Disclosure. Objectives. Which Target to Target? A Blood Pressure Goal Update

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1 Which Target to Target? A Blood Pressure Goal Update Portia N. Davis, Pharm.D. Assistant Professor of Pharmacy Practice Texas Southern University College of Pharmacy & Health Sciences Disclosure I have no financial interest or affiliation with one or more organizations that could be perceived as an actual or potential conflict of interest in the context of the subject of this presentation Objectives 1. Identify blood pressure targets for various patient populations. 2. Provide evidenced-based recommendations for the management of patients with hypertension 3. Enable pharmacist to provide comprehensive blood pressure goal education to patients with hypertension to improve patient outcomes 1

2 Poll Everywhere Please join in this interactive session Introduction Introduction Hypertension Defined Systolic blood pressure (SBP) of 140 mmhg or more, or a diastolic blood pressure (DBP) of 90 mmhg or more, or taking antihypertensive medications 1 Classification: Normal SBP <120, DBP <90 Prehypertension SBP , DBP Stage I SBP , DBP Stage II SBP > 160, DBP >100 Healthy People 2020 Goal Improve cardiovascular health and quality of life through prevention, detection, and treatment of risk factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; prevention of repeat cardiovascular events; and reduction in deaths from cardiovascular disease. 2 2

Prevalence of High Blood Pressure in Adults (NHANES 2011-2014) Emelia J. Benjamin et al. Circulation. 2017;135:e146-e603 Copyright American Heart Association, Inc. All rights reserved.

3 Prevalence of High Blood Pressure in Adults (NHANES ) Emelia J. Benjamin et al. Circulation. 2017;135:e146-e603 Copyright American Heart Association, Inc. All rights reserved. Introduction Established Need There are several practice guidelines and published primary literature sources that give guidance on the management of hypertension Many of these sources recommend different blood pressure goals based on various patient factors Result: ambiguity amongst providers Introduction Domestic Sources: *Eighth Joint National Committee Report (JNC 8) American Academy of Pediatrics (AAP) American College of Cardiology (ACC) American College of Obstetrics and Gynecology (ACOG) American Heart Association (AHA) American Society of Hypertension (ASH) Kidney Disease Improving Global Outcomes (KDIGO) National Hearth Blood and Lung Institute (NHLBI) Veteran s Affairs/Department of Defense (VA/DoD) International Sources Canadian Hypertension Education Program (CHEP) European Society of Cardiologists (ESC) European Society of Hypertension (ESH) International Society of Hypertension (ISH) Japanese Society of Hypertension (JSH) National Heart Foundation of Australia (NHFA) National Institute for Health and Care Excellence (NICE) 3

4 Blood Pressure Goals Domestic Source Goal/Target *JNC 8 (2014) 3 General Population DM or CKD Present 60 y/o <150/90 All ages, no CKD <140/90 <60 y/o <140/90 All ages, races w/ckd, w/wo DM AAP (2004) 4 General Population Concurrent conditions <95 th percentile <90 th percentile <140/90 ACCF/AHA General Population 65 y/o Uncomplicated 65 y/o (2011) 5 <140/90 <140/90 ACC/AHA/ASH (2015, CAD) 6 ACS, CAD, HF ASH/ISH (2014) 7 Post-MI, stroke, TIA, carotid artery disease, PAD, AAA <140/90 <130/80 General Population DM or CKD Present (all ages) 80 y/o <150/90 CKD w/albuminuria CKD w/o albuminuria <130/80 <140/90 <80 y/o <140/90 DM <140/90 Blood Pressure Goals Domestic Source Goal/Target ACOG (2013) 8 KDIGO (2012) 9 Pregnant, Chronic Hypertension / Non-Dialysis (ND), w/wo DM Transplant 130/80 Albumin excretion <30 mg/24hrs Albumin excretion >30 mg/24 hrs 140/90 Children, ND 50 th percentile 130/80 Elderly <140/90 (individualize) NHLBI (2003) 10 General Population DM and/or CKD VA/DoD (2014) 11 <140/90 <130/80 General Population DM Cerebrovascular Disease y/o <150/90 <140/85 <150/ y/o <150/90 <140/85 <150/90 >60 y/o <150/90 <150/85 <150/90 Blood Pressure Goals Foreign CHEP (2016) 12 Source Goal/Target 80 y/o <150/NA All ages, DM no CKD <130/80 General Population DM or CKD Present <80 y/o <140/90 All ages CKD, w/wo DM <140/90 General Population DM CKD 80 y/o <140/90 ESH (2013) /90; <80 y/o <140/90 (fit patients) <140/85 <140/90 JSH (2014) 14 <140/90 <150/90 <140/90, if tolerated General Population < 75 y/o General Population 75 y/o NHFA (2016) 15 General Population < 75 y/o DM and/or CKD <140/90; SBP <120 if tolerated <140/90 NICE (2016) 16 General Population < 80 y/o General Population 80 y/o <140/90 <150/90 4

5 Literature Review Literature Review Global Burden of Hypertension and Systolic Blood Pressure of at Least mmhg, A comparative risk assessment of health loss related to SBP of 140 mmhg and the burden of different causes of death and disability by age and sex for 195 counties and territories between studies from 154 countries of 8.69 million participants Results SBP increased from 73,119 to 81,373 per 100,000 persons SBP 140 increased from 17,307 to 20,526 per 100,000 persons Estimated rate of annual deaths with SBP increased from to per 100,000 persons Estimated rate of annual deaths with SBP 140 increased from 97.9 to per 100,000 persons Conclusion Over the past 25 years, the number of persons worldwide with SBP 110 to 115 and 140 and associated deaths have increased substantially Literature Review A Randomized Trial of Intensive versus Standard Blood Pressure Control (SPRINT) 18 Randomized, controlled, open-label study designed to evaluate intensive SBP lowering to either <140 (standard of care) or <120 (intensive care) Enrolled patients age 50+ with history of or high risk for CVD Excluded patients with diabetes, stroke history, and non-ambulatory patients Results Intensive care group experienced: 25% lower relative incidence of CVD (absolute rates 5.2% vs 6.8%) 43% lower relative CVD-related mortality rate (absolute rates 0.8% vs 1.4%) 27% lower relative all-cause mortality rate (absolute rates 3.3 vs 4.5%) Patients aged 75 years old benefited similarly to younger patients Terminated early due to ethical concerns 5

6 Literature Review The Action to Control Cardiovascular Risk in Diabetes Study Group (ACCORD) 19 Randomized, controlled, open-label trial designed to compare the effects of lowering SBP to either <140 (standard of care) or <120 (intensive care) Enrolled patients ages with type 2 diabetes (A1c > 7.5%) and CVD or patients ages with high risk of CVD Results No significant difference in primary outcome (A1c reduction) between intensive and standard care groups (patients with diabetes) Intensive treatment group - Stroke incidence was significantly decreased; A nonsignificant reduction in CVD was observed At the same time, 257 patients in the intensive-therapy group died, as compared with 203 patients in the standard-therapy group (hazard ratio, 1.22; 95% CI, 1.01 to 1.46; P=0.04). Terminated early due to ethical reasons The Pharmacists Role Patient Education Project ImPACT: Hypertension Outcomes of a Pharmacist-Provided Hypertension Service 20 Pharmacists met with patients for BP monitoring, lifestyle goal setting, and education about medications and disease state on 4 occasions over 6 months Patients not at BP goal at baseline had a significant decrease in BP and a significant increase in achievement of BP goals (change +21.0%, P<0.001) Patient knowledge increased from baseline and satisfaction with pharmacists service was high 6

7 Patient Education Patient Knowledge of Blood Pressure Target is Associated with Improved Blood Pressure Control in Chronic Kidney Disease 21 Study conducted by the University of Michigan Health System in collaboration with Vanderbilt University Medical Center to describe patient hypertension knowledge and associations with blood pressure measurements 338 adults with HTN and pre-dialysis CKD patients were asked about the impact of high blood pressure on kidneys and their target blood pressure goal; SBP was measured using automated sphygmomanometers Results: Lower SBP associated with Female gender, less advanced CKD, and patient ability to correctly identify SBP goal Knowledge of BP goal remained independently associated with lower SBP (-9.96 mmhg [-19.97, -1.95] in correct respondents vs incorrect; p<0.001 Collaborative Delivery of Care Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION) 22 Patient-level, randomized, controlled trial that enrolled 248 adults with above-above target BP through community pharmacies, hospitals, or primary care teams Intervention group received a pharmacist-led assessment of BP and CV risk, education on hypertension, prescribed antihypertensive medications, lab monitoring, and monthly follow-up visits for 6 months versus control group of usual physician/pharmacist care Results: intervention group had a mean ±SE reduction in SBP at 6 months of 18.3 ±1.2 compared with 11.8 ±1.9 mmhg (P=0.0006) Pharmacists prescribing for patient with hypertension resulted in clinically and statistically significant reduction in blood pressure Conclusion Pharmacists should Remain abreast of current guidelines, trends in practice, and goals of treating hypertension Provide patient counseling on antihypertensive medications (OBRA 90) and motivational interviewing for increased medication adherence Provide comprehensive blood pressure goal education to patients with hypertension to improve patient outcomes 7

8 Application Case 1 AS is a 58 year old African-American woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine microalbumin is mildly elevated. What is AS blood pressure goal? Case 2 NC is a 35 y/o white female with DM and HTN. She is trying to control BP with diet/exercise, but has not been successful. Her BP in clinic today is 150/70, HR 75 bpm What is NC s blood pressure goal? What is our role in NC s care? 8

9 Case 3 FR is a 71 y/o male with a strong FH of CAD was admitted with an STEMI 4 days ago. After management of his acute symptoms, he was found to have diagnoses of HTN, hyperlipidemia, and mild LV systolic dysfunction with an EF of 45%. You look back and a BP in the office 9 months ago was 165/98. What is FR s blood pressure goal? What is our role in FR s care? Questions References 1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: A Report from the American Heart Association. Circulation. 2017;135:e146-e603. doi: /cir Office of Disease Prevention and Health Promotion. (2017). Heart Disease and Stroke. In Healthy People Available at: Accessed 3/2/ James PA, Ortiz E, et al Evidence-Based Guideline for the Management of High Blood Pressure in Adults (JNC8). JAMA. 2014;311(5): National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics. 2004; 114(2): Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011;123: Rosendorff C, Lackland DT, Allison M, et al; on behalf of the American Heart Association, American College of Cardiology and American Society of Hypertension. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation. 2015;131:e435-e Weber MA, Schiffrin EL, White WB, et al. Clinical Practice Guidelines for the Management of Hypertension in the Community: A Statement by the American Society of Hypertension and the International Society of Hypertension. Hypertension. 2014; 32(1):3-15. doi: /HJH American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. Hypertension, Pregnancy-Induced Practice Guideline. AJOG Available at: Pregnancy. Accessed 3/2/ Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney inter. 2012;2: The Sevent Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7). Hypertension. 2003; 42: The Diagnosis and Management of Hypertension Working Group. VA/DoD Clinical Practice Guideline for the Diagnosis and Management of Hypertension in the Primary Care Setting Available at: Accessed 3/2/ Daskalopoulou SS, Rabi DM, Zarnke KB, et al. The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can Pharm J. 2015;31: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) ESH/ESC Guidelines for the management of arterial hypertension. Europ Heart J. 2013;34: doi: /eurheart/eht Lindholm LH, Carlberg B. The New Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2014): a giant undertaking. Hypertension Research. 2014;37: doi: /hr

10 References 15. National Heart Foundation of Austrailia. Guideline for the diagnosis and management of hypertension in adults Melbourne: National Heart Foundation of Austrailia. 16. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Available at: Accessed 3/2/ Forouzanfar MH, Liu P, Roth GA, et al. Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mmhg, JAMA. 2017;317(2): doi: /jama/ The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood Pressure Control. NEJM. 2015; 373: doi: /nejmoa The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med. 2008;358: doi: /NEJMoa Nemerovski CW, Young M, Mariani N, et al. Project ImPACT: Hypertension Outcomes of a Pharmacist-Provided Hypertension Service. Inov Pharm. 2013;4(3): Article 126. Available at: Wright-Nunes JA, Luther JM, Ikizler TA, et al. Patient Knowledge of Blood Pressure Target is Associated with Improved Blood Pressure Control in Chronic Kidney Disease. Patient Educ Couns. 2012;88(2): doi: /j.pec Chobanian AV. Hypertension in 2017 What is the right target?. JAMA. Published online January 30, doi: /jama Tsuyuki RT, Houle SKD, Charrios TL, et al. Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxAction). Circulation. 2015;132: doi: /CIRCULATIONAHA Fritts M, Corbitt S. Your pharmacist and you: preventing cardiovascular disease. American Pharmacists Association. Available at: American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J HealthSyst Pharm. 1997; 54: Which Target to Target? A Blood Pressure Goal Update Portia N. Davis, Pharm.D. Assistant Professor of Pharmacy Practice Texas Southern University College of Pharmacy & Health Sciences 10

Long-Term Care Updates

Long-Term Care Updates August 2015 By Darren Hein, PharmD Hypertension is a clinical condition in which the force of blood pushing on the arteries is higher than normal. This increases the risk for heart