% (245/2711) are Class I and LevelOf Evidence A

Scientific Evidence UnderlyingACC/AHA Guidelines

(JAMA. 2009; 301: 831 – 841)

How the JNC Process HasEvolved

• Strictly evidence-based• Focus only on randomized controlled trials assessing

important health outcomes (no use of intermediate/surrogatemeasures)

• Every included study is rated for quality by two independentreviewers using standardized tools

• Evidence statements graded for quality using prespecifiedcriteria

• Separate grading for recommendations• Independent methodology team to ensure objectivity of the

review• Initial set of recommendations focused on 3 key questions

Expertise Represented on JNC 8Panel

• Hypertension, primary care, cardiology,nephrology, clinical trials, research methodology,evidence-based medicine, epidemiology,guideline development and implementation,nutrition/lifestyle, nursing, pharmacology,systems of care, geriatrics, and informatics

• Panel also includes senior scientists from NHLBIand NIDDK with expertise in hypertension,clinical trials, translational research, nephrology,guideline development, and evidence-basedmethodology

Literature Review and Assessment Process

• Systematic search of literature for the CQ Citations found using inclusion/exclusion criteria Papers screened and reviewed for inclusion Result: unbiased list of studies based on a priori

criteria• Quality of each included study rated Good, Fair, Poor

• NHLBI study rating instruments Controlled randomized intervention studies

Data Abstraction andEvidence Tables

• Information from individual studies Key data abstracted into a database Evidence table for each study/paper: subjects, sample size,

intervention, comparison, results

• Evidence summaries by Critical Question Tables and text of major elements relevant to the CQ

• Graded evidence statements Multiple ESs for each CQ

• Graded recommendations based on theevidence Multiple ESs could result in a single recommendation

17

NHLBI Study Assessment Tool:Controlled Intervention Studies

Criteria Yes No Other

1.Was the study described as randomized, a randomized trial, a randomized clinicaltrial, or an RCT?

5. Were the people assessing the outcomes blinded to the participants’ groupassignments?

7. Was the overall drop-out rate from the study at its endpoint 20% or less than thenumber originally allocated to treatment?

14. Were all randomized participants analyzed in the group to which they wereoriginally assigned (i.e., did they use an intention-to-treat analysis)?

Quality Rating (Good, Fair, Poor) (see guidance)

Rater #1 initials: Rater #2 initials:

Additional Comments (If POOR, please state why):

Summary Table for Goal BP Question

NHLBI Systematic Review andGuideline Development Process

Literature Searched;All Eligible Studies

Identified

Studies Quality Rated;Evidence Tables

Developed

Evidence Summarized;

Graded by Panel w/ Methodologists

Resources Obtained;

Expert PanelEstablished

Topic Area Identified

Critical Questions, Study Eligibility

Criteria Identified

Draft ReportsWritten, Reviewed,

Revised

ReportsDisseminated &

Implemented

RecommendationsDeveloped and Graded

By Panel

*The Blue portion is the Systematic Review

This 2014 HTN evidence-based guideline focuses onthe panel’s 3 highest ranked questions related to HTN

management

1. In adults with HTN, does initiating antihypertensivepharmacologic therapy at specific BP thresholdsimprove health outcomes?

2. In adults with HTN, does treatment withantihypertensive pharmacologic therapy to aspecified BP goal lead to improvements in healthoutcomes?

3. In adults with HTN, do various antihypertensivedrugs or drug classes differ in comparative benefitsand harms on specific health outcomes?

Articles Screened =1496

Good = 8

Included = 44

Total Abstracted =26

Excluded = 1452(Did not meetprespecified

inclusioncriteria)

Poor = 18Fair = 18

Question 1: Among adults with hypertension, doesinitiating antihypertensive pharmacological therapy at specific BP

thresholds improve health outcomes?


Good = 17

Included = 92


Excluded =1886

(Did not meetprespecified

inclusioncriteria)

Poor = 36Fair = 39

Question 2: Among adults, does treatment with antihypertensivepharmacological therapy to a specified BP goal lead to improvements

in health outcomes?


Good = 15

Included = 101


Excluded =2561

(Did not meetprespecified

inclusioncriteria)

Poor = 35Fair = 51

Question 3: In adults with hypertension, do various antihypertensivedrugs or drug classes differ in comparative benefits and harms on

specific health outcomes?

In the general adult population 60 yearsof age and older, initiate pharmacologictreatment to lower blood pressure at SBP≥ 150mm Hg or DBP ≥ 90mm Hg and treatto a goal SBP <150 mm Hg and goal DBP<90mmHg.(Strong Recommendation – Grade A)

Recommendation

Why is it important not to recommend intensifyingmedication to reduce BP below the level proven in

clinical trials?

• Lower thresholds identify a much largerpopulation as having HTN and presumablyneeding drug therapy (e.g. reducing definitionof HTN from <140/90 to <120/80 doubles thosewith HTN

• Millions classified as HTN based on lowergoals require more drugs

• Treating to lower BP goals may be harmful• If neither beneficial or harmful, resources

would be wasted and patient adherence wouldsuffer

Corollary : In the general population 60 yearsof age and older, if pharmacologic treatmentfor high blood pressure results in a lowerachieved SBP (for example, less than 140mmHg) and treatment is well tolerated withoutadverse effects on health or quality of life,treatment does not need to be adjustedExpert opinion

Recommendation

Major Trials Testing SBP GoalsMajor Trials Testing SBP Goalsin General Populationsin General Populations

SHEP Syst-Eur HYVET JATOS VALISH

Number 4,736 4,695 3,845 4,418 3,260

Entry SBP 160-219 160-219 160-199 ≥160 ≥160

Goal SBP <148 <150 <150 <140 <140

Achieved SBP 142 151 144 136 137

Stroke 36% 42% ns ns ns

CVD 32% 31% 34% ns ns

Mortality ns ns 21% ns

nsSBP = systolic blood pressureCVD = cardiovascular disease

Why Not Use Achieved BloodPressures?

•Mean achieved BPs are not Goal BPs

•Post Hoc Analyses of patients achievinglower BPs tend to identify those at lowerrisk: less LVH, lower baseline BPs, fewermeds, improved med adherence

Cochrane Database of Systematic Reviews:Treatment Blood Pressure Targets for

Hypertension 2009

“The cohort of patients with low bloodpressure as identified by achieved bloodpressure selects for patients who did nothave sustained elevated blood pressure inthe first place, for patients in whom the bloodpressure is most easily reduced, for patientswith the lowest baseline blood pressure, andfor patients who are most compliant (healthyuser effect, Dormuth 2009).”continued …

Cochrane 2009 continued

“All of these factors are mostlikely associated with a lower riskof having an adversecardiovascular event. Theapproach is thus heavily biasedfor finding less cardiovascularevents in the patients with lowerblood pressure.”

Arguedas JA, Perez MI, Wright JM

The Secondary Prevention ofSmall Subcortical Strokes (SPS3) Study

Blood-pressure Targets in Patients withRecent Lacunar Stroke:

The SPS3 Randomized Trial

SPS3 is sponsored by National Institutes of Health - NINDSSPS3 is sponsored by National Institutes of Health - NINDSNINDS: U01 NS38529NINDS: U01 NS38529

SPS3 Coordinating Center: University of British Columbia, Vancouver,SPS3 Coordinating Center: University of British Columbia, Vancouver,CanadaCanada

SPS3 Statistical Center: University of Alabama at Birmingham, USSPS3 Statistical Center: University of Alabama at Birmingham, US

SPS3 Study Group, Benavente OR,et al. Lancet. 2013(Aug 10);382:507-15.

SPS3 Design• Randomized multicenter international trial.• Lacunar strokes within 180 days (mean 62), verified by

MRI.• Randomized to 2 interventions in a factorial design:

1) Antiplatelet therapy (double blind):-aspirin 325 mg + placebo-aspirin 325 mg + clopidogrel 75 mg

2) Target levels of blood pressure control (open label):-”higher” 130-149 mmHg systolic (mean 138 mm Hg)-”lower” <130 mmHg systolic (mean 127 mm Hg)

• Outcomes:-Primary: recurrent stroke.-Secondary: major vascular events, cognitive decline,death.

• 3020 participants, mean follow up 3.7 years.www.clinicaltrials.govNCT00059306

Efficacy Outcomes OutcomesSPS3

*Defined as: stroke, MI, vascular deaths.

Case Scenario: J-Point?

A 74 year old female on BP medshas a blood pressure of 152/50.Goal BP should be:

A) Standing SBP less than 140B) Standing SBP less than 150C) Standing DBP no less than 55-60D) 152/50

In the general adult population less than60 years of age, initiate pharmacologictreatment to lower blood pressure at SBP≥ 140 mm Hg and treat to a goal SBP<140 mm Hg.Expert Opinion

Recommendation

In the general adult population less than60 years of age, initiate pharmacologictreatment to lower blood pressure at DBP≥ 90 mm Hg and treat to a goal DBP < 90mm Hg.For age 30-59, Strong RecommendationGrade A; For age 18-29, Expert Opinion

Recommendation

In the adult population with diabetes,initiate pharmacologic treatment to lowerblood pressure at SBP ≥ 140 mm Hg orDBP ≥ 90 mm Hg and treat to a goal SBP< 140 mm Hg and goal <90 mmHg.Expert Opinion

Recommendation

RCTs Testing BP Goals In Hypertensive Diabetic Patients

Trial n Duration(years)

SBP goal,mmHg

DBP goal,mmHg

Mean BP,less

intense,mmHg

Mean BP,more

intense,mmHg

OutcomeRisk Reduction

SHEP 583 5 <148 none 155/72° 146/68°Stroke 22% (ns)CVD 34%CHD 56%

Syst-Eur 492 2 <150 none 162/82 153/78 Stroke 69%CVD 62%

HOT 1,501 3 none <80 148/85 144/81

CVD 51%MI 50%Stroke 30% (ns)CV death 67%

UKPDS 1,148 8.4 <150 <85 154/87 144/82

DM-related 34% deaths 32%Stroke 44%Microvasc 37%

ABCD 470 5.3 none <75 138/86 132/78

Renal (1º) ncMicrovasc ncDeath 49%CVD ns

ACCORD 4,733 4.7 <120 none 134 119 CVD (1º) 12% (ns)Stroke 41%

Ferrannini, Cushman. Lancet 2012;380:601-10.

Adverse EventsIntensive

N (%)Standard

N (%) P

Serious AE 77 (3.3) 30 (1.3) <0.0001

Hypotension 17 (0.7) 1 (0.04) <0.0001

Syncope 12 (0.5) 5 (0.2) 0.10

Bradycardia or Arrhythmia 12 (0.5) 3 (0.1) 0.02

Hyperkalemia 9 (0.4) 1 (0.04) 0.01

Renal Failure 5 (0.2) 1 (0.04) 0.12

eGFR ever <30 mL/min/1.73m2 99 (4.2) 52 (2.2) <0.001

Any Dialysis or ESRD 59 (2.5) 58 (2.4) 0.93

Dizziness on Standing† 217 (44) 188 (40) 0.36† Symptom experienced over past 30 days from HRQL sample ofN=969 participants assessed at 12, 36, and 48 months post-randomization

In the adult population with non-diabeticCKD, initiate pharmacologic treatment tolower blood pressure at SBP ≥ 140 mmHg or DBP ≥ 90 mm Hg and treat to a goalSBP < 140 mm Hg and goal DBP<90mmHg.Expert Opinion

Recommendation

Evidence Statement 15Regarding Goal BP in CKD

(CKD Subpopulation) In adults less than70 years of age with chronic kidneydisease, the evidence is insufficient todetermine if there is a benefit incardiovascular or cerebrovascular healthoutcomes, or mortality of treatment withantihypertensive drug therapy to a lowerblood pressure goal compared to a goalof <140/90mm Hg.


(CKD Subpopulation) In adults withhypertension and chronic kidney diseasewithout diabetes, there is evidence of nobenefit on the progression of kidney diseaseof treatment with antihypertensive drugtherapy to a lower blood pressure goalcompared to a goal of <140/90mm Hg.Vote: Agree with the statement (17/17);Evidence Quality: Moderate (16/17); Low(1/17)


(Proteinuria Subgroups) In adults withhypertension and proteinuria withoutdiabetes, there is insufficient evidence todetermine whether there is a benefit oftreatment with antihypertensive drug therapyto a lower blood pressure goal compared toa goal of <140/90mm Hg on cardiovascular orcerebrovascular health outcomes ormortality.Vote: Agree with the statement (17/17);Evidence Quality: Unable to determinebecause there is insufficient evidence

Recommendation

In the adult population age 18 to80 years of age with chronickidney disease and hypertension,initial antihypertensive treatmentshould include an ACE inhibitor orARB to improve kidney outcomes.

Moderate recommendation –Grade B

In the general non-black population, including thosewith diabetes, age 18 and over for whom bloodpressure medication is recommended, initialantihypertensive treatment with a single agent shouldbe with a thiazide-type diuretic, CCB, ACEI or ARB. Inthe general black population, including those withdiabetes, initial antihypertensive treatment with athiazide-type diuretic or CCB is preferred.

Recommendation

Initial Combinations of MedicationsInitial Combinations of MedicationsInitial Combinations of Medications

DiureticsDiuretics

ACE inhibitorsACE inhibitorsoror

ARBs*ARBs*

CalciumCalciumantagonistsantagonists

* Combining ACEI with ARB discouraged

ββ-blockers should be included in the regimen if-blockers should be included in the regimen ifthere is a compelling indication for a there is a compelling indication for a ββ-blocker-blocker

End Point Summary OR(95% CI) P

DeathDeath 1.10 (1.03-1.16)1.10 (1.03-1.16) 0.0030.003

CV DeathCV Death 1.13 (1.04-1.22)1.13 (1.04-1.22) 0.0050.005

MIMI 1.05 (0.97-1.14)1.05 (0.97-1.14) 0.190.19

StrokeStroke 1.26 (1.15-1.38)1.26 (1.15-1.38) 0.00000060.0000006

Elliott WJ. Elliott WJ. JACC. JACC. 2006;47 (Suppl):361A.2006;47 (Suppl):361A.

2006 Meta-Analysis:Atenolol vs Other Treatments

Relative Risk and 95% Confidence IntervalsRelative Risk and 95% Confidence Intervals

Final Outcomes ResultsDoxazosin vs. Chlorthalidone

Favors Doxazosin Favors ChlorthalidoneFavors Doxazosin Favors Chlorthalidone0.500.50 11 22 33

CHD

All-Cause Mortality

Combined CHD

Stroke

Heart Failure

Combined CVD, p< 0.0001 1.20 (1.13 - 1.27)

1.80 (1.61 - 2.02)

1.26 (1.10 - 1.46)

1.07 (0.99 - 1.16)

1.03 (0.94 - 1.13)

1.03 (0.92 - 1.15)

Hypertension 2003;42:239-246Hypertension 2003;42:239-246

ALLHAT

26

49

66

0

20

40

60

80

1 1 or 2 Any

Number of Prescribed Drugs

Per

cen

t

ALLHATALLHATCumulative Percent ControlledCumulative Percent Controlled

(BP <140/90 mm Hg) at Five Years(BP <140/90 mm Hg) at Five Years

Derived from Cushman et al. Derived from Cushman et al. J Clin HypertensJ Clin Hypertens. 2002;. 2002;4:393-404.4:393-404.

Management of Adult Hypertension 1

1.

If ACE I intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X _ daily ! 5 mg X 1 daily ! 10 mg daily

Beta -Blocker OR Spironolactone

Add a tenol ol 25 mg daily ! 50 mg daily (K eep heart rate > 55) OR

IF on thiazide AND eGFR ! 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily ! 25 mg daily

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12 .5 mg ! 25 mg

OR HCTZ 25 mg ! 50 mg

If not in control

ACE -Inhibitor 2 / Thiazide Diuretic

Lisinopril / HCTZ

(Advance as needed) 20 / 25 mg X _ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential : Avoid ACE -Inhibitors 2

Hypertension Treatment Algorithm


1.







If not in control

If not in control

If not in control

Thiazide Diuretic



If not in control


Lisinopril / HCTZ



Begin with Lisinopril/HCTZ

Simple Algorithm:Fixed Dose Combination Based

SIMPLICITY = PERFORMANCE Fewer steps Fewer pills Faster control Fewer visits/ improved access


1.







If not in control

If not in control

If not in control

Thiazide Diuretic



If not in control


Lisinopril / HCTZ


Pregnancy Potential : Avoid ACE -Inhibitors 2 Amlodipine is Third DrugManagement of Adult Hypertension 1

1.




Spironolactone or Beta-Blocker


OR Add a tenolol 25 mg daily ! 50 mg daily (K eep heart rate > 55)

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg ! 25 mg


If not in control


Lisinopril / HCTZ (A dvance as needed) 20 / 25 mg X _ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily


Spironolactone PreferredFourth Drug

Goal SBP < 150 mmHg for the General Population

Recommendation 1 had the highest level of JNC 8 evidentiary support

SHEP included 15% African American patients

SHEP included patients with history of MI and stroke, 10% haddiabetes

Syst Eur included patients with history of MI and stroke

HYVET included patients with MI, stroke, CKD, and HF

60

IHDIHDmortalitymortality(floating(floating

absolute riskabsolute riskand 95% CI)and 95% CI)

Usual SBP (mm Hg)Usual SBP (mm Hg)

IHD, ischemic heart disease.IHD, ischemic heart disease.Prospective Studies Collaboration. Prospective Studies Collaboration. LancetLancet. 2002;360:1903-1913.. 2002;360:1903-1913.

Ischemic Heart Disease Mortality Ratein Each Decade of Age

120120 140140 160160 180180

25625612812864643232161688442211

SBPSBP

40-49 y40-49 y

Age at risk:Age at risk:

70-79 y70-79 y60-69 y60-69 y50-59 y50-59 y

80-89 y80-89 y

Usual DBP (mm Hg)Usual DBP (mm Hg)7070 8080 9090 110110100100

25625612812864643232161688442211

DBPDBP

Experimentation Trumps Observation

JATOS and VALISH compared SBP goals <160 and <150 versus<140 in elderly patients

ACCORD showed no difference comparing SBP goal < 140versus <120 in patients with diabetes, except for more sideeffects with the lower goal

SPS3 did not show a significant difference comparing goal SBP<150 versus <130 for the primary endpoint of recurrent stroke inpatients with a personal history of stroke

Current NCQA proposal forControlling High Blood Pressure

• Rate 1: Members 18-59 years withmost recent BP <140/90

• Rate 2: Members 60 and older withmost recent BP < 150/90

• Rate 3: Total (Rate 1 + Rate 2) HEDIS 2015 performance metrics

Common Blood Pressure ErrorsThat Raise SBP 5-10 mmHg

mmHg too high•Cuff too small 5-10•Unsupported arm 5-10•Patient talking 10•Patient actively listening 5•Back unsupported 5-10•Feet not on floor 5-10•Legs crossed 5-10•Full bladder 10•Forearm blood pressure 5-10

Is the Hypertension Real?

26

14

28

0

5

10

15

20

25

30

SBP DBP % with controlled BP

Mean differencebetween referring

doctor BP and ABP(mmHg) in patients with

resistant HTN

Percent of patients withresistant HTN who hadBP < 135/85 mmHg with

ABP

MA Brown, et al. Am J Hypertens. 2001

ABP and CV Risk

Dolan: Hypertension, Volume 46(1).July 2005.156-161

Cause of ResistanceCause of resistance found in 133/141 – 94% (83/91 – 91%) cases

Drug-relatedcauses

58%

Nonadherence16%

Unknown6%

Officeresistance

6%Psychological

causes9%

SecondaryHTN5%

Interferingsubstances

1%

Primary cause of resistant hypertensionGarg JP, et al. Am J Hypertens 2003;16:925-930

Questions?

70

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HYPERTENSION UPDATE: NEW JNC 8 Guideline vs OLD Federal ...€¦ · Hypertension Lead Southern...

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