JNC 8 spotlights

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hypertension JNC 8 guidelines

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Mohamed EL-OKL , MD , MRCP Assistant Professor , Ain Shams University Cairo , Egypt Consultant Internist and Geriatrician [email protected]:

Mohamed EL-OKL , MD , MRCP Assistant Professor , Ain Shams University Cairo , Egypt Consultant Internist and Geriatrician [email protected] Hypertension Management Spotlight on JNC8

KISS … -Keep It Short and Simple :

KISS … -Keep It Short and Simple Provide guidance to busy primary care clinicians on the best approaches to manage and control hypertension in order to minimize patients’ risk for cardiovascular and other complications.

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Randomized Controlled trials 1966-present Minimum one year follow-up Studies with samples size <100 excluded

In Hypertensive patients ::

In Hypertensive patients : When to start medicine ? Old Young DM CKD What is the goal for bp control ? Which anti hypertensive to start with ? Can we use beta blockers as first choice for hypertension ?

Treat or not !:

Treat or not ! 68 year old with bp 145/85 and no other illness ? 68 year old with bp 145/85 and with Diabetes ? 68 year old with bp 145/85 and with CKD ?

Qs :

Qs Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Dees treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

Threshold and Goal in Elderly 60 and above … :

Threshold and Goal in Elderly 60 and above … Treart ≥ 150 / 90 Goal  150 / 90

Threshold and Goal in Elderly 60 and above … :

Threshold and Goal in Elderly 60 and above … Treart ≥ 150 / 90 Goal ≤ 150 / 90

Evidence elderly 150/90 :

Evidence elderly 150/90 The trials on which these evidence statements and this recommendation are based include HYVET, Syst-Eur , SHEP, JATOS, VALISH , and CARDIO-SIS.

Benefit of Treating HTN in Patients 80 Years and Older - HYVET:

Benefit of Treating HTN in Patients 80 Years and Older - HYVET Fatal/non-fatal stroke: 2.6% (indapamide) vs. 3.6% placebo (p=0.06) Death from any cause: 10.1% vs. 12.3% (p=0.02)

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Angeli F et al. Hypertension . 2010;56:182-184 Copyright © American Heart Association, Inc. All rights reserved. VALISH Valsartan in Elderly Isolated Systolic Hypertension

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Ogihara T et al. Hypertension 2010;56:196-202 Copyright © American Heart Association, Inc. All rights reserved. Systolic BP decreased by 5.4 mm Hg more in the tight BP control group Fatal and nonfatal CV disease and renal failure, was only modestly reduced in the more tight control group (10.6 versus 12.0 per 1000 patient-years; P =0.38). “The Lower the BP the Better” Vanished by VALISH? Elderly 150/90

Threshold and Goal in Adults  60 DBP  90 :

Threshold and Goal in Adults  60 DBP  90 This reduces Cerebrovascular events Heart failure Overall mortality HDFP, Hypertension-StrokeCooperative, MRC, ANBP,and VA Cooperative)

HOT … Hypertension optimal Treatment :

HOT … Hypertension optimal Treatment Chalmers J . Hypertension optimal treatment (HOT) study: a brilliant concept, but a qualified success. J Hypertens. 1998 Oct;16(10):1403-5. The (HOT) study was designed to answer two questions: low-dose aspirin (75 mg/day) in primary prevention of MI in hypertensive patients Any additional benefits with a progressive reduction of diastolic blood pressure from 90 mmHg to below 80 mmHg. Low-dose aspirin was indeed effective DISAPPOINTMENT: NO significant difference between the three randomized target blood pressure groups for the majority of cardiovascular events.

Threshold and Goal in Adults  60 SBP  140:

Threshold and Goal in Adults  60 SBP  140 Expert opinion …

Threshold and Goal in CKD 140/90 :

Threshold and Goal in CKD 140/90 Applies to individuals  70 years with GFR  60 mL/min/1.73 m2 People of any age with A/C ratio > 30 mg. No sufficient evidence for bp  130/80 compared with  140/90 Proteinuria … MDRD only : renal outcome better with 130/80 KDIGO, Kidney Disease: Improving Global Outcome 2012

Threshold and Goal in Diabetes 140/90 :

Threshold and Goal in Diabetes 140/90 Systolic  140 …. ACCORD study !

Adverse Events:

Adverse Events Intensive 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/1.73m 2 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 of N=969 participants assessed at 12, 36, and 48 months post-randomization

Primary & Secondary Outcomes :

Primary & Secondary Outcomes Intensive Events (%/yr) Standard Events (%/yr) HR (95% CI ) P Primary 208 (1.87) 237 (2.09) 0.88 ( 0.73-1.06) 0.20 Total Mortality 150 (1.28) 144 ( 1.19) 1.07 (0.85-1.35) 0.55 Cardiovascular Deaths 60 (0.52) 58 (0.49) 1.06 ( 0.74-1.52) 0.74 Nonfatal MI 126 (1.13) 146 (1.28) 0.87 (0.68-1.10) 0.25 Nonfatal Stroke 34 (0.30) 55 (0.47) 0.63 ( 0.41-0.96) 0.03 Total Stroke 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01 Also examined Fatal/Nonfatal HF (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal MI and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome, revascularization and unstable angina (HR=0.95, p=0.40)

Threshold and Goal in Diabetes diastolic  90 :

Threshold and Goal in Diabetes diastolic  90 Diastolic 90 …. Is it better if less than 90 ? HOT study = better outcome with lower diastolic BP !

HOT study … diastolic BP in DM :

HOT study … diastolic BP in DM The lower goal was associated with a reduction in a composite CVD outcome, but this was a post hoc analysis of a small subgroup (8%) of the study population that was not pre specified.

UKPDS: Tight Blood Control and Risk of Macrovascular and Microvascular Complications in Type 2 Diabetes:

UKPDS: Tight Blood Control and Risk of Macrovascular and Microvascular Complications in Type 2 Diabetes 1148 patients randomized to Tight control or less tight control Tight control defined as < 150/ 85 mm Hg Less tight control defined as < 180/ 105 mm Hg Half of tight control to ACE inhibitors (captopril) and half to beta blockers (atenolol) Mean follow-up of 8.4 years Part of larger UKPDS with follow-up every 3-4 months

UKPDS: Results:

UKPDS: Results Mean blood pressure during follow-up Tight control: 144/ 82 mm Hg Less tight control: 154/ 87 mm Hg 1/3 patients in tight control group required 3 or more medications 24% decrease in diabetes-related endpoints 32% decrease in deaths related to diabetes 37% decrease in microvascular endpoints Mostly related to reduced risk of laser treatment 44% decrease in strokes BMJ 317: 703, 1998

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Absolute number of events prevented by different interventions per 1000 patient years of treatment (data taken from Cholesterol Treatment Trialists ’ Collaboration and Blood Pressure Lowering Treatment Trialists ’ Collaboration). Preiss D , Ray K K BMJ 2011;343:bmj.d4243 ©2011 by British Medical Journal Publishing Group Target in DM is 140/90

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Choice of medicine !! Which medicine more suitable to which patient …?

Which group of medicine ? In Non – black { + or – Diabetes }:

Which group of medicine ? In Non – black { + or – Diabetes } Many require treatment with more than one antihypertensive drug to achieve BP control. Slide 26 Thiazide-type diuretics: which include thiazide diuretics, chlorthalidone, and indapamide. Medication dosed adequately to achieve results similar to those seen in the RCTs Doses of a group of ARBs

Which group of medicine ? In Non – black { + or – Diabet...:

Which group of medicine ? In Non – black { + or – Diabet...

Doses of a group of ARBs :

Doses of a group of ARBs

Choice of medicine in Blacks { + or – Diabetes } :

Choice of medicine in Blacks { + or – Diabetes } Thiazide CCB ALLHAT Thiazide-type diuretic more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACEI in the black patient subgroup, which included large numbers of diabetic and nondiabetic participants

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BP Results by Treatment Group Compared to chlorthalidone: SBP significantly higher in the amlodipine group ( ~ 1 mm Hg) and the lisinopril group ( ~ 2 mm Hg). Compared to chlorthalidone: DBP significantly lower in the amlodipine group ( ~ 1 mm Hg), similar in the lisinopril group. ALLHAT

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Amlodipine / Chlorthalidone Lisinopril / Chlorthalidone CHD 0.98 (0.91, 1.08) 0.99 (0.91, 1.08) Death 0.96 (0.89, 1.02) 1.00 (0.94, 1.08) CCHD 1.00 (0.94, 1.07) 1.05 (0.98, 1.11) Stroke 0.93 (0.82, 1.06) 1.15 (1.02, 1.30) CCVD 1.04 (0.99, 1.09) 1.10 (1.05, 1.16) HF 1.38 (1.25, 1.52) 1.19 (1.07, 1.31) Amlodipine Chlorthalidone Better Better 0.50 1 2 Lisinopril Chlorthalidone Better Better 0.50 1 2 Summary of Outcomes Relative Risks and 95% CI ALLHAT

Choice of medicine with CKD Black and Non Black , with or without DM ACEI / ARB :

Choice of medicine with CKD Black and Non Black , with or without DM ACEI / ARB Black and ACEI/ARB …….. Ask AASK This recommendation applies to CKD patients with and without proteinuria, as studies using ACEIs or ARBs showed evidence of improved kidney outcomes in both groups

AASK African-American Study of Kidney Disease and Hypertension :

AASK African-American Study of Kidney Disease and Hypertension Primary Renal Outcome Rate of decline in GFR in ml/min/1.73m 2 /year Secondary (Clinical) Composite Outcome 50% or > 25 ml/min reduction from baseline GFR ESRD Death Other Secondary Outcomes ESRD or Death ESRD alone African-American (self report) 18-70 yr old with DBP > 95 mmHg GFR 20 - 65 ml/min/1.73 m 2 Non-diabetic Baseline urine protein/creatinine < 2.5

AASK :

AASK

GOAL is the GOAL ! Attain and maintain goal …. :

GOAL is the GOAL ! Attain and maintain goal ….

Increase the dose or add another drug ?! Is it Possible to combine ACEi And ARBs ?!:

Increase the dose or add another drug ?! Is it Possible to combine ACEi And ARBs ?!

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Copyright © 2014 American Medical Association. All rights reserved. From: 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) JAMA. 2014;311(5):507-520.

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Copyright © 2014 American Medical Association. All rights reserved.

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ADA, American Diabetes Association; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CHEP, Canadian Hypertension Education Program; CKD, chronic kidney disease; VD, cardiovascular disease; DHPCCB, dihydropyridine calcium channel blocker; ESC, European Society of Cardiology; ESH, European Society of Hypertension; ISHIB, International Society for Hypertension in Blacks; JNC, Joint National Committee; KDIGO, Kidney Disease: Improving Global Outcome; NICE, National Institute for Health and Clinical Excellence.

PowerPoint Presentation:

ADA, American Diabetes Association; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CHEP, Canadian Hypertension Education Program; CKD, chronic kidney disease; VD, cardiovascular disease; DHPCCB, dihydropyridine calcium channel blocker; ESC, European Society of Cardiology; ESH, European Society of Hypertension; ISHIB, International Society for Hypertension in Blacks; JNC, Joint National Committee; KDIGO, Kidney Disease: Improving Global Outcome; NICE, National Institute for Health and Clinical Excellence.

Epilogue :

Epilogue Recommendations are not a substitute for clinical judgment. Decisions should consider the clinical characteristics and circumstances of each individual patient.

Thank you :

Thank you Tailor medicine according to patient’s situation …..

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