Guide to the New Hypertension Guidelines

Transcription

1 Guide to the New Hypertension Guidelines LCDR J. Garrett Sims, PharmD, BCPS Advanced Practice Pharmacist Crow/Northern Cheyenne Hospital Hypertension St

2 Disclosures None

3 Objectives Describe the new hypertension staging and blood pressure goals and first line therapies. Identify a blood pressure goal for a special population group. 3

4 Goal Help you understand the new blood pressure guidelines including some of its history. Encourage you to maximize your abilities in your area of practice to have a positive impact on the treatment of hypertension for your patients. Give you tools to either modify or create your protocols and or collaborative practice agreements.

5 Prevalence Fryar, CD. CDC, October 2017.

6 Prevalence based on Age Sex and Race Men > Men > IINCREASES WITH AGE Women > Women > Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

7 Cardiovascular Mortality Risk Cardiovascular Mortality Risk Increases as Blood Pressure Rises * x 5 4 4x 3 2 2x /75 135/85 155/95 175/105 Systolic/Diastolic Blood Pressure (mm Hg) * Measurements taken in individuals aged years, beginning with a blood pressure of 115/75 mm Hg. Lewington S, et al. Lancet. 2002;360: ; Chobanian AV, et al. JAMA. 2003;289: Slide by Goroski, used with permission

8 Complications of Hypertension: End-Organ Damage Hypertension Hemorrhage, Stroke LVH, CHD, CHF Retinopathy CHD = coronary heart disease CHF = congestive heart failure LVH = left ventricular hypertrophy Peripheral Vascular Disease Slide by Goroski, used with permission Renal Failure, Proteinuria Chobanian AV, et al. JAMA. 2003;289:

9 NHLBI Guidelines JNC JNC JNC JNC JNC JNC JNC JNC loses commission 2013 JNC AHA/ACC

10 Introduction to: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (New NHLBI Guidelines)

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12 Guideline Topics not in Presentation 4.3 Masked and White Coat Hypertension 5. Causes of Hypertension 5.1 Secondary Causes of Hypertension 7. Patient evaluation 7.1 Laboratory tests and other procedures BP treatment and CVD Risk Estimation Monitoring strategies to improve control 9.7 Metabolic Syndrome 9.8 A. fib 9.9 Valvular heart disease Aortic Disease

13 Guideline Topics not in Presentation (Cont.) Resistant Hypertension Hypertensive Crises Emergencies and Urgencies Cognitive Decline and Dementia Patients undergoing surgical procedures Health information technology to promote control Improving Quality of Care for Patients Financial incentives 13. The Plan of Care for Hypertension. And many details in between

14 Guideline Format Modular Knowledge Chunk Format Table of related recommendations Brief synopsis Full publication (481 pages) Executive Summary ( pages)

15 Guideline Format Modular Knowledge Chunk Format (Cont.) Recommendation-specific supportive text Flow Diagrams and additional tables when needed Streamline updates

16 Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary Strength of Recommendation and Quality of Evidence

17 Example Recommendation Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

18 Answering these questions: Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

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20 Classification of BP Average of two or more readings on two or more different occasions. American Heart Association. "DETAILED SUMMARY FROM THE 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults." November Heart.org. 20

21 Measurement of BP ) Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary 21

22 Measurement of BP (Cont.) Step 1: Properly prepare the patient Step 2: Use proper technique for BP measurements Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension Step 4: Properly document accurate BP readings Step 5: Average the readings Step 6: Provide BP readings to patient 22

23 Measurement of BP (Cont.) Step 1: Properly prepare the patient Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min. The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement. Ensure patient has emptied his/her bladder. Neither the patient nor the observer should talk during the rest period or during the measurement. Remove all clothing covering the location of cuff placement. Measurements made while the patient is sitting or lying on an examining table do not fulfill these criteria. 23

24 Measurement of BP (Cont.) Step 2: Use proper technique for BP measurements Use a BP measurement device that has been validated, and ensure that the device is calibrated periodically. Support the patient s arm (e.g., resting on a desk). Position the middle of the cuff on the patient s upper arm at the level of the right atrium (the midpoint of the sternum). Use the correct cuff size, such that the bladder encircles 80% of the arm, and note if a larger- or smaller-than-normal cuff size is used. Either the stethoscope diaphragm or bell may be used for auscultatory readings. 24

25 Measurement of BP (Cont.) Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension 1 st visit, take BP on both arms, keep highest, and be consistent at subsequent visits. 25

26 Home Measurement of BP Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary 26

27 Home Measurement of BP Make sure patient is instructed on how to take his or her own blood pressure appropriately (See table 10 in the guidelines). Instruction videos available online: essure/symptomsdiagnosismonitoringofhighbloodpressure/ Home-Blood-Pressure- Monitoring_UCM_301874_Article.jsp#.WcQNfLKGMnM Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary 27

28 Treatment of High BP 28 Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

29 Treatment of High Blood Pressure Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

30 Treatment of High Blood Pressure Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

31 Treatment of High Blood Pressure Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

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33 Treatment of High BP Nonpharmacologic Marrs, Joel and Joseph Saseen. "New HYPErtension Guidelines: Are They Worth All the Hype." Olrando: ASHP, 3 December Presentation. 33

34 Treatment of High BP Nonpharmacologic Weight loss - 5mm Hg DASH Diet -11mm Hg Sodium Restriction (1000mg-1500mg/day) Approx. -6mm Hg 34

35 Treatment of High BP Nonpharmacologic Diet High in Potassium ( mg/day) Approx. -5mm Hg Exercise -5-8mm Hg Moderation in Alcohol Consumption -4mm Hg 35

36 Question 1 CQ is a 45 yo white Male. He recently was diagnosed with stage 1 hypertension with a blood pressure of 135/86 on first visit and 134/82 one week later. Blood pressures were taken and averaged appropriately. All Labs WNL. No other comorbidities. BMI 25

37 Question 1 Which class of medication would be considered first line in this patient? A. Thiazide B. Calcium Channel Blocker C. ACE-I D. ARB E. Any of the above

38 Question 1 Which class off medication would be considered first line in this patient? A. Thiazide B. Calcium Channel Blocker C. ACE-I D. ARB E. Any of the above

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40 Treatment of High BP Pharmacologic 40 Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

41 Thiazides Chlorthalidone is preferred. Prolonged half-life Better data HCTZ still ok Monitor Hyponatremia Hypokalemia Uric acid and calcium levels 41

42 Thiazides Caution in patients with gout Generally avoid in patients with GFR <30 42

43 ACE Inhibitors Monitor (1-2 weeks after initiation, then periodically) Hyperkalemia Impaired renal function Medications that increase K+ Renal function DO NOT USE History of angioedema with ACE-I s With ARBs or direct renin inhibitors Pregnancy 43

44 ARBs Monitor (1-2 weeks after initiation, then periodically) Hyperkalemia Impaired renal function Medications that increase K+ Renal function DO NOT USE History of angioedema with ARBs Note: Patients with a history of angioedema with an ACE inhibitor can receive an ARB beginning 6 weeks after ACE inhibitor is discontinued. With ACE-Is or direct renin inhibitors Pregnancy 44

45 Calcium Channel Blockers Dihydropyridines (Examples: amlodipine, nifedipine) Avoid in heart failure with reduced ejection fraction Could consider amlodipine or felodipine Pedal edema Women Nondihydropyridines (Examples: Diltiazem, Verapamil) Avoid with betablockers DO NOT USE in heart failure with reduced ejection fraction Drug-Drug interactions CYP3A4 substrate and inhibitor 45

46 Secondary Agents (Diuretics) Loop Diuretics (ex. Furosemide) Preferred Symptomatic HF Preferred over thiazides when GFR <30 Potassium sparing diuretic (ex. Triamterene) Consider with thiazide in cases of hypokalemia secondary to thiazide, otherwise limited use. Avoid if GFR <45 Aldosterone antagonists (ex. Spironolactone) Preferred Primary aldosteronism Resistant hypertension Avoid with potassium supp. and potassium sparing diuretics

47 Secondary Agents (Beta Blockers) All Avoid abrupt discontinuation. Cardioselective (ex. Metoprolol) Preferred Ischemic heart disease HF (metoprolol succinate and bisoprolol in HFrEF) Reactive airway if beta blocker is needed Non-Cardioselective (ex. Propranolol) Avoid reactive airway disease Combined Alpha- and Beta-receptor (ex. Carvedilol) Carvedilol preferred in HFrEF Labetalol preferred in pregnancy

48 Secondary Agents (Alpha-1 Blockers and central acting) Alpha-1 Blocker (ex. Doxazosin) Orthostasis in PTSD Second line agent for HTN in patient who have BPH Alpha-1 Blockers and central acting (ex. Clonidine) Clonidine Avoid abrupt discontinuation Must be tapered Avoid with beta blockers Methyldopa 1 st line pregnancy

49 Secondary Agents (Others) Beta blockers cardioselective and vasodilatory Beta blockers intrinsic sympathomimetic activity Direct renin inhibitor Direct vasodilators

50 Special Patient Groups: Black Patients 1. First line drugs are thiazides and calcium channel blockers. Not ACE-I or ARBs unless CKD or HF. 2. Often times 2 or more medications are needed. Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

51 Special Patient Groups: Pregnancy 1. First line drugs are methyldopa, nifedipine, and or labetalol. 2. DO NOT USE ACE-I s OR ARB s Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

52 Question 2 EY is a 86 yo F, who is frail but lives independent and is adequately able to take care of herself. She presents to your clinic today for a refill of lisinopril. She has been out for one month. PMH: DM type 2, Hypertension BP today 145/85 BMI 18 Meds Glipizide ER 5mg, Atorvastatin 10mg, ASA 81mg, lisinopril 10mg. Labs A1c 7.5

53 Question 2 What is EY s goal blood pressure? A. <150/90 B. <140/90 C. <130/90 D. <130 (SBP)

54 Question 2 What is EY s goal blood pressure? A. <150/90 B. <140/90 C. <130/90 D. <130 (SBP)

55 Special Patient Groups: Older Persons 1. Goal is <130 mm Hg SBP for all patients 65 and older. No DBP goal. 2. Consider less intensive treatment in some patients. Frail and increasing age are not in and of themselves reasons for less intensive treatment. Whelton PK, et al High Blood Pressure Clinical Practice Guideline: Executive Summary

56 Comorbidities Specific comorbidities BP Threshold, mm Diabetes mellitus 130/80 <130/80 Diabetes mellitus with Albuminuria 130/80 <130/80 Chronic kidney disease 130/80 <130/80 Chronic kidney disease after renal transplantation 130/80 <130/80 Heart failure preserved ejection fraction 130/80 <130/80 Heart failure reduced ejection fraction 130/80 <130/80 Stable ischemic heart disease 130/80 <130/80 Stable ischemic heart disease w/ angina 130/80 <130/80 Secondary stroke prevention 140/90 <130/80 Secondary stroke prevention (lacunar) 130/80 <130/80 Peripheral arterial disease 130/80 <130/80 Hg BP Goal, mm Hg

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58 Putting it all together BP Threshold, mm Hg BP Goal, mm Hg Clinical Condition(s) First line Medications General Clinical CVD or 10-year ASCVD risk 10% 130/80 <130/80 Thiazide, CCB, ACE-I or ARB No clinical CVD and 10-year ASCVD risk <10% 140/90 <130/80 Thiazide, CCB, ACE-I or ARB Older persons ( 65 years of age; noninstitutionalized, ambulatory, community-living adults) 130 (SBP) <130 (SBP) Thiazide, CCB, ACE-I or ARB Black 130/80 <130/80 Thiazide, CCB methyldopa, nifedipine, and/or labetalol Pregnant <130/80 Specific comorbidities Diabetes mellitus 130/80 <130/80 Thiazide, CCB, ACE-I or ARB Diabetes mellitus with Albuminuria 130/80 <130/80 ACE-I or ARB Chronic kidney disease 130/80 <130/80 ACE-I or ARB Chronic kidney disease after renal transplantation 130/80 <130/80 ACE-I or ARB Heart failure preserved ejection fraction 130/80 <130/80 BB, ACE-I or ARB Heart failure reduced ejection fraction 130/80 <130/80 BB, ARA, ACE-I or ARB Stable ischemic heart disease 130/80 <130/80 BB, ACE-I or ARB Stable ischemic heart disease w/ angina 130/80 <130/80 BB, CCB Secondary stroke prevention 140/90 <130/80 Thiazide, ACE-I or ARB Secondary stroke prevention (lacunar) 130/80 <130/80 Thiazide, ACE-I or ARB Peripheral arterial disease 130/80 <130/80 Thiazide, CCB, ACE-I or ARB

59 Pharmacists can NEED to Help Fryar, CD. CDC, October 2017.

60 Pharmacists can NEED to Help Hypertension Team Clinical Pharmacist Comprehensive Medication Management Identification and documentation of medication-related problems Therapy Initiating Modifying (monitoring) Discontinuing Address identified problems educating patients

61 They want Pharmacists to Help Dunn, et al.j Am Col Cardiol 2015;66(19), 2015;

62 They want Pharmacists to Help American College of Cardiology position statement. Expansion of clinical pharmacy services is often impeded by policy, legislation, and compensation barriers. Multidisciplinary organizations, including the American College of Cardiology, should support efforts to overcome these barriers, allowing pharmacists to deliver high-quality patient care to the full extent of their education and training.

63 Conclusion Blood pressure continues to be highly prevalent and yet poorly controlled disease state nationally. New blood pressure guidelines offer an evidence based all-in-one resource for the treatment and management of blood pressure. Pharmacists need to help in the management of blood pressure to include: Initiation of therapy Changing therapy Discontinuing therapy And so on

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65 References American Heart Association. "DETAILED SUMMARY FROM THE 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults." November Heart.org. Document. 26 November Fryar, CD. "Hypertension Prevalence and Control Among Adults: United States, NCHS Data Brief." CDC, October Dunn, Steven, et. al. "The Role of the Clinical Pharmacist in the Care of Patients With Cardiovascular Disease." Journal of the American College of Cardiology (2015): Goroski, Dean. Clinical Update on the JNC 7/8 Hypertension Guidelines Hypertension Guidelines. USPHS COA Symposium, 21 June Marrs, Joel and Joseph Saseen. "New HYPErtension Guidelines: Are They Worth All the Hype." Olrando: ASHP, 3 December Presentation. Whelton PK, Carey RM, et. al. "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the ACC/AHA Task Force on Clinical Practice Guidelines." Hypertension (2017).

66 Questions?? LCDR James Garrett Sims Crow/N. Cheyenne Hospital 1 Hospital Rd Crow Agency, MT James.sims@ihs.gov