Hypertension is an important global public

Size: px
Start display at page:

Download "Hypertension is an important global public"

Transcription

1 IN THE LITERATURE Blood Pressure Target in Individuals Without Diabetes: What Is the Evidence? Commentary on Verdecchia P, Staessen JA, Angeli F, et al; on behalf of the Cardio-Sis Investigators. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial. Lancet. 2009;374(9689): Hypertension is an important global public health problem affecting more than a quarter of the world s population, with the number of adults with hypertension predicted to increase by about 60% to a total of 1.56 billion worldwide by Epidemiologic studies have shown that hypertension is associated with increased cardiovascular morbidity and mortality, 2,3 and hypertension is an important modifiable risk factor because treatment to decrease blood pressure decreases the incidence of coronary artery disease and stroke. 4 Hypertension guidelines recommend decreasing systolic (SBP) and diastolic blood pressure (DBP) to 140/90 mm Hg except in individuals with diabetes, chronic kidney disease (CKD), and established cardiovascular disease, for whom the target is 130/80 mm Hg. 5,6 In recent years, there has been a trend toward evaluating lower blood pressure targets in the general population based on extrapolation from observational studies that suggest an increase in cardiovascular events in those with highnormal blood pressure ( /85-89 mm Hg). 7 In this context, it is important to consider results of the Cardio-Sis (Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica) clinical trial conducted by Verdecchia et al, 8 which was published in 2009 in the Lancet, to assess whether tight SBP control compared with usual control would be beneficial in hypertensive patients without diabetes. Originally published online as doi: /j.ajkd on July 5, Address correspondence to Mark J. Sarnak, MD, MS, Box 391, Tufts Medical Center, 800 Washington St, Boston, MA msarnak@tuftsmedicalcenter.org 2010 by the National Kidney Foundation, Inc /10/ $36.00/0 doi: /j.ajkd WHAT DOES THIS IMPORTANT STUDY SHOW? Cardio-Sis was a multicenter open-labeled trial that enrolled 1,111 nondiabetic participants 55 years or older with SBP 150 mm Hg and one additional cardiovascular risk factor. Participants were randomly assigned to a target SBP of 140 mm Hg (usual control) or 130 mm Hg (tight control). The primary end point was prevalence of electrocardiographic left ventricular hypertrophy (LVH) at 2 years, and the secondary end point was a composite of cardiovascular events. At baseline, mean age was 67 years, all participants were white, 21% had LVH, and mean blood pressure was 163/90 mm Hg. 9 At the end of follow-up, mean blood pressures were 135.6/78.7 and 131.9/ 77.4 mm Hg in the usual- and tight-control groups, respectively; 87% of participants (equal between groups) had readable electrocardiograms for the intent-to-treat analysis. Of patients in the usual- and tight-control groups, 17% and 11.4% had evidence of LVH, respectively (odds ratio, 0.63; 95% confidence interval, ). The risk of composite cardiovascular events was significantly lower in the tight-control (4.8%) compared with the usualcontrol group (9.4%; hazard ratio, 0.50; 95% confidence interval, ) and was accounted for mainly by lower rates of both coronary revascularization and new-onset atrial fibrillation in those randomly assigned to tight control. Other adverse events were similar between the 2 groups. Participants in the tight-control group were more likely to receive diuretics (P 0.009), and use of angiotensin receptor blockers was 17% higher in the tight-control group (P 0.07). The investigators concluded that tight control of SBP to 130 mm Hg compared with usual control to 140 mm Hg in hypertensive nondiabetic individuals with one additional cardiovascular risk factor decreased the likelihood of LVH and clinical events. 434 American Journal of Kidney Diseases, Vol 56, No 3 (September), 2010: pp

2 In the Literature 435 HOW DOES THIS STUDY COMPARE WITH PRIOR STUDIES? From the outset, it is important to note the distinction between blood pressure target trials versus blood pressure agent trials. Target trials aim for different blood pressure levels and by design are likely to lead to a difference in prevalence of agent used during the trial. Agent trials compare different antihypertensive agents with either each other or placebo and in general aim to achieve similar blood pressure targets. Few trials have assessed blood pressure targets in the present era of usual (140/90 mm Hg) versus low (140/90 mm Hg) blood pressure control in either diabetic or nondiabetic individuals. The recent ACCORD (Action to Control Cardiovascular Risk in Diabetics) study randomly assigned 4,733 diabetic participants to SBP 120 mm Hg versus 140 mm Hg and noted no difference in the primary outcome of major cardiovascular events. 10 Trials in nondiabetic individuals that have compared tight versus usual blood pressure control in the general population and patients with CKD are listed in Table 1. In the HOT (Hypertension Optimal Treatment) trial, the largest clinical trial in the general population comparing different DBP targets, major cardiovascular events were similar among groups, perhaps because similar blood pressures were achieved in all 3 groups (mean follow-up DBPs, 85.2, 83.2, and 81.1 mm Hg). 11 However, there was a significant benefit associated with the lower DBP target in the subgroup with diabetes. In the JATOS (Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients), no difference was noted in cardiovascular events in the tight- (SBP 140 mm Hg) versus moderatecontrol (SBP mm Hg) groups. 13 In another study, in individuals with prevalent LVH and SBP in the reference range (defined as SBP 130 mm Hg in those with diabetes, kidney impairment, or established cardiovascular disease and 140 mm Hg for other participants), targeting SBP 10 mm Hg below the baseline versus maintaining the baseline SBP led to a significant decrease in left ventricular mass index using cardiac magnetic resonance scanning. Limitations of this study included small numbers, use of a surrogate outcome, and potential bias because 16 of 51 patients randomly assigned were not available for the follow-up magnetic resonance scanning and there was differential loss to follow-up between the randomized groups. 14 Trials such as the MDRD (Modification of Diet in Renal Disease) Study, 15 AASK (African American Study of Kidney Disease and Hypertension), 19 and REIN-2 (Ramipril Efficacy in Nephropathy) 21 focused on kidney outcomes and randomly assigned patients with CKD to tight and usual blood pressure targets. In the MDRD Study, there was no difference in the decrease in glomerular filtration rate between the 2 blood pressure groups at 3 years 16 ; however, there was an interaction with baseline urine protein excretion. In the subgroup with protein excretion 1 g/d, lower target blood pressure was associated with a significantly slower decrease in glomerular filtration rate. 15 In addition, in longterm follow-up, patients assigned to the lower blood pressure target had delayed onset of kidney failure. 17 The primary limitation of the latter analysis was the lack of blood pressure measurements during long-term follow-up. Primary results from the AASK and REIN-2 trials showed no benefit of a lower blood pressure target for the primary outcome; however, in AASK, there was a slight trend favoring the lower blood pressure target in the subgroup with baseline urine protein-creatinine ratio 0.22 (300 mg/d). 19 Furthermore, preliminary results of longterm follow-up of the AASK cohort study suggested that a lower blood pressure target decreases the incidence of a composite outcome (doubling of creatinine level, end-stage renal disease, or death) in those with urine proteincreatinine ratio 0.22 (300 mg/d). 22,20 A recently published Cochrane review investigated whether a lower blood pressure target (135/85 mm Hg) was associated with a decrease in morbidity (cardiovascular and kidney outcomes) and mortality compared with a standard blood pressure target (140 to 160/90 to 100 mm Hg) in 7 trials. 23 Five of the 7 were in nondiabetic individuals and are listed in Table 1. 11,16,18,19,21 All trials used mean arterial pressure or DBP as targets for treatment. The conclusions reached were that a lower blood pressure target did not decrease cardiovascular or kidney-related morbidity or all-cause mortality. 23

3 Table 1. Trials in Nondiabetic Individuals Comparing Usual Versus Low Blood Pressure Target Baseline Target BP Outcomes 436 Study N Age (y) Creatinine (mg/dl) Usual Low Follow-up (y) Primary Outcome Result of Primary Outcome d Comment General Population HOT 11 18, / DBP 90 DBP 85 or Composite CVD & mortality In those with diabetes, a benefit of the lower target BP BBB 12 2, /95 NA DBP DBP Several outcomes including Few clinical CVD events, insufficient statistical power composite CVD JATOS 13 4, /89 NA SBP SBP Composite CVD Interaction between age and treatment effect, with suggestion of benefit for lower target in those 75 y and harm in those 75 y Simpson et al /70-73 a NA Baseline SBP b SBP 10 compared with baseline b 1.0 LVMi by cardiac MRI 31% dropout with a slightly higher proportion in those randomly assigned to tight control Cardio-Sis 8 1, / SBP 140 SBP c LVH by ECG MDRD /80 a 2.38 MAP 107 if 60 y Study MAP 113 if 61 y Chronic Kidney Disease MAP 92 if 60 y MAP 98 if 61 y 2.2 Rate of decrease Toto et al /76-77 a 2.3 DBP DBP Rate of decrease AASK 19,20 1, / a MAP MAP c Rate of decrease Interaction between baseline proteinuria and treatment effect, with benefit in those with higher baseline proteinuria Lower BP target also decreased kidney failure in long-term follow-up 16 Small study Trend for benefit in the lower BP target in those with UPCr 0.22 (300 mg/d) In preliminary results, lower BP target also decreased the composite outcome (doubling of creatinine, ESRD, or death) in those with UPCr 0.22 (300 mg/d) in long-term follow-up 20 REIN /84 c 2.7 DBP 90 DBP 130/ ESRD At first interim analysis, study was stopped for futility Abbreviations: AASK, African American Study of Kidney Disease and Hypertension; BBB, Behandla Blodtryck Bättre; BP, blood pressure; Cardio-Sis, Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica; CVD, cardiovascular disease; DBP, diastolic blood pressure; ECG, electrocardiographic; ESRD, end-stage renal disease; GFR, glomerular filtration rate; HOT, Hypertension Optimal Treatment; JATOS, Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients; LVH, left ventricular hypertrophy; LVMi, left ventricular mass index; MAP, mean arterial pressure; MDRD, Modification of Diet in Renal Disease; MRI, magnetic resonance imaging; N, number of participants; NA, not available; REIN-2, Ramipril Efficacy in Nephropathy; SBP, systolic blood pressure; UPCr urine protein-creatinine ratio. a Different mean values were reported for the comparison groups. b Baseline SBP 130 mm Hg in those with diabetes, kidney impairment, or established CVD and 140 mm Hg for other participants. c Median. d () indicates benefit in the lower BP group, () no difference between the groups. Shastri and Sarnak

4 In the Literature 437 WHAT SHOULD CLINICIANS AND RESEARCHERS DO? Cardio-Sis is the second largest trial evaluating target SBP on cardiovascular outcomes in individuals without diabetes. The trial, although very well executed and internally valid, has limitations. These include lack of generalizability to nonwhites, use of a surrogate primary end point, and relatively short follow-up for clinical outcomes. Furthermore, the difference in composite events was driven primarily by a difference in risk of coronary revascularization and new-onset atrial fibrillation, and, as acknowledged by the investigators, awareness of the randomization code (open-label trial) may have introduced bias in clinical decisions, especially for coronary revascularization. Last, use of angiotensin receptor blockers was higher in the tight-control group and therefore may have conferred cardiovascular protection (regression of prevalent LVH or prevention of incident LVH) independent of the blood pressure lowering effect. Therefore, results of Cardio-Sis, although encouraging, need to be confirmed in large clinical trials with hard clinical outcomes before recommending changes to current guidelines. More definitive evidence about blood pressure targets in the nondiabetic population, as well as in those with CKD, will be available from SPRINT (Systolic Blood Pressure Intervention Trial), which will randomly assign as many as 10,000 participants to target SBP 120 mm Hg compared with SBP 140 mm Hg. Inclusion criteria will be nondiabetic individuals 55 years or older with SBP 150 mm Hg and an additional cardiovascular disease risk factor, and the primary outcome will be cardiovascular disease. The trial will focus on 3 high-risk groups: patients with clinical cardiovascular disease other than stroke, individuals with CKD (estimated glomerular filtration rate, ml/min/1.73 m 2 ), and individuals with cardiovascular risk factors, but without prevalent cardiovascular disease. Results of this study are eagerly awaited to guide management decisions. Shani Shastri, MD Mark J. Sarnak, MD, MS Tufts Medical Center Boston, Massachusetts ACKNOWLEDGEMENTS Financial Disclosure: The authors declare that they have no relevant financial interests. REFERENCES 1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455): Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA. 1996;275(20): Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch Intern Med. 1993;153(5): Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet. 1990;335(8693): National Kidney Foundation. K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Am J Kidney Dis. 2004;43(5 suppl 1):S Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19): Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18): Verdecchia P, Staessen JA, Angeli F, et al; on behalf of the Cardio-Sis Investigators. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial. Lancet. 2009;374(9689): Cardio-Sis Study Group. Randomized study of traditional versus aggressive systolic blood pressure control (Cardio-Sis): rationale, design and characteristics of the study population. J Hum Hypertens. 2008;22(4): The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus [published online ahead of print March 14, 2010]. N Engl J Med. doi: /nejmoa Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118): Hannson L. The BBB Study: the effect of intensified antihypertensive treatment on the level of blood pressure, side-effects, morbidity and mortality in well-treated hypertensive patients. Behandla Blodtryck Bättre. Blood Press. 1994;3(4): JATOS Study Group. Principal results of the Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS). Hypertens Res. 2008;31(12): Simpson HJ, Gandy SJ, Houston JG, Rajendra NS, Davies JI, Struthers AD. Left ventricular hypertrophy: reduc-

5 438 tion of blood pressure already in the normal range further regresses left ventricular mass. Heart. 2010;96(2): Peterson JC, Adler S, Burkart JM, et al. Blood pressure control, proteinuria, and the progression of renal disease. The Modification of Diet in Renal Disease Study. Ann Intern Med. 1995;123(10): Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330(13): Sarnak MJ, Greene T, Wang X, et al. The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease Study. Ann Intern Med. 2005;142(5): Toto RD, Mitchell HC, Smith RD, Lee HC, McIntire D, Pettinger WA. Strict blood pressure control and progression of renal disease in hypertensive nephrosclerosis. Kidney Int. 1995;48(3): Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288(19): Shastri and Sarnak 20. Appel L. Progression of hypertensive chronic kidney disease (CKD): long-term results from the African-American Study of Kidney Disease and Hypertension (AASK). Presented at the Oral Session 34-Hot topics: experimental and clinical studies II at the Hypertension 2008: 18th Scientific Meeting of the European Society of Hypertension and 22nd Scientific Meeting of the International Society of Hypertension; June 14-19, 2008; Berlin, Germany. legacy.vanguardistas.net/cmss/hypertensionmultilang/ html/en/multimedia/webcasts.html. Accessed March 15, Ruggenenti P, Perna A, Loriga G, et al. Bloodpressure control for renoprotection in patients with nondiabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365(9463): Sika M, Lewis J, Douglas J, et al. Baseline characteristics of participants in the African American Study of Kidney Disease and Hypertension (AASK) Clinical Trial and Cohort Study. Am J Kidney Dis. 2007;50(1):78-89, 89 e Arguedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database Syst Rev. 2009:3;CD

Reducing proteinuria

Reducing proteinuria Date written: May 2005 Final submission: October 2005 Author: Adrian Gillin Reducing proteinuria GUIDELINES a. The beneficial effect of treatment regimens that include angiotensinconverting enzyme inhibitors

More information

The Seventh Report of the Joint National Commission

The Seventh Report of the Joint National Commission The Effect of a Lower Target Blood Pressure on the Progression of Kidney Disease: Long-Term Follow-up of the Modification of Diet in Renal Disease Study Mark J. Sarnak, MD; Tom Greene, PhD; Xuelei Wang,

More information

HYPERTENSION GUIDELINES WHERE ARE WE IN 2014

HYPERTENSION GUIDELINES WHERE ARE WE IN 2014 HYPERTENSION GUIDELINES WHERE ARE WE IN 2014 Donald J. DiPette MD FACP Special Assistant to the Provost for Health Affairs Distinguished Health Sciences Professor University of South Carolina University

More information

The CARI Guidelines Caring for Australasians with Renal Impairment. Blood Pressure Control role of specific antihypertensives

The CARI Guidelines Caring for Australasians with Renal Impairment. Blood Pressure Control role of specific antihypertensives Blood Pressure Control role of specific antihypertensives Date written: May 2005 Final submission: October 2005 Author: Adrian Gillian GUIDELINES a. Regimens that include angiotensin-converting enzyme

More information

SpringerLink Header: Hypertension (WB White and AJ Peixoto, Section

SpringerLink Header: Hypertension (WB White and AJ Peixoto, Section SpringerLink Header: Hypertension (WB White and AJ Peixoto, Section Editors) What Are Optimal Blood Pressure Targets for Patients with Hypertension and Chronic Kidney Disease? Gopesh K. Modi, MD DM 1,

More information

Lessons learned from AASK (African-American Study of Kidney Disease and Hypertension)

Lessons learned from AASK (African-American Study of Kidney Disease and Hypertension) Lessons learned from AASK (African-American Study of Kidney Disease and Hypertension) Janice P. Lea, MD, MSc, FASN Professor of Medicine Chief Medical Director of Emory Dialysis ASH Clinical Specialist

More information

Blood Pressure Targets: Where are We Now?

Blood Pressure Targets: Where are We Now? Blood Pressure Targets: Where are We Now? Diana Cao, PharmD, BCPS-AQ Cardiology Assistant Professor Department of Clinical & Administrative Sciences California Northstate University College of Pharmacy

More information

Optimal blood pressure targets in chronic kidney disease

Optimal blood pressure targets in chronic kidney disease Optimal blood pressure targets in chronic kidney disease Pr. Michel Burnier Service of Nephrology and Hypertension University Hospital Lausanne Switzerland Evidence-Based Guideline for the Management

More information

New Recommendations for the Treatment of Hypertension: From Population Salt Reduction to Personalized Treatment Targets

New Recommendations for the Treatment of Hypertension: From Population Salt Reduction to Personalized Treatment Targets New Recommendations for the Treatment of Hypertension: From Population Salt Reduction to Personalized Treatment Targets Sidney C. Smith, Jr. MD, FACC, FAHA Professor of Medicine/Cardiology University of

More information

DISCLOSURE PHARMACIST OBJECTIVES 9/30/2014 JNC 8: A REVIEW OF THE LONG-AWAITED/MUCH-ANTICIPATED HYPERTENSION GUIDELINES. I have nothing to disclose.

DISCLOSURE PHARMACIST OBJECTIVES 9/30/2014 JNC 8: A REVIEW OF THE LONG-AWAITED/MUCH-ANTICIPATED HYPERTENSION GUIDELINES. I have nothing to disclose. JNC 8: A REVIEW OF THE LONG-AWAITED/MUCH-ANTICIPATED HYPERTENSION GUIDELINES Tiffany Dickey, PharmD Assistant Professor, UAMS COP Clinical Pharmacy Specialist, Mercy Hospital Northwest AR DISCLOSURE I

More information

JNC 8 -Controversies. Sagren Naidoo Nephrologist CMJAH

JNC 8 -Controversies. Sagren Naidoo Nephrologist CMJAH JNC 8 -Controversies Sagren Naidoo Nephrologist CMJAH Joint National Committee (JNC) Panel appointed by the National Heart, Lung, and Blood Institute (NHLBI) First guidelines (JNC-1) published in 1977

More information

T. Suithichaiyakul Cardiomed Chula

T. Suithichaiyakul Cardiomed Chula T. Suithichaiyakul Cardiomed Chula The cardiovascular (CV) continuum: role of risk factors Endothelial Dysfunction Atherosclerosis and left ventricular hypertrophy Myocardial infarction & stroke Endothelial

More information

ALLHAT RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR)

ALLHAT RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR) 1 RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR) 6 / 5 / 1006-1 2 Introduction Hypertension is the second most common cause of end-stage

More information

Firenze 22 settembre 2007

Firenze 22 settembre 2007 Istituto di di medicina dello sport di di Firenze AMES Prevenzione cardiovascolare e cambiamenti negli stili di vita Firenze 22 settembre 2007 Orientamenti attuali per un intervento farmacologico e non

More information

Hypertension and the SPRINT Trial: Is Lower Better

Hypertension and the SPRINT Trial: Is Lower Better Hypertension and the SPRINT Trial: Is Lower Better 8th Annual Orange County Symposium on Cardiovascular Disease Prevention Saturday, October 8, 2016 Keith C. Norris, MD, PhD, FASN Professor of Medicine,

More information

Management of Hypertensive Chronic Kidney Disease: Role of Calcium Channel Blockers. Robert D. Toto, MD

Management of Hypertensive Chronic Kidney Disease: Role of Calcium Channel Blockers. Robert D. Toto, MD R e v i e w P a p e r Management of Hypertensive Chronic Kidney Disease: Role of Calcium Channel Blockers Robert D. Toto, MD Both the prevalence and incidence of end-stage renal disease have been increasing

More information

Clinical Updates in the Treatment of Hypertension JNC 7 vs. JNC 8. Lauren Thomas, PharmD PGY1 Pharmacy Practice Resident South Pointe Hospital

Clinical Updates in the Treatment of Hypertension JNC 7 vs. JNC 8. Lauren Thomas, PharmD PGY1 Pharmacy Practice Resident South Pointe Hospital Clinical Updates in the Treatment of Hypertension JNC 7 vs. JNC 8 Lauren Thomas, PharmD PGY1 Pharmacy Practice Resident South Pointe Hospital Objectives Review the Eighth Joint National Committee (JNC

More information

Prevention And Treatment of Diabetic Nephropathy. MOH Clinical Practice Guidelines 3/2006 Dr Stephen Chew Tec Huan

Prevention And Treatment of Diabetic Nephropathy. MOH Clinical Practice Guidelines 3/2006 Dr Stephen Chew Tec Huan Prevention And Treatment of Diabetic Nephropathy MOH Clinical Practice Guidelines 3/2006 Dr Stephen Chew Tec Huan Prevention Tight glucose control reduces the development of diabetic nephropathy Progression

More information

Hypertension is a major risk factor for

Hypertension is a major risk factor for OPTIMAL RISK MANAGEMENT OF THE HYPERTENSIVE PATIENT WITH MULTIPLE RISK FACTORS * Keith C. Ferdinand, MD, FACC ABSTRACT To determine the risk of cardiovascular disease in patients with hypertension, it

More information

In the Literature 1001 BP of 1.1 mm Hg). The trial was stopped early based on prespecified stopping rules because of a significant difference in cardi

In the Literature 1001 BP of 1.1 mm Hg). The trial was stopped early based on prespecified stopping rules because of a significant difference in cardi Is Choice of Antihypertensive Agent Important in Improving Cardiovascular Outcomes in High-Risk Hypertensive Patients? Commentary on Jamerson K, Weber MA, Bakris GL, et al; ACCOMPLISH Trial Investigators.

More information

The prevalence of hypertension in a representative

The prevalence of hypertension in a representative CLINICAL STRATEGIES FOR OPTIMAL HYPERTENSION MANAGEMENT Roger S. Blumenthal, MD * ABSTRACT In the United States, approximately 25% of the adult population older than 40 years has hypertension. Americans

More information

Int. J. Pharm. Sci. Rev. Res., 36(1), January February 2016; Article No. 06, Pages: JNC 8 versus JNC 7 Understanding the Evidences

Int. J. Pharm. Sci. Rev. Res., 36(1), January February 2016; Article No. 06, Pages: JNC 8 versus JNC 7 Understanding the Evidences Research Article JNC 8 versus JNC 7 Understanding the Evidences Anns Clara Joseph, Karthik MS, Sivasakthi R, Venkatanarayanan R, Sam Johnson Udaya Chander J* RVS College of Pharmaceutical Sciences, Coimbatore,

More information

Blood Pressure Treatment Goals

Blood Pressure Treatment Goals Blood Pressure Treatment Goals Kenneth Izuora, MD, MBA, FACE Associate Professor UNLV School of Medicine November 18, 2017 Learning Objectives Discuss the recent studies on treating hypertension Review

More information

The problem of uncontrolled hypertension

The problem of uncontrolled hypertension (2002) 16, S3 S8 2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh The problem of uncontrolled hypertension Department of Public Health and Clinical Medicine, Norrlands

More information

What s In the New Hypertension Guidelines?

What s In the New Hypertension Guidelines? American College of Physicians Ohio/Air Force Chapters 2018 Scientific Meeting Columbus, OH October 5, 2018 What s In the New Hypertension Guidelines? Max C. Reif, MD, FACP Objectives: At the end of the

More information

KDIGO conference on high CV risk associated with CKD. The role of BP in CKD stage 1-4

KDIGO conference on high CV risk associated with CKD. The role of BP in CKD stage 1-4 KDIGO conference on high CV risk associated with CKD The role of BP in CKD stage 1-4 Johannes Mann, MD & Catherine Clase, MB BChir Friedrich Alexander University, Erlangen-Nuremberg Munich General Hospitals,

More information

Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD?

Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD? Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD? Suzanne Oparil, MD Distinguished Professor of Medicine, Professor of Cell, Developmental and Integrative Biology Director, Vascular

More information

Update on Current Trends in Hypertension Management

Update on Current Trends in Hypertension Management Friday General Session Update on Current Trends in Hypertension Management Shawna Nesbitt, MD Associate Dean, Minority Student Affairs Associate Professor, Department of Internal Medicine Office of Student

More information

Cardiovascular disease (CVD), including stroke, is the

Cardiovascular disease (CVD), including stroke, is the Review: Clinical Cardiology: New Frontiers Hypertensive Therapy: Part I Veronica Franco, MD; Suzanne Oparil, MD; Oscar A. Carretero, MD Cardiovascular disease (CVD), including stroke, is the most common

More information

The CARI Guidelines Caring for Australians with Renal Impairment. Specific effects of calcium channel blockers in diabetic nephropathy GUIDELINES

The CARI Guidelines Caring for Australians with Renal Impairment. Specific effects of calcium channel blockers in diabetic nephropathy GUIDELINES Specific effects of calcium channel blockers in diabetic nephropathy Date written: September 2004 Final submission: September 2005 Author: Kathy Nicholls GUIDELINES a. Non-dihydropyridine calcium channel

More information

2014 HYPERTENSION GUIDELINES

2014 HYPERTENSION GUIDELINES 2014 HYPERTENSION GUIDELINES Eileen M. Twomey, Pharm.D., BCPS 1 Learning Objectives Describe specific blood pressure thresholds at which antihypertensive therapy should be initiated and blood pressure

More information

The relation between elevated blood pressure (BP) and

The relation between elevated blood pressure (BP) and ACE Inhibitors and Appearance of Renal Events in Hypertensive Nephrosclerosis Julián Segura, Carlos Campo, José L. Rodicio, Luis M. Ruilope Abstract Nephrosclerosis constitutes a major cause of end-stage

More information

Guest Speaker Evaluations Viewer Call-In Thanks to our Sponsors: Phone: Fax: Public Health Live T 2 B 2

Guest Speaker Evaluations Viewer Call-In Thanks to our Sponsors: Phone: Fax: Public Health Live T 2 B 2 Public Health Live T 2 B 2 Chronic Kidney Disease in Diabetes: Early Identification and Intervention Guest Speaker Joseph Vassalotti, MD, FASN Chief Medical Officer National Kidney Foundation Thanks to

More information

ΑΡΥΙΚΗ ΠΡΟΔΓΓΙΗ ΤΠΔΡΣΑΙΚΟΤ ΑΘΔΝΟΤ. Μ.Β.Παπαβαζιλείοσ Καρδιολόγος FESC - Γιεσθύνηρια ιζμανόγλειον ΓΝΑ Clinical Hypertension Specialist ESH

ΑΡΥΙΚΗ ΠΡΟΔΓΓΙΗ ΤΠΔΡΣΑΙΚΟΤ ΑΘΔΝΟΤ. Μ.Β.Παπαβαζιλείοσ Καρδιολόγος FESC - Γιεσθύνηρια ιζμανόγλειον ΓΝΑ Clinical Hypertension Specialist ESH ΑΡΥΙΚΗ ΠΡΟΔΓΓΙΗ ΤΠΔΡΣΑΙΚΟΤ ΑΘΔΝΟΤ Μ.Β.Παπαβαζιλείοσ Καρδιολόγος FESC - Γιεσθύνηρια ιζμανόγλειον ΓΝΑ Clinical Hypertension Specialist ESH Hypertension Co-Morbidities HTN Commonly Clusters with Other Risk

More information

Aggressive blood pressure reduction and renin angiotensin system blockade in chronic kidney disease: time for re-evaluation?

Aggressive blood pressure reduction and renin angiotensin system blockade in chronic kidney disease: time for re-evaluation? http://www.kidney-international.org & 2013 International Society of Nephrology Aggressive blood pressure reduction and renin angiotensin system blockade in chronic kidney disease: time for re-evaluation?

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Tsai WC, Wu HY, Peng YS, et al. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: a systematic

More information

Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, Financial Disclosures

Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, Financial Disclosures Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, 2015 William C. Cushman, MD Professor, Preventive Medicine, Medicine, and Physiology University

More information

The earlier BP control the better cardiovascular outcome. Jin Oh Na Cardiovascular center Korea University Medical College

The earlier BP control the better cardiovascular outcome. Jin Oh Na Cardiovascular center Korea University Medical College The earlier BP control the better cardiovascular outcome Jin Oh Na Cardiovascular center Korea University Medical College Index Introduction HOPE-3 Trial Sprint Study Summary Each 2 mmhg decrease in SBP

More information

New Clinical Trends in Geriatric Medicine. April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine

New Clinical Trends in Geriatric Medicine. April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine New Clinical Trends in Geriatric Medicine April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine Objectives Review current guidelines for blood pressure (BP) control in older adults

More information

Hypertension in Geriatrics. Dr. Allen Liu Consultant Nephrologist 10 September 2016

Hypertension in Geriatrics. Dr. Allen Liu Consultant Nephrologist 10 September 2016 Hypertension in Geriatrics Dr. Allen Liu Consultant Nephrologist 10 September 2016 Annual mortality (%) Cardiovascular Mortality Rates are Higher among Dialysis Patients 100 10 1 0.1 0.01 0.001 25-34

More information

Long-term outcomes in nondiabetic chronic kidney disease

Long-term outcomes in nondiabetic chronic kidney disease original article http://www.kidney-international.org & 28 International Society of Nephrology Long-term outcomes in nondiabetic chronic kidney disease V Menon 1, X Wang 2, MJ Sarnak 1, LH Hunsicker 3,

More information

Systolic Blood Pressure Intervention Trial (SPRINT)

Systolic Blood Pressure Intervention Trial (SPRINT) 09:30-09:50 2016.4.15 Systolic Blood Pressure Intervention Trial (SPRINT) IN A NEPHROLOGIST S VIEW Sejoong Kim Seoul National University Bundang Hospital Current guidelines for BP control Lowering BP

More information

1. Albuminuria an early sign of glomerular damage and renal disease. albuminuria

1. Albuminuria an early sign of glomerular damage and renal disease. albuminuria 1. Albuminuria an early sign of glomerular damage and renal disease albuminuria Cardio-renal continuum REGRESS Target organ damage Asymptomatic CKD New risk factors Atherosclerosis Target organ damage

More information

Hypertension targets: sorting out the confusion. Brian Rayner, Division of Nephrology and Hypertension, University of Cape Town

Hypertension targets: sorting out the confusion. Brian Rayner, Division of Nephrology and Hypertension, University of Cape Town Hypertension targets: sorting out the confusion Brian Rayner, Division of Nephrology and Hypertension, University of Cape Town Historical Perspective The most famous casualty of this approach was the

More information

Chronic kidney disease (CKD) has received

Chronic kidney disease (CKD) has received Participant Follow-up in the Kidney Early Evaluation Program (KEEP) After Initial Detection Allan J. Collins, MD, FACP, 1,2 Suying Li, PhD, 1 Shu-Cheng Chen, MS, 1 and Joseph A. Vassalotti, MD 3,4 Background:

More information

Hypertension Management: A Moving Target

Hypertension Management: A Moving Target 9:45 :30am Hypertension Management: A Moving Target SPEAKER Karol Watson, MD, PhD, FACC Presenter Disclosure Information The following relationships exist related to this presentation: Karol E. Watson,

More information

HYPERTENSION: UPDATE 2018

HYPERTENSION: UPDATE 2018 HYPERTENSION: UPDATE 2018 From the Cardiologist point of view Richard C Padgett, MD I have no disclosures HYPERTENSION ALWAYS THE ELEPHANT IN THE EXAM ROOM BUT SOMETIMES IT CHARGES HTN IN US ~78 million

More information

2 Furthermore, quantitative coronary angiography

2 Furthermore, quantitative coronary angiography ORIGINAL PAPER Estimated Glomerular Filtration Rate Reversal by Blood Pressure Lowering in Chronic Kidney Disease: Japan Multicenter Investigation for Cardiovascular DiseaseB CKD Study Yoshiki Yui, MD;

More information

(renoprotective (end-stage renal disease, ESRD) therapies) (JAMA)

(renoprotective (end-stage renal disease, ESRD) therapies) (JAMA) [1], 1., 2. 3. (renoprotective (end-stage renal disease, ESRD) therapies) (JAMA) (multiple risk (renal replacement therapy, RRT) factors intervention treatment MRFIT) [2] ( 1) % (ESRD) ( ) ( 1) 2001 (120

More information

New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD

New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD None Disclosures Objectives Understand trend in blood pressure clinical practice guidelines

More information

Hypertension: What s new since JNC 7. Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF

Hypertension: What s new since JNC 7. Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF Hypertension: What s new since JNC 7 Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF Disclosures Spectral Diagnostics Site investigator Eli Lilly Site investigator ACP IM ITE writing committee NBME Step

More information

None. Disclosure: Relationships with Industry Conflicts of Interests. Learning Objectives: Participants will be able to:

None. Disclosure: Relationships with Industry Conflicts of Interests. Learning Objectives: Participants will be able to: 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) James W. Shaw, MD Memorial Lecture

More information

ACEIs / ARBs NDHP dihydropyridine ( DHP ) ACEIs ARBs ACEIs ARBs NDHP. ( GFR ) 60 ml/min/1.73m ( chronic kidney disease, CKD )

ACEIs / ARBs NDHP dihydropyridine ( DHP ) ACEIs ARBs ACEIs ARBs NDHP. ( GFR ) 60 ml/min/1.73m ( chronic kidney disease, CKD ) 005 16 175-180 1 1 ( chronic kidney disease, CKD ) 003 ( end-stage renal disease, ESRD ) Angiotensin-converting enzyme inhibitors ( ) angiotensin receptor blockers ( ) nondihydropyridine ( NDHP ) / NDHP

More information

The control of hypertension in the. Reaching for Aggressive Blood Pressure Goals: Role of Angiotensin Receptor Blockade in Combination Therapy REPORTS

The control of hypertension in the. Reaching for Aggressive Blood Pressure Goals: Role of Angiotensin Receptor Blockade in Combination Therapy REPORTS REPORTS Reaching for Aggressive Blood Pressure Goals: Role of Angiotensin Receptor Blockade in Combination Therapy By Richard V. Milani, MD Abstract Elevated blood pressure, particularly systolic blood

More information

JNC Evidence-Based Guidelines for the Management of High Blood Pressure in Adults

JNC Evidence-Based Guidelines for the Management of High Blood Pressure in Adults JNC 8 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults Table of Contents Why Do We Treat Hypertension? Blood Pressure Treatment Goals Initial Therapy Strength of Recommendation

More information

Antihypertensive Trial Design ALLHAT

Antihypertensive Trial Design ALLHAT 1 U.S. Department of Health and Human Services Major Outcomes in High Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic National Institutes

More information

Cedars Sinai Diabetes. Michael A. Weber

Cedars Sinai Diabetes. Michael A. Weber Cedars Sinai Diabetes Michael A. Weber Speaker Disclosures I disclose that I am a Consultant for: Ablative Solutions, Boston Scientific, Boehringer Ingelheim, Eli Lilly, Forest, Medtronics, Novartis, ReCor

More information

Evolving Concepts on Hypertension: Implications of Three Guidelines (JNC 8 Panel, ESH/ESC, NICE/BSH)

Evolving Concepts on Hypertension: Implications of Three Guidelines (JNC 8 Panel, ESH/ESC, NICE/BSH) Evolving Concepts on Hypertension: Implications of Three Guidelines (JNC 8 Panel, ESH/ESC, NICE/BSH) Sidney C. Smith, Jr. MD, FACC, FAHA, FESC Professor of Medicine/Cardiology University of North Carolina

More information

Treating Hypertension in Individuals with Diabetes

Treating Hypertension in Individuals with Diabetes Treating Hypertension in Individuals with Diabetes Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any

More information

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Management of Hypertension M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Disturbing Trends in Hypertension HTN awareness, treatment and control rates are decreasing

More information

Kidney Disease, Hypertension and Cardiovascular Risk

Kidney Disease, Hypertension and Cardiovascular Risk 1 Kidney Disease, Hypertension and Cardiovascular Risk George Bakris, MD, FAHA, FASN Professor of Medicine Director, Hypertensive Diseases Unit The University of Chicago-Pritzker School of Medicine Chicago,

More information

The Road to Renin System Optimization: Renin Inhibitor

The Road to Renin System Optimization: Renin Inhibitor The Road to Renin System Optimization: Renin Inhibitor A New Perspective on the Renin-Angiotensin System (RAS) Yong-Jin Kim, MD Seoul National University Hospital Human and Economic Costs of Hypertension

More information

Treating Hypertension in 2018: What Makes the Most Sense Today?

Treating Hypertension in 2018: What Makes the Most Sense Today? Treating Hypertension in 2018: What Makes the Most Sense Today? Daniel Blanchard, MD Professor of Medicine UC San Diego Cardiovascular Center La Jolla, California 1 2 Speaker Disclosures Consultant and/or

More information

Instructions Read out the case authors and their disclosure information.

Instructions Read out the case authors and their disclosure information. 1 Instructions Read out the case authors and their disclosure information. Instructions Fill out prior to the meeting and disclose to the group any real or apparent conflict(s) of interest that may have

More information

Analytical Methods: the Kidney Early Evaluation Program (KEEP) The Kidney Early Evaluation program (KEEP) is a free, community based health

Analytical Methods: the Kidney Early Evaluation Program (KEEP) The Kidney Early Evaluation program (KEEP) is a free, community based health Analytical Methods: the Kidney Early Evaluation Program (KEEP) 2000 2006 Database Design and Study Participants The Kidney Early Evaluation program (KEEP) is a free, community based health screening program

More information

The Latest Generation of Clinical

The Latest Generation of Clinical The Latest Generation of Clinical Guidelines: HTN and HLD Dave Brackett Clinical Guideline Purpose Uniform approach Awareness of key details Diagnosis Treatment Monitoring Evidence based approach Inform

More information

Hypertension Update Clinical Controversies Regarding Age and Race

Hypertension Update Clinical Controversies Regarding Age and Race Hypertension Update Clinical Controversies Regarding Age and Race Allison Helmer, PharmD, BCACP Assistant Clinical Professor Auburn University Harrison School of Pharmacy July 22, 2017 DISCLOSURE/CONFLICT

More information

Hypertension. Risk of cardiovascular disease beginning at 115/75 mmhg doubles with every 20/10mm Hg increase. (Grade B)

Hypertension. Risk of cardiovascular disease beginning at 115/75 mmhg doubles with every 20/10mm Hg increase. (Grade B) Practice Guidelines and Principles: Guidelines and principles are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines and principles should be followed

More information

Objectives. Describe results and implications of recent landmark hypertension trials

Objectives. Describe results and implications of recent landmark hypertension trials Hypertension Update Daniel Schwartz, MD Assistant Professor of Medicine Associate Medical Director of Heart Transplantation Temple University School of Medicine Disclosures I currently have no relationships

More information

on the progression of chronic kidney disease: a systematic review and meta-analysis

on the progression of chronic kidney disease: a systematic review and meta-analysis CMAJ Research Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis Jicheng Lv MD PhD, Parya Ehteshami BSc, Mark J. Sarnak MD,

More information

www.usrds.org www.usrds.org 1 1,749 + (2,032) 1,563 to

More information

Blood Pressure Monitoring in Chronic Kidney Disease

Blood Pressure Monitoring in Chronic Kidney Disease Blood Pressure Monitoring in Chronic Kidney Disease Aldo J. Peixoto, MD FASN FASH Associate Professor of Medicine (Nephrology), YSM Associate Chief of Medicine, VACT Director of Hypertension, VACT American

More information

Objective & Outline. How the JNC Process Has Evolved. Expertise Represented on JNC 8 Panel

Objective & Outline. How the JNC Process Has Evolved. Expertise Represented on JNC 8 Panel Implementation: Joint National Committee on High Blood Pressure JNC 8 Joel Handler, MD Kaiser Permanente Care Management Institute Hypertension Lead Southern California Permanente Group Objective & Outline

More information

Hypertension Guidelines: Lessons for Primary Care. Paul A James MD Professor and Chair Department of Family Medicine University of Washington

Hypertension Guidelines: Lessons for Primary Care. Paul A James MD Professor and Chair Department of Family Medicine University of Washington Hypertension Guidelines: Lessons for Primary Care Paul A James MD Professor and Chair Department of Family Medicine University of Washington Disclaimer and Financial Disclosure I have no financial interests

More information

DISCLOSURES OUTLINE OUTLINE 9/29/2014 ANTI-HYPERTENSIVE MANAGEMENT OF CHRONIC KIDNEY DISEASE

DISCLOSURES OUTLINE OUTLINE 9/29/2014 ANTI-HYPERTENSIVE MANAGEMENT OF CHRONIC KIDNEY DISEASE ANTI-HYPERTENSIVE MANAGEMENT OF CHRONIC KIDNEY DISEASE DISCLOSURES Editor-in-Chief- Nephrology- UpToDate- (Wolters Klewer) Richard J. Glassock, MD, MACP Geffen School of Medicine at UCLA 1 st Annual Internal

More information

Using Cardiovascular Risk to Guide Antihypertensive Treatment Implications For The Pre-elderly and Elderly

Using Cardiovascular Risk to Guide Antihypertensive Treatment Implications For The Pre-elderly and Elderly Using Cardiovascular Risk to Guide Antihypertensive Treatment Implications For The Pre-elderly and Elderly Paul Muntner, PhD MHS Professor and Vice Chair Department of Epidemiology University of Alabama

More information

ACE Inhibitors and Protection Against Kidney Disease Progression in Patients With Type 2 Diabetes: What s the Evidence?

ACE Inhibitors and Protection Against Kidney Disease Progression in Patients With Type 2 Diabetes: What s the Evidence? Reviews ACE Inhibitors and Protection Against Kidney Disease Progression in Patients With Type 2 Diabetes: What s the Evidence? George L. Bakris, MD; 1 and Matthew Weir, MD 2 Although angiotensin-converting

More information

Prevalence of Comorbidities and Their Influence on Blood Pressure Goal Attainment in Geriatric Patients

Prevalence of Comorbidities and Their Influence on Blood Pressure Goal Attainment in Geriatric Patients Original Paper Prevalence of Comorbidities and Their Influence on Blood Pressure Goal Attainment in Geriatric Patients CME Credit 1 www.lejacq.com/cme John D. Bisognano, MD, PhD; 1 Kevin A. Townsend, MS,

More information

Health Benefits of Lowering Sodium Intake in the US

Health Benefits of Lowering Sodium Intake in the US Health Benefits of Lowering Sodium Intake in the US Lawrence J Appel, MD, MPH Professor of Medicine, Epidemiology and International Health (Human Nutrition) Director, Welch Center for Prevention, Epidemiology

More information

The CARI Guidelines Caring for Australasians with Renal Impairment. Protein Restriction to prevent the progression of diabetic nephropathy GUIDELINES

The CARI Guidelines Caring for Australasians with Renal Impairment. Protein Restriction to prevent the progression of diabetic nephropathy GUIDELINES Protein Restriction to prevent the progression of diabetic nephropathy Date written: September 2004 Final submission: September 2005 Author: Kathy Nicholls GUIDELINES a. A small volume of evidence suggests

More information

Solving Slowing Progressive Renal Disease

Solving Slowing Progressive Renal Disease Focus on CME at Memorial University of Newfoundland Solving Slowing Progressive Risk factors and treatment strategies for patients with kidney and cardiovascular disease overlap. Thus, evaluating renal

More information

Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine

Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine The Scope of Optimal BP BP Reduction CV outcomes & mortality CKD progression - Albuminuria - egfr decline

More information

MANAGEMENT OF HYPERTENSION: TREATMENT THRESHOLDS AND MEDICATION SELECTION

MANAGEMENT OF HYPERTENSION: TREATMENT THRESHOLDS AND MEDICATION SELECTION Management of Hypertension: Treatment Thresholds and Medication Selection Robert B. Baron, MD MS Professor and Associate Dean Declaration of full disclosure: No conflict of interest Presentation Goals

More information

Blood Pressure Targets in Diabetes

Blood Pressure Targets in Diabetes Stockholm, 29 th August 2010 ESC Meeting Blood Pressure Targets in Diabetes Peter M Nilsson, MD, PhD Department of Clinical Sciences University Hospital, Malmö Sweden Studies on BP in DM2 ADVANCE RCT (Lancet

More information

ORIGINAL INVESTIGATION. Prevalence of High Blood Pressure and Elevated Serum Creatinine Level in the United States

ORIGINAL INVESTIGATION. Prevalence of High Blood Pressure and Elevated Serum Creatinine Level in the United States ORIGINAL INVESTIGATION Prevalence of High Blood Pressure and Elevated Serum Creatinine Level in the United States Findings From the Third National Health and Nutrition Examination Survey (1988-1994) Josef

More information

The CARI Guidelines Caring for Australians with Renal Impairment. Cardiovascular Risk Factors

The CARI Guidelines Caring for Australians with Renal Impairment. Cardiovascular Risk Factors Cardiovascular Risk Factors ROB WALKER (Dunedin, New Zealand) Lipid-lowering therapy in patients with chronic kidney disease Date written: January 2005 Final submission: August 2005 Author: Rob Walker

More information

Causes of Poor BP control Rates

Causes of Poor BP control Rates Goals Of Hypertension Management in Clinical Practice World Hypertension League (WHL) Meeting Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular

More information

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 67, NO. 5, 2016 ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN /$36.

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 67, NO. 5, 2016 ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN /$36. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 67, NO. 5, 2016 ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jacc.2015.10.037

More information

Outline. Outline CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW. Question 1: Which of these patients has CKD?

Outline. Outline CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW. Question 1: Which of these patients has CKD? CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW MICHAEL G. SHLIPAK, MD, MPH CHIEF-GENERAL INTERNAL MEDICINE, SAN FRANCISCO VA MEDICAL CENTER PROFESSOR OF MEDICINE, EPIDEMIOLOGY AND BIOSTATISTICS,

More information

Interpreting SPRINT: How low should you go?

Interpreting SPRINT: How low should you go? INTERPRETING KEY TRIALS CME CREDIT EDUCATIONAL OBJECTIVE: Readers will engage their patients in a shared decision-making process regarding intensive lowering of blood pressure, with discussion of the benefits

More information

Hypertension and diabetic nephropathy

Hypertension and diabetic nephropathy Hypertension and diabetic nephropathy Elisabeth R. Mathiesen Professor, Chief Physician, Dr sci Dep. Of Endocrinology Rigshospitalet, University of Copenhagen Denmark Hypertension Brain Eye Heart Kidney

More information

Reframe the Paradigm of Hypertension treatment Focus on Diabetes

Reframe the Paradigm of Hypertension treatment Focus on Diabetes Reframe the Paradigm of Hypertension treatment Focus on Diabetes Paola Atallah, MD Lecturer of Clinical Medicine SGUMC EDL monthly meeting October 25,2016 Overview Physiopathology of hypertension Classification

More information

ADVANCE post trial ObservatioNal Study

ADVANCE post trial ObservatioNal Study Hot Topics in Diabetes 50 th EASD, Vienna 2014 ADVANCE post trial ObservatioNal Study Sophia Zoungas The George Institute The University of Sydney Rationale and Study Design Sophia Zoungas The George Institute

More information

Effective Health Care Program

Effective Health Care Program Comparative Effectiveness Review Number 37 Effective Health Care Program Chronic Kidney Disease Stages 1 3: Screening, Monitoring, and Treatment Executive Summary Objectives This systematic review evaluates

More information

Tread Carefully Because you Tread on my Nephrons. Prescribing Hints in Renal Disease

Tread Carefully Because you Tread on my Nephrons. Prescribing Hints in Renal Disease Tread Carefully Because you Tread on my Nephrons Prescribing Hints in Renal Disease David WP Lappin,, MB PhD FRCPI Clinical Lecturer in Medicine and Consultant Nephrologist and General Physician, Merlin

More information

Hypertension and Cardiovascular Disease

Hypertension and Cardiovascular Disease Hypertension and Cardiovascular Disease Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic,

More information

Preventing the cardiovascular complications of hypertension

Preventing the cardiovascular complications of hypertension European Heart Journal Supplements (2004) 6 (Supplement H), H37 H42 Preventing the cardiovascular complications of hypertension Peter Trenkwalder* Department of Internal Medicine, Starnberg Hospital, Ludwig

More information

4/4/17 HYPERTENSION TARGETS: WHAT DO WE DO NOW? SET THE STAGE BP IN CLINICAL TRIALS?

4/4/17 HYPERTENSION TARGETS: WHAT DO WE DO NOW? SET THE STAGE BP IN CLINICAL TRIALS? HYPERTENSION TARGETS: WHAT DO WE DO NOW? MICHAEL LEFEVRE, MD, MSPH PROFESSOR AND VICE CHAIR DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE UNIVERSITY OF MISSOURI 4/4/17 DISCLOSURE: MEMBER OF THE JNC 8 PANEL

More information

The CARI Guidelines Caring for Australasians with Renal Impairment. ACE Inhibitor and Angiotensin II Antagonist Combination Treatment GUIDELINES

The CARI Guidelines Caring for Australasians with Renal Impairment. ACE Inhibitor and Angiotensin II Antagonist Combination Treatment GUIDELINES ACE Inhibitor and Angiotensin II Antagonist Combination Treatment Date written: September 2004 Final submission: September 2005 Author: Kathy Nicholls GUIDELINES No recommendations possible based on Level

More information

SPRINT: Consequences for CKD patients

SPRINT: Consequences for CKD patients SPRINT: Consequences for CKD patients 29 e Workshop Nierziekten Papendal 2018 December 12, 2018 MICHAEL ROCCO, MD, MSCE VARDAMAN M. BUCKALEW JR. PROFESSOR OF MEDICINE PROFESSOR OF PUBLIC HEALTH SCIENCES

More information