Objectives. JNC 7 Is Nice But What s Up With JNC 8? Why Do We Care? Hypertension Background: Prevalence

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1 JNC 7 Is Nice But What s Up With JNC 8? 37 th Annual CAPA Conference October 4 th 2013 Ignacio de Artola, Jr. M.D. Assistant Professor of Clinical Family Medicine Medical Director, Primary Care Physician Assistant Program Keck School of Medicine of USC Objectives Overview of Hypertension Review of JNC 7 Guidelines Gain insight into the process for the next HTN practice guidelines Brief overview of the data contributing to the new guideline development A stab at what JNC 8 (?) might say Hypertension Background: Prevalence ~65 million American adults (1 in 3) have HTN Very common and often severe in African Americans Middle-aged Americans: 90% chance of developing HTN Why Do We Care? Increasing blood pressure linearly correlates with increasing cardiovascular mortality, morbidity and all cause mortality More than 75 percent of patients with Heart Failure have antecedent Hypertension Number one cause of Chronic Kidney Disease is Hypertension Hypertension 2004;44:1 7 1

2 Women and Hypertension Age Adjusted CV Disease Mortality Rate by SBP and DBP Level Used to Define Each JNC VI Stratum JAMA. 2002;287:2615 Defining Hypertension: History of the JNC Guidelines JNC 1; 1976 no specific recommendation on treating SBP; Identified DHTN at 105; consider treatment JNC 2; 1980 no specific recommendation on treating SBP; Identified DHTN as mild;90-105, moderate; , severe; >115 JNC 3; 1984 identified SBP as borderline; DBP normal; <85, high normal; 85-90, DHTN, as mild;90-105, moderate; , severe; >115 JNC 4; 1988 identified SBP < 140 as normal, as borderline; DBP normal; <85, high normal; 85-90, DHTN, as mild;90-105, moderate; , severe; >115 JNC 5; 1992 SBP <110; optimal, ; normal, ; High Normal, SHTN ; Stage1, ; Stage 2, ; Stage 3, >210; Stage 4. DBP, 80-85; normal, 85-90; high normal, ; Stage 1, ; Stage 2, ; Stage 3, >120; Stage 4 JNC 6; 1997 Essentially unchanged, deletes Stage 4 concept for both systolic and diastolic HTN Criteria (JNC 7) Normal less than 120/80 Pre hypertension /80 89 Stage /90 99 Stage 2 greater than 160/100 JNC 7; 2003 JNC 8?? 2

3 Hypertension Background: Risk factors Obesity Diabetes Type 2 Hyperlipidemia Alcohol Smoking Black race Salt intake Hostile/impatient personality Family history of HTN Prehypertension Causes of Hypertension Essential (primary) hypertension (>90%) [maybe not so essential] Renal insufficiency (parenchymal disease) Renal artery stenosis (fibromuscular dysplasia or atherosclerosis) Primary hyperaldosteronism Pheochromocytoma Cushing's disease/syndrome Coarctation of the aorta Thyroid disorders Sleep apnea Alcohol (excessive) Obesity (contributing factor) Medications that may increase blood pressure: Estrogen (oral contraceptives) Glucocorticoids Nonsteroidal anti inflammatory drugs (NSAIDs) Sympathomimetics Cyclosporine Most Patients With Hypertension Have Other Risk Factors for CVD Hypertension: More of the Usual Suspects 26 % 18% BP BP % % 21% 40% of persons with hypertension have impaired glucose tolerance the direct relationship between hyperinsulinemia and hypertension has not been proven but; insulin stimulates the sympathetic nervous system vascular endothelial inflammation and damage Other sources of risk = TC, HDL-C, TG, BMI, Glucose Kannel WB. Am J Hypertens. 2000;13:3s-10s. 3

4 Metabolic Syndrome: Hypertension JNC 7; Recommendations How can hyperinsulinemia increase blood pressure? renal Na + /water reabsorption SNS activity NA + K + ATPase activity Na + H + exchanger growth factors Number of Different BP Meds Needed to Reach Target BP Levels Increasing Dose vs. Combination AJHP 2006; 63:

5 What about JNC 8? JNC LATE JNC WAIT Probably will be called JNC 2013 It s tough to make predictions, especially about the future Yogi Berra Heartwire; November 24, 2011 Dr. Suzanne Oparil: it s a different process The Expert Committee has taken its literature review back to 1966 moving forward, the guidelines will be continually updated. Guidelines will only be based on RCTs. Boring But Important! Understanding the genesis of the recommendations will help foster acceptance in clinical practice 5

6 Ranking the Evidence Ranking Recommendations Guidelines-Current State of Affairs: Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines Among ACC/AHA guidelines updated by Sept % increase (1330 to 1973) in # of recommendations most are based on Class II (conflicting evidence) Of 16 current guidelines with level of evidence recommendations 12% (314/2711) are Level A (multiple RCTs) 46% (1246/2711) are Level C (expert opinion,... no RCTs) Only 9% (245/2711) are Class I and Level A Increased Resources($) are needed to fund trials supporting guideline development Tricoci, et al. JAMA. 2009; 301: To be trustworthy, clinical practice guidelines should: Be based on a systematic review of the existing evidence Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups Consider important patient subgroups and patient preferences, as appropriate Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of recommendations Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations. 6

7 Critical Questions Being Addressed Among adults, does treatment with antihypertensive pharmacological therapy to a specific BP goal lead to improvements in health outcomes? (how low should you go) n=56 RCTs Among adults with hypertension, does initiating antihypertensive pharmacological therapy at specific BP thresholds improve health outcomes? (when to initiate drug treatment) n=26 RCTs In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? (How do we get there?) n=66 RCTs How Low Should We Go? JNC 7; 140/90 (130/85 for DM/CKD) HOT trial; no difference between 80/90 DBP (except maybe some CVD reduction in DM2) AASK trial; no difference between 125/75 and 140/90 (except maybe if proteinuria >300) ACCORD trial; no difference for SBP < 135 ABCD trial; no benefit for intensive SBP lowering (132 v. 138 achieved) SHEP, SYS EURO, HOT, UKPDS trials showed 30 69% risk reduction by reducing SBP to about 140 When Do We Initiate Drug Treatment? Most would agree that we use lifestyle changes first unless blood pressure is more than 20mmHg over target JNC 7; 140/90 (130/85 for DM/CKD) HOT trial; no difference between 80/90 DBP (except maybe some CVD reduction in DM2) AASK trial; no difference between 125/75 and 140/90 (except maybe if proteinuria >300) ACCORD trial; no difference for SBP < 135 ABCD trial; no benefit for intensive SBP lowering (132 v. 138 achieved) SHEP, SYS EURO, HOT, UKPDS trials showed 30 69% risk reduction by reducing SBP to about 140 How Do We Get There? ALLHAT; chlorthalidone vs. amlodipine v. lisinopril: no significant difference ONTARGET; telmisartan vs. ramipril vs combo: no significant difference alone no benefit from combo MRFIT; chlorthalidone vs. HCTZ: chlorthalidone better especially at night ACCOMPLISH; amlodipine + HCTZ vs. amlodipine + benazepril: Amlodipine + benazepril better (note: not chlorthalidone) 7

8 NICE Hypertension Guidelines 2011 Key points It doesn t matter what you use Doing something is better (cheaper) than doing nothing Ambulatory blood pressure monitoring preferable Beta blocker least cost effective Guidelines: <55 >55 or Black Race Step 1: ACE/ARB CCB Step 2: ACE/ARB + CCB STEP 3: ACE/ARB + chlorthalidone + CCB Step 4: add spironolactone and consider consultation STITCH Simplified Therapeutic Intervention to Control HTN Trial Canadian Heath System, 2048 patients 3 groups; usual care vs. standard guidelines vs. STITCH intervention Guidelines similar to JNC 6 At 6 months 67% vs. 53% at goal compared to usual care or standard guidelines Guidelines Step 1 ½ tab of ACE or ARB/Thiazide Diuretic combination Step 2 increase to full tablet Step 3 add CCB Step 4 add alpha blocker or beta blocker or spironolactone What About JNC 13? Its always wise to look ahead but difficult to look further than you can see Winston Churchill JNC 2013?? The BP target for most will be <140/90 mmhg BP for those age >60, <150/90 mmhg Combinations of RAS blockers with thiazide diuretics or RAS blockers and dihydropyridine CCBs are acceptable first line combos to get BP to goal, if >20/10 mmhg above goal Chlorthalidone preferable to HCTZ Beta Blocker only if compelling indication Spironolactone for resistant HTN ACEi + ARB not recommended 8

9 My Thoughts Consider ambulatory BP monitoring Don t hesitate to ask for the evidence!! Lifestyle changes are dramatically effective Resist temptation of therapeutic inertia JUST TREAT IT!!! 9

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