Hypertension- Updates on Current GuidelinesThu Nguyen

Pharm.D. Candidate (Class of 2018)Touro College of Pharmacy02/23/16

Presentation Outline:

• Overview on current guidelines

• Discussion on reimbursement issues

• SPRINT clinical trial

• Q&A

Hypertension

• Hypertension (HTN) is defined as a sustained diastolic blood pressure greater than 90 mmHg usually accompanied by an elevated systolic blood pressure greater than 140 mmHg.

• Several studies indicate that SBP is a better predictor of CV risk than DBP and is often used as the primary clinical marker of disease control in HTN.*

*Mourad J-J. The evolution of systolic blood pressure as a strong predictor of cardiovascular risk and the effectiveness of fixed-dose ARB/CCB combinations in lowering levels of this preferential target. Vascular

Health and Risk Management. 2008;4(6):1315-1325.http://stroke.ahajournals.org/content/early/2012/01/26/STROKEAHA.111.636688

Blood Pressure Staging

Blood Pressure Category

Systolic mmHg

Diastolic mmHg

Normal <120 AND <80

Pre-hypertension

120-139 OR 80-89

Hypertension Stage 1

140-159 OR 90-99

Hypertension Stage 2

≥ 160 OR ≥ 100

2014. Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension

JNC7 Guidelines• Published in 2003

• Commissioned and reviewed by National Heart, Lung & Blood Institute

(NHLBI)

• Patients have 90% lifetime risk to develop HTN at age 55

• Goal: To prevent HTN and CVD before it happens

JNC8 Guidelines• JNC8- results of 5 key trials: HDFP, Hypertension-Stroke Cooperative, MRC, ANBP,

and VA Cooperative.

• In the above trials, patients between 30-59 year old received medication to lower DBP <90mmHg.o Results showed a reduction in cerebrovascular events. heart failure and overall mortality

in patients treated to the DBP target level.o JNC8 panel wanted to keep DBP < 90mmHg as the only goal among younger patients.

• Patients 60 and older SBP control remains the most important factor.o More conservative panelists pushed to keep the target SBP goal as well as the DBP goal.

• Patients age 60 years and older, blood pressure goal is <150/90.o In the general population aged 60 years and older, if pharmacologic treatment for high

BP results in lower SBP and treatment is not associated with ADRs or quality of life, treatment does not need to be adjusted.

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)

JNC8 Treatment Algorithm

James P, et al. JAMA. 2013; 284427

JNC8 controversy

• National consensus on guideline.

• Conflicts between major organizations/guidelines.

• Insurance reimbursement for performance accountability

James P, et al. JAMA. 2013; 284427Wright J, et al. Ann Intern Med. 2014; Special Article

American/International Society of Hypertension (ISH) - BP Targets• Most evidence linking the effects on cardiovascular or renal outcomes to treated blood

pressures have been based on clinical trials in middle-aged to elderly patients (typically between 55 and 80 years).

• Some recent trials suggest that in people 80 or older, achieving a systolic blood pressure of <150 mm Hg is associated with strong cardiovascular and stroke protection

o A target of <150/90 mm Hg is recommended for patients in this age group.

• Almost no clinical trial evidence regarding blood pressure targets in patients younger than 50 years exists.

o Diastolic blood pressure may be important in this age group, so achieving a value <90 mm Hg should be a priority

o In addition, it is also a reasonable expectation that targets <140/90 mmHgo In addition, it is also a reasonable expectation that targets <140/90 mm Hg (eg, <

130/80 mm Hg) could be appropriate in young adults and can be considered

• Some experts still recommend <130/80 mm Hg if albuminuria is present in patients with chronic kidney disease.

2014. Clinical Practice Guidelines for the Management of Hypertension in the Community .A Statement by the American Society of Hypertension and the International Society of Hypertension

Weber M, et al. J of Clin HTN. , 2014

American/International Society of Hypertension (ISH) - Treatment for HTN and Comorbidities

Comorbidities HTN Standard treatment Add-on therapyDM ACE-I or ARB

* For AA pts, CCB or Thiazide is ok to start

Thiazide or CCB* For AA pts, if CCB/Thiazide is started, add ACE-I/ARB

CAD BB + ACE-I/ARB

*If hx of MI, a BB + ACE-I/ARB are needed regardless of BP

Thiazide or CCB

Systolic HF ACE-I/ARB + BB + Diuretic + Spironolactone

DHP CCB

Diastolic HF ACE-I/ARB + BB + Diuretic DHP CCBRecurrent Stroke Prevention

ACE-I or ARB Thiazide or CCB

CKD ACE-I or ARB Thiazide or CCB

13 James P, et al. JAMA. 2013; 28442713

Reimbursement Issues

• There are many guidelines available for healthcare professionals.

• Many major guidelines can cause confusions National consensus?

• Which one to use for patient’s better outcomes?

• How healthcare professional get reimbursed for performance measurement?

James P, et al. JAMA. 2013; 284427Wright J, et al. Ann Intern Med. 2014; Special Article

SPRINT clinical trial: (Systolic Blood Pressure Intervention trial)• Landmark clinical trial sponsored by the NHLBI and NIH.

• Evaluate the benefits of maintaining a new target for SBP (120 mmHg) among adults age 50 or older .

• The study population included variety of women, racial/ethnic minorities, and the elderly.

• These patients had risk factors for cardiovascular disease.o Excluded patients with DM, prior stroke, or polycystic kidney disease.

• Manage intensive blood pressure may save lives, can be beneficial and yield better health results overall

• Published Nov. 2015

https://www.sprinttrial.org https://www.nhbli.nih.gov/news/spotlight/fact-sheet/systolic-blood-pressure-intervention-trial-sprint-

questions-and-answers

Questions?

References:• American heart association. Understanding blood pressure readings. The American Heart

Association.http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/All-About-Heart-Rate-Pulse_UCM_438850_Article.jsp.Published August 4, 2014

• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)

• 2014. AHA/ACC/CDC Science Advisory. An Effective Approach to High Blood Pressure Control. A Science Advisory From the American Heart 

• 2014. Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension

• Go A, et al. Journal of the American College of Cardiology, 2014

• https://www.sprinttrial.org

• https://www.nhbli.nih.gov/news/spotlight/fact-sheet/systolic-blood-pressure-intervention-trial-sprint-questions-and-answers

• James P, et al. JAMA. 2013; 284427; Wright J, et al. Ann Intern Med. 2014; Special Article

• Weber M, et al. J of Clin HTN. , 2014

THANK YOU!