New Hypertension Guidelines
-
Upload
magdy-elmasry -
Category
Health & Medicine
-
view
247 -
download
2
description
Transcript of New Hypertension Guidelines
I am a gentle killerAll over the world, I am called HYPERTENSION
World Hypertension Day, annually celebrated on May 17th
Statement of Need
“My greatest challenge as a doctor in the management of
patients with hypertension is……………”
Please write down your answer to the following:
When to begin treatment,How low to aim for, and Which antihypertensive medications to use.
Evidence-Based Cardiology Consult
Highes
t LOE
Lowes
t LOE
Levels Of Evidence Pyramid
Nov 2013
Oct 2011 Oct 2013
2013 20102012
Dec 2013
Jun 2013
Dec 2013
Category Systolic Diastolic
Optimal <120 and <80
Normal 120-129 and/or 80–84
High normal 130-139 and/or 85–89
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
Definitions and classification of office BP levels (mmHg)
The blood pressure (BP) category is defined by the highest level of BP, whethersystolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3according to systolic BP values in the ranges indicated
Risk Factors
• Male sex• Age (men ≥55 years; women ≥65
years)• Smoking• DyslipidaemiaTC > 190 mg/dL, and/orLDL >115 mg/dL, and/orHDL: men <40 mg/dL, women < 46
mg/dL, and/orTriglycerides >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
Blood Pressure (mmHg)
High normalSBP 130–139or DBP 85–89
Grade 1 HTSBP 140–159or DBP 90–99
Grade 2 HTSBP 160–179or DBP 100–109
Grade 3 HTSBP ≥180or DBP ≥110
Other risk factors,asymptomatic organ damage or disease
No other RF
1-2 RF
≥3 RF
OD, CKD stage 3 or diabetes
Symptomatic CVD, CKD stage ≥4 or
diabetes with OD/RFs
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
Total CV RISK
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.)
Blood Pressure (mmHg)
High normalSBP 130–139or DBP 85–89
Grade 1 HTSBP 140–159or DBP 90–99
Grade 2 HTSBP 160–179or DBP 100–109
Grade 3 HTSBP ≥180or DBP ≥110
Other risk factors,asymptomatic organ damageor disease
No other RF
1-2 RF
≥3 RF
OD, CKD stage 3 or diabetes
Symptomatic CVD, CKD stage ≥4 or
diabetes with OD/RFs
Compelling in
dications
No Compelling indications
Any Body Can Dance
A B C D
2013 2014
Any Body Can DanceAny Body Can Dance 2
The A,B,C,D drug classes
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
Choice of drug treatmentNo suggestion, all 5 classes
No ranking or classification of preferred drugs
AA BB CC DD
Possible combinations of classes of antihypertensive drugs
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.
DD
AA
AA
CC
BB
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.
Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 < 80
Pre – hypertension 120-139 80-90
Hypertension
Stage 1 140 – 159 90 – 99
Stage 2 160 and above 100 and above
Hypertension
Heart Failure
Coronary Heart Disease
Diabetes
Chronic Kidney Disease
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 FailureACE-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 DiseaseACE-I and ARB’s can slow
progression of kidney disease.
A limited increase in serum creatinine of as much as 30% above baseline with ACE-I or ARB is acceptable and not a reason to withhold treatment, unless hyperkalemia develops.
A limited increase in serum creatinine of as much as 30% above baseline with ACE-I or ARB is acceptable and not a reason to withhold treatment, unless hyperkalemia develops.
In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²) higher doses of loop diuretics may be needed in combination with other drug classes.
In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²) higher doses of loop diuretics may be needed in combination with other drug classes.
Stages of Chronic Kidney DiseaseTwo 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
Recommendation 1 (Strong recommendation)
Recommendation 2 (Strong recommendation)
Recommendation 3 (Expert opinion)
General population ≥60 years
SBP ≥150 mm Hgor DBP ≥90 mm Hg
SBP <150 mm Hgand DBP <90 mm Hg
General population <60 years DBP ≥90 mm Hg DBP <90 mm Hg
General population <60 years SBP ≥140 mm Hg SBP <140 mm Hg
RecommendationsGoalsBP thresholds
Recommendation 4 (Expert opinion)
Recommendation 5 (Expert opinion)
Recommendation 6 (Moderate recommendation)
Population with CKD ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
Population with diabetes ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
General nonblack population ( ± diabetes )
or
RecommendationsGoalsBP thresholds
Initial treatment
AA CC DDor
RecommendationsRecommendation 7 (Moderate recommendation)
Recommendation 8 (Moderate recommendation)
Recommendation 9 (Expert opinion)
General ( ± diabetes )
black population or
Population with CKD ≥18 years(irrespective of
race or diabetes)
Goal BP not reachedwithin a month of treatment
Increase the dose of the initial drug,or add a second drug (from the list provided)
Goal BP not reachedwith 2 drugs
Add and titrate a third drug (from the list provided)Do not use an ACEI and an ARB together in the same patient
Initial treatments
Initial or add-on treatments
Non control strategies
CC DD
AA
Black CD
DM CKD
CC DD AA
BB
AA CC DDAlone or in combination
Alone or in combination with other drug class
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
Major changes from JNC 7
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.
ESH/ESC BP-lowering drugs recommended when total cardiovascular risk is high because of organ damage, diabetes, cardiovasculardisease, 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
Recommendation in patients with grade I hypertension (BP 140–159 mm Hg systolic or 90–99 mm Hg diastolic)
Guidelines are meant to “guide” and not to “mandate”
One Size Does Not Fit All.
New hypertension guidelines:
One size fits most?
New hypertension guidelines:
One size fits most?
?
Lower
your
num
ber
Lower
your
risk
Population Goal BP,mm Hg
Initial Drug Treatment Options
General nonelderly
<140/90
General elderly <80 yGeneral ≥80 y
<150/90
Diabetes <140/85
CKD <140/90
CKD + proteinuria <130/90
General <60 y <140/90 Nonblack
Black
General ≥60 y <150/90
Diabetes <140/90
CKD 140/90
ESH/E
SCJN
C 8
AA BB CC DD
AA
AA CC DD
CC DD
AA CC DDAA
The JNC 8 : Nine recommendations
AACC
DD
AABB
CCDD
Replaces
As first line drug 2013 “ESH/ESC”
2014 “ JNC 8 ”
Beta-blockers Yes No (Step 4)
Initial Drug Choices
DD
AA CC
BBß-blocker should be included in the regimen if there a compelling indication for a ß-blocker
Possible combinations of ABCD classes
Angina PectorisPost-MI
Heart FailureAtrial Fib.
Aortic Aneurysm