Ups and Downs of Outpatient Hypertension Management · Based upon the 2017 ACC/AHA guidelines for...
Transcript of Ups and Downs of Outpatient Hypertension Management · Based upon the 2017 ACC/AHA guidelines for...
Ups and Downs of Outpatient
Hypertension Management
Jay Shah M.D.Carolina Cardiology
Greenville Health System
Disclosures
• None
Objectives
• Discuss optimal methods for BP measurement
• Recognize the stages of HTN as defined by
2017 ACC/AHA Guidelines
• Discuss new targets for BP in the management of HTN
• Discuss lifestyle approaches to improve BP during
treatment
Background
• HTN is the most common chronic disease of adulthood
• A leading cause of disability and mortality worldwide
• HTN is the #1 modifiable risk factor for CV disease in US
• The effects of HTN in promoting CV disease appears to be more prominent in women vs men and among blacks vs whites
New Guidelines
• 2014 AHA and ACC convened a 21 member
group to develop new guideline for the diagnosis
and management of HTN
Applying Class of
Recommendation and
Level of Evidence to
Clinical Strategies,
Interventions,
Treatments, or
Diagnostic Testing
in Patient Care* (Updated August 2015)
New 2017
AHA/ACC HTN Guidelines
Emphasis on 5 main areas:
• BP measurement
• New BP classification system
• New approach to decision making for treatment
incorporates CV risk
• Lower target BP during management of HTN
• Strategies to improve BP during treatment- emphasis
on lifestyle approaches
2017 Hypertension Guideline
Accurate Measurement of BP in the Office
COR LOERecommendation for Accurate Measurement of BP in
the Office
I C-EO
For diagnosis and management of high BP,
proper methods are recommended for accurate
measurement and documentation of BP.
Arm Circumference Usual Cuff Size
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigh
Key Steps for Proper BP Measurements
Step 1: Properly prepare the patient.
Step 2: Use proper technique for BP measurements.
Step 3: Take the proper measurements needed for diagnosis and
treatment of elevated BP/hypertension.
Step 4: Properly document accurate BP readings.
Step 5: Average the readings.
Step 6: Provide BP readings to patient.
Out-of-Office and Self-Monitoring of BP
COR LOERecommendation for Out-of-Office and Self-
Monitoring of BP
I ASR
Out-of-office BP measurements are recommended to
confirm the diagnosis of hypertension and for titration
of BP-lowering medication, in conjunction with
telehealth counseling or clinical interventions.
SR indicates systematic review.
BP Measurement
• Out of office and self monitoring BP are recommended to confirm diagnosis and titration of BP lowering medication
• Ambulatory BP monitor and home BP monitors are strongly recommend
• Aid in screening for white coat hypertension and masked hypertension
BP Measurement
• Important to use an average based on > 2
readings obtained on > 2 occassions to estimate
BP for diagnosis
*Individuals with SBP and DBP in 2 categories should be
designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm
Hg
and <80 mm Hg
Hypertension
Stage 1 130–139 mm
Hg
or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg
Blood Pressure
Classification
Blood Pressure
Classification
BP Risk
• 2010 - HTN was leading cause of death and disability
• Greater contributor to events in women and African Americans
• Risk of CVD increase in log linear fashion
• A 20 mg Hg higher SBP and 10 mm Hg DBP are each associated with doubling in the risk of death, stroke, heart disease and vascular disease.
• SBP has consistently been associated with increase CVD risk
New Goals for
Treatment of HTN
• Target recommended BP is 130/80
• This also includes older adults based
upon results from the SPRINT study
BP Thresholds for and Goals of Pharmacological
Therapy in Patients With Hypertension According to Clinical Conditions
Clinical Condition(s)BP Threshold,
mm Hg
BP Goal,
mm Hg
General
Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized,
ambulatory, community-living adults)
≥130 (SBP) <130 (SBP)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80
ASCVD indicates atherosclerotic cardiovascular disease; BP,
blood pressure; CVD, cardiovascular disease; and SBP,
systolic blood pressure.
2017 Hypertension Guideline
Elevated Blood Pressure
120-129 mm Hg and <80 mm High
• Healthy Lifestyle Changes
• Lose weight
• Reduce NA intake to < 1500 mg/day
• Increase K+ to 3500 mg/day
• Increase physical activity to a minimum of 30
min exercise 3X/week
• Limit alcohol to 2 drink or less for men and 1
drink or less for women per day
2017 Hypertension Guideline
Nonpharmacological Interventions
COR LOERecommendations for Nonpharmacological
Interventions
I A
Weight loss is recommended to reduce BP in adults
with elevated BP or hypertension who are overweight
or obese.
I A
A heart-healthy diet, such as the DASH (Dietary
Approaches to Stop Hypertension) diet, that facilitates
achieving a desirable weight is recommended for
adults with elevated BP or hypertension.
I ASodium reduction is recommended for adults with
elevated BP or hypertension.
IA
Potassium supplementation, preferably in dietary
modification, is recommended for adults with elevated
BP or hypertension, unless contraindicated by the
presence of CKD or use of drugs that reduce
potassium excretion.
Nonpharmacological Interventions (cont.)
COR LOERecommendations for Nonpharmacological
Interventions
I A
Increased physical activity with a structured exercise
program is recommended for adults with elevated BP or
hypertension.
I A
Adult men and women with elevated BP or hypertension
who currently consume alcohol should be advised to
drink no more than 2 and 1 standard drinks* per day,
respectively.
*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is
typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually
about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
Nonpharmacologi-
cal InterventionDose Approximate Impact on SBP
Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.
-5 mm Hg -2/3 mm Hg
Healthy diet DASH dietary pattern
Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
-11 mm Hg -3 mm Hg
Reduced intake
of dietary
sodium
Dietary sodium Optimal goal is <1500 mg/d, but aim
for at least a 1000-mg/d reduction in
most adults.
-5/6 mm Hg -2/3 mm Hg
Enhanced intake
of dietary
potassium
Dietary potassium
Aim for 3500–5000 mg/d, preferably
by consumption of a diet rich in
potassium.
-4/5 mm Hg -2 mm Hg
Nonpharmacological
Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Physical
activity
Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
-5/8 mm Hg -2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
-4 mm Hg -2 mm Hg
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
-5 mm Hg -4 mm Hg
Moderation
in alcohol
intake
Alcohol consumption In individuals who drink alcohol,
reduce alcohol† to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
-4 mm Hg -3 mm
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of
regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
Hypertension: Stage 1
130-139 mm Hg or 80-89 mm Hg
• Assess 10 year risk of ASCVD using ASCVD
risk calculator
• If risk <10%, start with healthy lifestyle
• If risk >10% or known CVD, DM or CKD, start
with lifestyle changes and BP lowering
medication
Hypertension: Stage 2
≥ 140 mm Hg or ≥ 90 mm Hg
• Healthy lifestyle changes
• Start two BP lowering medication of different
classes
• Reassess after 1 month
Choice of Initial Medication
COR LOE Recommendation for Choice of Initial Medication
IASR
For initiation of antihypertensive drug therapy, first-
line agents include thiazide diuretics, CCBs, and ACE
inhibitors or ARBs.
Choice of Initial Monotherapy Versus Initial Combination Drug Therapy
COR LOERecommendations for Choice of Initial Monotherapy
Versus Initial Combination Drug Therapy*
I C-EO
Initiation of antihypertensive drug therapy with 2 first-line
agents of different classes, either as separate agents or in a
fixed-dose combination, is recommended in adults with stage
2 hypertension and an average BP more than 20/10 mm Hg
above their BP target.
IIa C-EO
Initiation of antihypertensive drug therapy with a single
antihypertensive drug is reasonable in adults with stage 1
hypertension and BP goal <130/80 mm Hg with dosage
titration and sequential addition of other agents to achieve the
BP target.
2017 Hypertension Guideline
Age-Related Issues
COR LOERecommendations for Treatment of Hypertension in
Older Persons
IA
Treatment of hypertension with a SBP treatment goal of less than
130 mm Hg is recommended for noninstitutionalized ambulatory
community-dwelling adults (≥65 years of age) with an average SBP
of 130 mm Hg or higher.
IIa C-EO
For older adults (≥65 years of age) with hypertension and a high
burden of comorbidity and limited life expectancy, clinical judgment,
patient preference, and a team-based approach to assess risk/benefit
is reasonable for decisions regarding intensity of BP lowering and
choice of antihypertensive drugs.
Racial and Ethnic Differences in Treatment
COR LOE Recommendations for Race and Ethnicity
IB-R
In black adults with hypertension but without HF or CKD, including
those with DM, initial antihypertensive treatment should include a
thiazide-type diuretic or CCB.
I C-LD
Two or more antihypertensive medications are recommended to
achieve a BP target of less than 130/80 mm Hg in most adults with
hypertension, especially in black adults with hypertension.
Pregnancy
COR LOERecommendations for Treatment of Hypertension in
Pregnancy
IC-LD
Women with hypertension who become pregnant, or are planning to
become pregnant, should be transitioned to methyldopa, nifedipine,
and/or labetalol during pregnancy.
III:
HarmC-LD
Women with hypertension who become pregnant should not be
treated with ACE inhibitors, ARBs, or direct renin inhibitors.
How can I use this in my
practice?
• 130/80 is the new 140/90
• Encourage out of office BP checks
• Encourage healthy lifestyle
• Calculate ASCVD risk for stage 1 HTN
• Consider 2 medications first line for Stage 2 HTN
Question
Based upon the 2017 ACC/AHA guidelines for hypertension, a 75 y/o male with history HTN and Diabetes has an average BP 170/80 and pulse rate of 78? What would you recommend for treatment of this patient’s hypertension?
A. Carvedilol 6.25 mg po BID
B. Lisinopril 10 mg po QD
C. Amlodipine 5mg QD and Lisinopril 10mg po QD
D. Metoprolol 25mg po BID and HCTZ 25 mg po QD