Emerging Challenges in Primary Care: Hypertension 2017: The Times and Guidelines Are Changing

Transcription

1 Emerging Challenges in Primary Care: 2017 Hypertension 2017: The Times and Guidelines Are Changing 1

2 Faculty Jan Basile, MD Professor of Medicine Seinsheimer Cardiovascular Health Program Division of General Internal Medicine Medical University of South Carolina Ralph H. Johnson VA Medical Center Charleston, SC 2

3 Disclosures Jan Basile, MD serves on the speakers bureau for Amgen, Arbor, and Janssen. Dr. Basile also serves as a consultant for Novartis, Medtronic, and Up-to-date. 3 3

4 Learning Objectives: Recognize the evolving epidemiology and improvements in control rates of hypertension. Review proper blood pressure (BP) measurement technique and the role of office, home, and 24-hr Ambulatory BP measurement in the diagnosis and treatment of hypertension. Recognize current recommendations for firstline agents in the treatment of hypertension. Discuss the impact of recent trials and recommendations on evolving BP treatment goals for individualized therapy.

5 PRE-TEST QUESTIONS 5 5

6 Pre-test ARS Question 1 Recent BP Control Rates (< 140/90 mm Hg) in a the Kaiser Permanente Health Care System Has Been As High As: 1. 95% 2. 80% 3. 70% 4. 50% 5. I am unsure

7 Pre-test ARS Question 2 The BP Measurement that correlates least with Clinical Outcome is the: 1. Nighttime BP 2. Daytime BP hour BP 4. Office BP 5. None of the above

8 Pre-test ARS Question 3 Recently recommended systolic BP targets in different populations at risk include all of the following except: 1. <150 mmhg 2. <140 mmhg 3. <130 mmhg 4. <120 mmhg 5. <110 mm Hg

9 Pre-test ARS Question 4 The thiazide/thiazide-like diuretic with the shortest half life is: 1. Hydrochlorthiazide 2. Indapamide 3. Chlorothalidone 4. Metolazone 5. They all have the same half-life

10 Pre-test ARS Question 5 Choose the Best Answer: According to JNC 8, which of the following antihypertensive drug classes is not appropriate for initial use in an uncomplicated hypertensive patient? 1. Calcium Channel Blocker 2. Thiazide-type diuretic 3. Beta-blocker 4. ACE Inhibitor or ARB 5. None of the above

11 Educational Objective #1 Recognize the evolving epidemiology and improving control rates of hypertension.

12 The Impact of Hypertension - 1 in 3 US adults > 20 years of age have hypertension - Approximately 69% of people who have a first heart attack, 77% of those who have a first stroke, and 74% of those who have HF have a BP >140/90 mm Hg - HTN contributes to 360,000 deaths each year in the US - Poor Medication Adherence is a major barrier to effective BP control as only about 57% remain adherent to their BP medication at 2 years follow-up - HTN is associated with shorter overall life expectancy cutting about 5 years of life compared to normotensive adult men and women Mozzafarian D et al. Circulation 2015; 131: e Roger VL, et al. Circulation. 2012;125:e2 e220. Rapsomaniki, E et al. Lancet. 2014;/383: May 31, 2014

13 Awareness, Treatment, and Control of HBP by Race/Ethnicity NHANES: White Black Hisp Mozzafarian D et al. Circulation 2016; 131: e

14 Kaiser Permanente Hypertension Control Rates KPNC=Kaiser Permanente Northern California HEDIS=Healthcare Effectiveness Data and Infomation Set JAMA Aug 21; 310(7):

15 Adult Hypertension Kaiser Permanente Hypertension Algorithm ACE-Inhibitor 2 / Thiazide Diuretic Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily Pregnancy Potential: Avoid ACE-Inhibitors 2 BP Goal < 140/90 mm Hg If ACEI intolerant or pregnancy potential Thiazide Diuretic Chlorthalidone 12.5 mg à 25 mg OR HCTZ 25 mg à 50 mg If not in control If not in control Calcium Channel Blocker Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily If not in control Beta-Blocker OR Spironolactone Add atenolol 25 mg daily à 50 mg daily (Keep heart rate > 55) OR IF on thiazide AND egfr 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily If not in control Go,AS et al J Am Coll Cardiol. 2013

16 Aspects of a Capitated Health Care System and Improved BP Control Rates 1. Access 2. Formulary Availability 3. More Frequent Follow-up with In-House Laboratory 4. Best Electronic Health Record with Evidence- Based Metrics 5. Pay for Performance 6. Nurse and Pharmacist-Managed Clinics

17 Educational Objective #2 Review proper blood pressure (BP) measurement technique and the role of office, home, and 24-hr Ambulatory BP measurement in the diagnosis and treatment of hypertension.

18 Limitations of Office Blood Pressure Measurement CHALLENGES TO ACCURATE OFFICE BLOOD PRESSURE MEASUREMENTS Insufficient number of readings plus an inherent variability of blood pressure in the office Poor technique (e.g., operator use and equipment status) White coat effect Masked effect Pickering TG, White W. J Clin Hypertens. 2008;10:

19 Poor BP Measurement Technique May Be Associated with Elevated BP in the Office Chobanian AV et al. Hypertension. 2003;42: ; Izzo JL, Sica DA, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 4th ed. Philadelphia: 2008:

20 Devices BPTru, Omron HEM-907, Welch Allyn PRO BP 2400 Myers MG. et al. Hypertension 2010;55: Automated Oscillometric BP Device

21 Automated BP and Office HTN Accurate and Representative BP Blood Pressure (mmhg) #1 #2 #3 #4 #5 #6 Mean Automated (BpTRU) Readings 50 HTN patients #1 BP reading by physician using BpTRU #2 6 BP readings taken with only the patient in the exam room using BpTRU (clinician leaves) White coat response associated with office BP can be virtually eliminated with the BpTru device Myers MG et al. J Hypertension. 2009;27: Myers MG et al. Blood Press Monitoring. 2006;11:59-62.

22 BP Measurement in the Office in Established Patient 1. Preferably taken before the patient ever sees the clinician caring for the patient minutes of rest-(built into the device to wait 5 min) - no conversation - seated comfortably with feet on the floor - arm at heart level - no tobacco or caffeine for 30 minutes before BP - have the examiner leave the room 3. Two to Three seated readings taken 1 minute apart (averaged) using an automated oscillometric BP device (AOBP) 4. An upright reading (after 1 minute of quiet standing)

23 The Concept of White-Coat and Masked Hypertension Office 140 Home or Day<me ABPM SBP mmhg 135 Masked Hypertension True Normotensive 140 True Hypertensive White Coat HTN Office Measurement SBP mmhg 135 Home or Day<me ABPM Derived from Pickering et al. Hypertension 2002:40:

24 Office, 24-hr, Daytime and Night-time SBP as Predictors of Cardiovascular Endpoints Syst-Eur 2-yr incidence of cardiovascular endpoints Nighttime 24-hr Daytime Conventional (office) Conclusion: Non-Office SBP: A Better Predictor of CV Events than Office BP Staessen JA et al. JAMA. 1999;282: Systolic blood pressure (mm Hg)

25 Out-of-Office Blood Pressure Measurement Use and Advantages: Helps identify WCH and masked hypertension Multiple readings throughout the day may reveal patterns in blood pressure and periods when control is inadequate Improves patient adherence Reduces costs Provides a better risk prediction than office-based monitoring Correlates better with the cardiac (LVH) and renal (albuminuria) consequences of hypertension than office readings Take readings 1 week per month, 2 readings in the am and pm, throw out the first day and get 24 values for a week q month Pickering TG, White W. J Clin Hypertens. 2008;10: ; Izzo JL, Sica DA, Black HR, eds, and the Council for High Blood Pressure Research (American Heart Association). Hypertension Primer: The Essentials of High Blood Pressure. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008:

26 US Preventative Service Task Force (USPSTF) Draft Recommendations Old Guideline, 2007 Population Recommendation Adults The USPSTF recommends screening for high BP in adults age 18 years and older. Grade A New Guideline, 2015 Population Recommendation Adults 18 and Older Use office BP as screening test Confirm diagnosis with out of office BP readings prior to initiation of antihypertensive therapy - ABPM is reference standard - Use home BP monitoring when ABPM not available Grade A Siu AL et al US Preventative Services Task Force (USPSTF). Screening for High Blood Pressure in Adults Annals Int Med 2015; 163(10).

27 Why Is It That We Continue To Deny Our Patients Ambulatory Blood Pressure Monitoring ABPM recommended to confirm the diagnosis of hypertension by: 1. USPSTF (2015) 2. Canadian Hypertension Education Program 2016 (CHEP) 3. NICE British European Society of Hypertension Position Paper on ABPM-2013 O Brien Eon. Hypertension. 2016;67: DOI: /HYPERTENSIONAHA )

28 Ambulatory BP monitoring Multiple readings over the course of 24 hours Superior to office BP in predicting outcomes Considered to be the noninvasive gold standard

29 Educational Objective #3 Recognize Current First-Line Antihypertensive Agents in the Treatment of hypertension.

30 Development of HTN Guidelines: The JNCs and Initial Drug Therapy Earliest guidelines JNC I JNC II JNC III JNC IV JNC V JNC VI JNC 7 8 th report NHBPEP starts 28 drugs DBP 105 diuretics 34 drugs diuretics 43 drugs Low-dose diuretics, β-blockers added 50 drugs ACEI, CAs added 68 drugs diuretics/ β-blockers 84 drugs 7 options >125 drugs diuretics (ALLHAT) December 18, 2013

31 Initial Medications For The Management of Hypertension Lifestyle Modification Especially Diet and Exercise Thiazide Thiazide-Type Diuretics ACE inhibitors or ARBs Calcium antagonists 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311(5): Feb 5, 2014

32 Cumulative Event Rates for the Primary Outcome (Fatal CHD or Non-fatal MI) by ALLHAT Treatment Group Cumulative CHD Event Rate RR (95% CI) p value A/C 0.98 ( ) 0.65 L/C 0.99 ( ) 0.81 Chlorthalidone Amlodipine Lisinopril Years to CHD Event ALLHAT Collaborative Research Group. JAMA. 2002;288:

33 ADA 2017: Hypertension (HTN) Managment Previously ACE Inhibitors or ARBs were 1 st -line recommendations for HTN management Expansion of recommended anti-hypertensives w/o clinical proteinuria to include thiazide diuretics or DHP-CCBs as 1 st -line agents The BP goal in Diabetes is < 140/90 mm Hg Consideration of empagliflozin or liraglutide for certain high-risk individuals ADA Standards of Medical Care in Diabetes. Diabetes Care 2017; 40 (Suppl.1):S75-S87.

34 Cochrane Review: Beta-blockers should not be first line for hypertension The available evidence does not support the use of betablockers as first-line drugs in the treatment of hypertension. Cochrane Database of Systematic Reviews. Published by John Wiley & Sons, Ltd. January 24, 2007.

35 β-blocker Meta-analysis Stroke: Atenolol vs Other Antihypertensive Agents Atenolol Other drug RR RR (n/n) (n/n) (95% Cl) (95% Cl) ASCOT-BPLA ELSA INVEST LIFE MRC Old UKPDS Total events 422/ / / / / / / /9639 9/ / / / / / ( ) 1.58 ( ) 1.14 ( ) 1.34 ( ) 1.22 ( ) 0.90 ( ) 1.26 ( ) Favors Favors atenolol other drug ASCOT-BPLA, Anglo-Scandinavian Cardiac Outcomes Trial Blood Pressure Lowering Arm; CI, confidence interval; ELSA, European Lacidipine Study on Atherosclerosis; INVEST, International Verapamil-Trandolapril Study; LIFE, Losartan Intervention For Endpoint reduction; MRC, Medical Research Council; RR, relative risk; UKPDS, United Kingdom Prospective Diabetes Study. Lindholm LH et al. Lancet. 2005;366(9496):

36 Educational Objective #4 Discuss the impact of recent trials and recommendations on evolving BP treatment goals for individualized therapy.

37 JNC 7 Lifestyle Modifications for BP Control Prevention Modification Recommendation Approximate SBP Reduction Range Weight reduction DASH eating plan Maintain normal body weight (BMI= ) Diet rich in fruits, vegetables, low fat dairy and reduced in fat 5-20 mm Hg/10 kg weight lost 8-14 mmhg Restrict sodium intake <2.4 grams of sodium per day 2-8 mmhg Physical activity Moderate alcohol Regular aerobic exercise for at least 30 minutes most days of the week <2 drinks/day for men and <1 drink/day for women 4-10 mmhg 2-4 mmhg BP = Blood pressure, BMI = Body mass index, SBP = Systolic blood pressure Chobanian AV et al. JAMA 2003;289:

38 Management of Blood Pressure-JNC 7 LIFESTYLE MODIFICATIONS Not at Goal Blood Pressure (<140/90 mmhg) (<130/80 mmhg for those with diabetes or CKD) INITIAL DRUG CHOICES In Patients With Hypertension Stage 1 Hypertension (SBP or DBP mmhg) Thiazide-type diuretics for most May consider ACEI, ARB, β-blocker, CCB, or combination Stage 2 Hypertension (SBP >160 or DBP >100 mmhg) 2-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or β-blocker or CCB) In Patients With Compelling Indications Related to Hypertension Not at Goal Blood Pressure Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, β-blocker, CCB) as needed Optimize dosages or add additional drugs until goal blood pressure is achieved Consider consultation with hypertension specialist Adapted from Chobanian AV et al. Hypertension. 2003;42:

39 JNC 8 Hypertension Guideline Management Algorithm James PA, Oparil S, Carter BL et al. JAMA 2014: 311 (5): , Feb 5, 2014.

40 ACP/AAFP Hypertension Pharmacologic Guideline in Adults > 60 Years of Age 1.Start treatment for persistent SBP >150 mm Hg and achieve < 150 mm Hg to reduce risk for stroke, cardiac events, and death.-strong recommendation, High-Quality Evidence 2. In patients with a hx of stroke or TIA achieve a goal of < 140 mm Hg to reduce recurrent stroke-weak recommendation, Moderate, Quality Evidence 3. In high CV risk (diabetes, vascular disease, metabolic syndrome, CKD, for example) achieve a SBP of < 140 mm Hg-Weak recommendation, low-quality evidence Qaseem A et al. ACP/AAFP Drug Rx of HTN in Adults 60 and Over: A clinical practice guideline from the ACP and AAFP. Ann Intern Med Jan 17. [Epub ahead of print] 40

41 2016 Canadian Hypertension BP Guidelines AOBP* has replaced auscultatory BP measurement Provider leaves the room eliminating white-coat effect Eliminates conversation with provider or nurse Multiple measurements taken with mean value calculated Provides greater visit-to-visit consistency Avoids digit preference and rounding In adults > 50 years of age, using AOBP, with SBP > 130 mm Hg, in selected high-risk patients **, intensive management to achieve a target SBP < 120 mm Hg is recommended ** Referring to the 4 SPRINT categories of patients-clinical or subclinical CVD, CKD, aged > 75 years of age, 10-yr CVD risk > 15% Leung AA et al.can J Card. 2016;32: AOBP=Automated Office Blood Pressure

42 Intensive Group < 120 mm Hg; Standard Group < 140 mm Hg. N Engl J Med 2015;373:

43 Major Inclusion Criteria At least 50 years old (30% AA, 10% Hispanic, 58% White) with no upper age exclusion Systolic blood pressure SBP: mm Hg on 0 or 1 medication SBP: mm Hg on up to 2 medications SBP: mm Hg on up to 3 medications SBP: mm Hg on up to 4 medications Risk (one or more of the following 4 high-risk groups) Presence of clinical or subclinical CVD (not stroke)-20% Chronic Kidney Disease (CKD), defined as egfr ml/min/1.73m 2-28% Framingham Risk Score for 10-year CVD risk 15% Not needed if eligible based on preexisting CVD or CKD Age 75 years-28% SPRINT Research Group, NEJM 2015; 373:

44 Major Exclusion Criteria Stroke (SPS3) Diabetes (ACCORD) Congestive heart failure (symptoms or EF < 35%) Proteinuria >1g/d CKD with egfr < 20 ml/min/1.73m 2 (MDRD) Polycystic Kidney Disease Adherence issues in the past Non-ambulatory Living in a Nursing home SPRINT Research Group, NEJM 2015; 373:

45 SPRINT BP Target Measurement of BP by rigorous use of an automated office device (OMRON-HEM907XL) in SPRINT (to minimize white-coat effect): No health professional in the room Patients seated in a chair 5 minutes, then 3 readings 1 minute apart Average of these readings = official reading This method likely gives values at least 5-7 mmhg lower than the typical office value* BP monitored monthly x first 3 months then at least q 3 months thereafter THUS, SPRINT value of translates into an office value 127 mmhg; in other words, an office target of <130 mmhg Adapted from SPRINT Research Group. N Engl J Med. 2015;373: *Myers, et al. Hypertension ;

46 BP Treatment Agents from all major antihypertensive drug classes available free of charge Classes with best CVD outcomes in trials given priority Chlorthalidone encouraged as thiazide-type diuretic Amlodipine encouraged as CCB SPRINT Research Group, NEJM 2015; 373:

47 Chlorthalidone: The Preferred Thiazide-Type Diuretic for HTN Greater potency 24-hour duration of action Much greater evidence base for CV outcome improvement at the current doses recommended (12-25 mg)

48 Diuretics Used to Treat Hypertension Thiazide and Thiazide-like Diuretics Loop Diuretics Potassium- Sparing Diuretics BA (%) T ½ (hours) DOA (hours) Hydrochlorothiazide Chlorothiazide Chlorthalidone Bendroflumethiazide Indapamide Metolazone Bumetanide Furosemide Torsemide Amiloride Triamterene 83 (55) * 3.0 (3.0) * 7-9 Spironolactone > Eplerenone NA *Parentheses denote active metabolite. The half-life of one active metabolite, potassium canrenoate, is 15 h. BA = bioavailability; T½ = half-life; DOA = duration of action: NA = unknown. Reprinted from Brater DC. In: Principles of Pharmacology: Based Concepts and Clinical Applications. 1995: , with permission from Springer Science and Business Media; Delyani JA, et al. Cardiovasc Drug Rev. 2001;19: ; Rosenberg J, et al. Cardiovasc Drug Ther. 2005;19: ; Sica DA. Congest Heart Fail. 2003;9:

49 Representative Outcome Studies Using Chlorthalidone vs HCTZ Chlorthalidone MRFIT ( mg) SHEP ( mg) ALLHAT ( mg) Treatment of Mild Hypertension trial (TOMHS) ( mg) HCTZ (dose) MRFIT ( mg) ACCOMPLISH ( mg) Medical Research Council trial in the Elderly (MRC-E) (25 50 mg) VA Cooperative Study Group on antihypertensive agents ( mg) Hypertension Detection and Follow-up Program (HDFP) ( mg) HCTZ=hydrochlorothiazide. Germino F.W. Curr Cardiol Rep. 2012;14:

50 Chlorthalidone 25 mg Has Greater BP-Lowering Efficacy vs HCTZ 50 mg, Especially at night Reduction in Mean SBP Baseline to Week 8, mm Hg hour Mean SBP Daytime Mean SBP Night-time Mean BP P=0.054 P=0.230 P=0.009 CLD 25 mg HCTZ 50 mg Daytime was 6:00 AM to 10:00 PM; night-time, 10:00 PM to 6:00 AM. CLD=chlorthalidone; HCTZ=hydrochlorothiazide. Ernst ME, et al. Hypertension. 2006;47:

51 Medication Classes by Treatment Group Last Visit Per Participant Prior to 8/20/2015 Intensive Group < 120 mm Hg; Standard Group < 140 mm Hg. Supplement to N Engl J Med. 2015;373:

52 Systolic BP During Follow-up (N=9361) Year 1 Mean SBP mm Hg Mean SBP mm Hg Standard Intensive Average SBP (During Follow- up) Standard: mm Hg Intensive: mm Hg Average number of anhhypertensive medicahons Number of parhcipants SPRINT Research Group, Figure 2. NEJM 2015; 373:2110.

53 SPRINT Primary Outcome* Cumulative Hazard Hazard RaHo = 0.75 (95% CI: 0.64 to 0.89) Standard (319 events) Intensive (243 events) During Trial (median follow- up = 3.26 years) Number Needed to Treat (NNT) to prevent a primary outcome = 61 SPRINT Research Group, Figure 3. NEJM 2015; 373:2112. Number of ParHcipants * MI, ACS other than MI, Stroke, Heart Failure**, Death from CV Causes** ** Primary Endpoints Statistically Significant

54 Primary Outcome Experience in the 6 Pre-specified Subgroups of Interest *Treatment by subgroup interaclon SPRINT Research Group. N Engl J Med. 2015;373:

55 All Cause Mortality Experience in the Six Pre-specified Subgroups of Interest * *p=0.34, azer Hommel adjustment for mulhple comparisons SPRINT Research Group. N Engl J Med. 2015;373:

56 SPRINT: Serious Adverse Events* Percent of pa<ents Total SAE Similar 1.4 HR: % CI: P < Acute Kidney Injury 30% Reduc<on in egfr Hypotension Acute or Acute kidney Renal injury Failure or acutre renal failure to 30% < 60mL/min/1.73 reduc<on egfr m2 in to those <60mL/min/1.73 w/o CKD on entry m2 Intensive Treatment Standard Treatment *Fatal or life threatening event, resulhng in significant or persistent disability, requiring or prolonging hospitalizahon, or judged important medical event. SPRINT Research Group. N Engl J Med. 2015;373: P <.001 P <

57 Number of Participants with a Monitored Clinical Measure During F/U Number (%) of ParHcipants Intensive Standard HR (P Value) Laboratory Measures 1 Sodium <130 mmol/l 180 (3.8) 100 (2.1) 1.76 (<0.001) Potassium <3.0 mmol/l 114 (2.4) 74 (1.6) 1.50 (0.006) Potassium >5.5 mmol/l 176 (3.8) 171 (3.7) 1.00 (0.97) Signs and Symptoms OrthostaHc hypotension (16.6) 857 (18.3) 0.88 (0.01) OrthostaHc hypotension with dizziness 62 (1.3) 71 (1.5) 0.85 (0.35) 1. Detected on rouhne or PRN labs; rouhne labs drawn quarterly for first year, then q 6 months 2. Drop in SBP 20 mmhg or DBP 10 mmhg 1 minute azer standing (measured at 1, 6, and 12 months and yearly thereazer) SPRINT Research Group, Adapted from Table 3. NEJM 2015; 373:2114.

58 Implications of SPRINT for Guidelines and HTN Management SPRINT likely will change SBP goal recommenda<ons in the new guidelines coming out Sept 2017 As big a ques<on is will we change how BP is measured in office prac<ce? If SPRINT- like pa<ents will have a goal of <130 mm Hg* - What about other high- risk popula<ons? Diabetes mellitus (ACCORD BP) mm Hg* Post- stroke (SPS3) mm Hg* - What about lower risk popula<ons? Age yrs, SBP 130 mm Hg but lower CVD risk- < 140 mm Hg* Age <50 years with SBP <140 mm Hg- already at goal* ONE SIZE DOES NOT FIT ALL- INDIVIDUALIZE *-Basile opinion.

59 Hypertension Treating Hypertension to Reduce the Incidence of HF COR LOE Recommenda.ons I B- R In palents at increased risk, stage A HF, the oplmal blood pressure in those with hypertension should be less than 130/80 mm Hg. Comment/ Ra.onale NEW: RecommendaLon reflects new RCT data. CirculaLon. 2017;April 27, DOI: /CIR

60 Hypertension Treating Hypertension in Stage C HFrEF COR LOE Recommenda.ons I C- EO PaLents with HFrEF and hypertension should be prescribed GDMT Ltrated to a\ain systolic blood pressure less than 130 mm Hg. Comment/ Ra.onale NEW: RecommendaLon has been adapted from recent clinical trial data but not specifically tested per se in a randomized trial of palents with HF. CirculaLon. 2017;April 27, DOI: /CIR

61 Take Home Messages Previous guideline recommendations for SBP targets of < 150 mmhg if aged 60 years old as in JNC 8 and recently resurrected by the AAFP/ACP will not be endorsed. In most adults regardless of age and diabetes status reducing SBP to mmhg (< 140)/ mm Hg (< 90 mm Hg (if tolerated) appears to offer the best overall organ protection; ie sweet spot for the heart, brain, and kidney. How close we get to 130/80 mmhg should be Individualized!

62 Take Home Messages In older and higher-risk hypertensive populations, if a lower BP goal is chosen (< 130 mm Hg), check renal function and electrolytes more regularly. How you measure BP is a key determinant to what your target BP should be. In patients at increased risk for, or with HFrEF, the optimal BP in those with hypertension should be < 130/80 mm Hg.

63 You want the truth? You can t handle the truth! Jack Nicholson A Few Good Men 1992

64 Post-test ARS Question 1 Recent BP Control Rates (< 140/90 mm Hg) in a the Kaiser Permanente Health Care System Has Been As High As: 1. 95% 2. 80% 3. 70% 4. 50% 5. I am unsure 64

65 Post-test ARS Question 2 The BP Measurement that correlates least with Clinical Outcome is the: 1. Nighttime BP 2. Daytime BP hour BP 4. Office BP 5. None of the above 65

66 Post-test ARS Question 3 Recently recommended systolic BP targets in different populations at risk include all of the following except: 1. <150 mmhg 2. <140 mmhg 3. <130 mmhg 4. <120 mmhg 5. <110 mm Hg 66

67 Post-test ARS Question 4 The thiazide/thiazide-like diuretic with the shortest half life is: 1. Hydrochlorthiazide 2. Indapamide 3. Chlorothalidone 4. Metolazone 5. They all have the same half-life 67

68 Post-test ARS Question 5 Choose the Best Answer: According to JNC 8, which of the following antihypertensive drug classes is not appropriate for initial use in an uncomplicated hypertensive patient? 1. Calcium Channel Blocker 2. Thiazide-type diuretic 3. Beta-blocker 4. ACE Inhibitor or ARB 5. None of the above 68

69 Thank you! Comments or Questions?