Jackson T. Wright, Jr. MD, PhD

Size: px
Start display at page:

Download "Jackson T. Wright, Jr. MD, PhD"

Transcription

1 DIFFERENTIAL EFFECTS OF BLOOD PRESSURE MEDICATIONS IN BLACK PATIENTS Jackson T. Wright, Jr. MD, PhD Professor of Medicine Program Director, WT Dahms MD Clinical Research Unit Clinical and Translational Science Collaborative Director, Clinical Hypertension Program University Hospitals Case Medical Center

2 Presenter Disclosure Information Jackson T. Wright, Jr, MD, PhD FINANCIAL DISCLOSURE: Research support: NIH Consulting: Novartis, Takada, Sanofi-Aventis, CVRx, NIH UNLABELED / UNAPPROVED USES DISCLOSURE: None

3 RACE IN MEDICINE Definition not standardized Usually defined by self-identification in research studies Unless participant questionnaire utilized or telephone survey, often have little assurance that all participants are actually asked the question Especially a problem for retrospective studies where method of ascertainment often not defined Racial differences usually confounded by SES which usually cannot be adequately adjusted for statistically However, racial differences are often sufficiently large that ambiguity in the definition of race is unlikely to account for these differences

4 RACE IN MEDICINE Some have suggested that race is a social construct, BUT it does have biological consequences Blacks have a higher rate of complications all of the major causes of death and hospitalization, including CVD, many cancers, infectious diseases, etc. A Black child born today has the life-expectancy of a White child born yrs ago and is twice as likely to die in the first year of life Racial differences often confused with genetic differences; however genetics is only one (and probably least important explanation)

5 RACE IN MEDICINE Clinically significant differences in disease presentation, pathophysiologic characteristics and response to treatment are evident by race and ethnicity Evaluation of disease differences in subsegments of the population is essential to understand the variation in pathophysiological mechanisms The study of population differences may provide valuable information on the disease in the affected population but is also likely to benefit the overall population

6 Increased Complications in Black Hypertensive Patients Cause of death in 30% African American males and 20% Black females Nonfatal strokes 30% than in whites Fatal strokes 80% than in whites Heart disease deaths 50% than in whites and occurs at younger age Kidney failure 400% than in whites (HTNrelated up to 2000% greater)

7 Prevalence of Hypertension, % Prevalence of HTN in African- and European- Origin Populations* *Age-adjusted. Cooper RS et al. BMC Medicine. 2005;3:2.

8 Percentage of Population Prevalence of HTN Among the African Diaspora St. Lucia Jamaica Maywood, IL Barbados Cameroon (rural) Nigeria Cameroon (urban) Average BMI Adapted from Cooper R, et al. Am J Public Health. 1997;87:166.

9 Development of Antihypertensive Therapies Effectiveness Tolerability 1940 s s 1970 s 1980 s 1990 s 2002 Peripheral sympatholytics Ganglion blockers Veratrum alkaloids Direct vasodilators Thiazide diuretics Central 2 agonists Calcium antagonistsnon DHPs -blockers -blockers Calcium antagonists- DHPs ACE inhibitors ARBs DRIs

10 % of Treated Patients on Medication Hypertension Treatment by Drug Class Diuretics ß-Blocker ACE Inhibitors CCBs ARBs Year IMS Health NDTI,

11 The reason to prescribe a treatment is that there is good evidence that it provides benefit NOT that there is insufficient evidence that it does not THIS IS PARTICULARLY TRUE IN POPULATIONS (LIKE BLACKS) AT HIGHEST RISK

12 RENIN ANGIOTENSIN SYSTEM (RAS) INHIBITORS Angiotensin converting enzyme (ACE)- Inhibitors Angiotensin Receptor Blockers (ARBs) Direct Renin Inhibitors (DRIs) (Beta Blockers)

13

14 HISTORY OF RAS INHIBITOR USE IN US RAS inhibitors leading class of CV medications since the early 80 s (> $7 billion/yr market) During much of their history on the market, industry avoided studies containing significant numbers of Blacks It more commonly generously supported programs and speakers aimed at promoting their use Lessened efficacy of β-blockers and ACEIs lowering BP in Black hypertensives not appreciated for 10 yrs after introduction Efficacy of ACEI on renal disease not available in Blacks for 8 yrs after proven effective in non-blks A-level evidence still missing for both β-blockers and ACEIs in Blacks for CHF

15 Patients with Response (%) Patients with Response (%) BP Response Rates in VA Trial by Race Older Blacks Older Whites DILT HCTZ CLON PRAZ ATEN PLAC CAPT ATEN DILT CAPT CLON HCTZ PRAZ PLAC Materson, B. J. et. al. N Engl J Med 1993;328:

16 Frequency Distribution SBP in Response to Quinapril in Black and White Participants (E. Mokwe et. al., HTN 2004;43:1) White s n = 2046 Black s n = 533

17 Decrement in Blood Pressure Mean Black-White Difference in mmhg (CI) 4.6 ( )/3.0 ( ) Ashwini R. Sehgal, Hypertension 2004; 43;

18 HOPE Trial Heart Outcomes Prevention Evaluation Ramipril Vs Placebo in 9,541 High CV Risk Participants Event(s) Risk Reduction CV deaths + MI + stroke 22% CV death 25% Nonfatal MI 20% Nonfatal stroke 32% Revascularization 15% CHF hospitalizations (#) 16% New-onset diabetes 30% HOPE Investigators. NEJM 2000; 342:145

19 Representation of Blacks in Major CVD/DM/Renal Clinical Trials Trial Year # Blacks (%) Trial Year # Blacks (%) ALLHAT ,133 (35.6%) SOLVD/Rx (15.3%) AASK ,094 (100%) TONE (24.0%) A-HeFT ,050 (100%) IDNT (14%) HDFP ,846 (44.3%) RENAAL (15%) SHEP (13.9%) HOPE 2000 ~175 (1.8%) VA Coop (53.8%) UKPDS (7.6%) VA Coop (41.3%) MDRD (7.9%) ACCOMPL ,416 (12%) ABCD (13.8%) HOT (3.1%) MRFIT (7.2%) LIFE (5.8%) ELITE (4.7%) VALUE (2.7%) CAPT-DM (7.3%) ASCOT 2005 ~960 (5%)* DREAM 2006 <5%

20 AASK Clinical Endpoint Analysis ACEI vs. CCB ACEI vs. BB Outcome % Risk 95 % Reduction 1 Confidence Interval % Risk Reduction 95 % Confidence Interval GFR event, 38% (+ 14 to + 55) ESRD or Death 2 p< % (+ 1 to + 38) p< GFR event or ESRD 3 40% (+ 13 to + 59) p<0.007 ESRD or Death 4 48% (+ 26 to + 65) p< % (- 1 to + 41) p< % (- 5 to + 40) p< 0.11 ESRD alone 5 59% (+ 34 to + 74) p< % (- 10 to + 45) p< ) Adjusted for baseline proteinuria, MAP,gender, Hx CHF and age; 2) 179 declining GFR, 84 ESRD, 77 death; 3) 170 declining GFR, 84 ESRD; 4) 171 ESRD, 79 deaths; events, deaths censored. Wright et al 2002; JAMA, 288:2421

21 Blood Pressure During Follow-up Ramipril Amlodipine Metoprolol Low MAP Goal Usual MAP Goal SBP (mm Hg) DBP (mm Hg) MAP (mm Hg) * * * 104 *Significantly different between two blood pressure goals P<0.01 Wright et al. JAMA. 2002;288:2421.

22 Cumulative Incidence (%) AASK Grp. Arch Intern Med 2008;168:832 Cumulative Incidence of Events (Doubling SCr, ESRD, or Death) Only Trial Mixed Trial and Post-Trial Composite Follow-up Time (Years) Only Post-Trial ESRD or Doubling SCr Death Number at Risk:

23 Cumulative Incidence (%) 60 Cumulative Incidence of Events in (1) ACEI with Low BP Group and (2) Non-ACEI with Usual BP Groups Only Trial Mixed Trial and Post-Trial Only Post-Trial Non-ACEI with Usual BP ACEI with Low BP 0 Number At Risk Usual BP & non-acei: Low BP and ACEI: Follow-Up Time (Years)

24 ALLHAT Hypertension Trial 42,418 high-risk hypertensive patients 90% previously treated 10% untreated STEP 1 AGENTS Chlorthalidone mg Amlodipine mg Lisinopril mg Doxazosin 1-8 mg Non-Blacks: 9,886 Blacks: 5,369 Non-Blacks: 5,844 Blacks: 3,210 Atenolol 28.0% STEP 2 AND 3 AGENTS (5 years) Clonidine 10.6% Reserpine 4.3% Hydralazine 10.9%

25 ALLHAT Blood Pressure at 5 Years by Race Chlorthalidone Amlodipine Lisinopril SBP mean (sd) DBP mean (sd) BP compared with chlorthalidone Black (15.8) (15.3) (19.7) (14.8) (14.6) (16.7) Black 77.4 (10.0) 76.3 (10.1) 78.0 (11.4) 74.4 (9.5) 73.6 (9.6) 74.1 (10.1) Black / -1.1* +4.1* / +0.6 Nonblack Nonblack Nonblack / -0.8* +0.9 / -0.3 Wright JT et al. JAMA 2005; 293:1593 *P<0.005

26 ALLHAT Black vs. Non-Black Lisinopril/Chlorthalidone Relative Risk and 95% Confidence Intervals Nonfatal MI + CHD Death All-Cause Mortality Combined CHD Combined CVD Stroke End Stage Renal Disease Heart Failure Black 1.10 ( ) 1.06 ( ) 1.15 ( ) 1.19 ( ) 1.40 ( ) 1.30 ( ) 1.30 ( ) Non-Black 0.94 ( ) 0.97 ( ) 1.01 ( ) 1.06 ( ) 1.00 ( ) 0.93 ( ) 1.13 ( ) right JT et al JAMA 2005; Favors Lisinopril Favors Chlorthalidone Favors Lisinopril Favors Chlorthalidone

27 ALLHAT Summary Lisinopril vs. Amlodipine Non-Blacks Blacks SBP Control <+0.5 mmhg mmhg # antihypertensive drugs similar Combined CHD, Mortality, ESRD, cancer Stroke Combined CVD HF hospitalized angina PAD similar similar but men -11%, women +46% similar - 15% similar + 18% similar + 45% + 13% - 11% + 26% + 22% GI Bleed + 16% + 28% Angioedema > >> +favors amlodipine - favors lisinopril Leenen F,et.al. Hypertens 2006;48:1

28 ALLHAT ANGIOEDEMA Total Chlorthalidone 8 / 15, % Lisinopril 38 / 9, % Blacks 2 / 5,369 <0.1% 23 / 3, % Nonblacks 6 / 9, % 15 / 5, % P<0.001 P<0.001 P=0.002 There were 3 cases (<0.1%) of angioedema in the amlodipine group (comparison to chlorthalidone not significant).

29 Endpoint Rate LIFE: Primary Composite Endpoint Intention-to-Treat Atenolol Losartan Adjusted Risk Reduction 13 0%, p=0 021 Unadjusted Risk Reduction 14 6%, p= Study Day Study Month Losartan (n) Atenolol (n) B Dahlof et al. Lancet 2002;359:

30 Results of Primary Composite Endpoint in LIFE by Ethnic Group Results of primary composite end point by ethnic group. The dots represent the hazard ratio; dot size is proportional to the number of patients for each ethnic group, as shown to the left. The line through each dot corresponds to the 95% confidence interval. Results of primary composite end point by ethnic group in the U.s.: blacks versus nonblacks. Julius et al. J Am Coll Cardiol. 2004;43:

31 Figure 2 J Hypertens 2006;24:2163

32 ALLHAT Biochemical Results Fasting Glucose mg/dl Chlorthalidone Amlodipine Lisinopril Total mean (SD) Baseline (58.3) (57.0) (56.1) 4 Years (55.6) (52.0) (51.3)* Among baseline nondiabetics with baseline <126 mg/dl mean (SD) Baseline 93.1 (11.7) 93.0 (11.4) 93.3 (11.8) 4 Years (28.5) (27.7) (19.5)* Diabetes incidence (follow-up fasting glucose 126 mg/dl) 4 Years 11.6% 9.8%* 8.1%* *P<0.05 compared to chlorthalidone

33 DREAM RAS Blockade & New Diabetes (Diabetes - Not Primary Outcome) Study N (no DM) Active Control RRR ACE Inhibitors HOPE 5720 Ramipril 10 OD Placebo 34% PEACE 6174 Trandolapril Placebo 17% Overall Effect (HOPE, EUROPA, PEACE): 0.86 ( ) EUROPA 10716Dagenais Perindopril et al. Lancet 8 mg 2006;368:581 Placebo 3% D-SOLVD 291 Enalapril Placebo 74% Angiotensin Receptor Blockers SCOPE 4368 Candesartan 16/d Placebo 20% CHARM 5436 Candesartan 4-32/d Placebo 24%

34 Cardiovascular Mortality Rate per 10,000 Patient-Years Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk Elevated SBP increases risk of CV death almost twofold in diabetic vs nondiabetic patients Nondiabetic patients Diabetic patients < Stamler J et al. Diabetes Care. 1993;16: SBP (mm Hg) MRFIT 20

35 DREAM Metabolic Changes Baseline 4 Years A B A B Serum cholesterol, mg/dl Serum potassium, mmol/l Fasting serum glucose, mg/dl Serum creatinine, mg/dl

36 DREAM Summary of Chlorthalidone / Doxazosin Comparisons from ALLHAT Outcome RR (95% CI) p value CVD 1.20 ( ) <0.001 Heart failure 1.80 ( ) <0.001 Stroke 1.26 ( ) CHD 1.03 ( ) 0.62 All-cause mortality 1.03 ( ) 0.50 ALLHAT Collab Res Grp. Hypertens 2003; 42:239

37 ALLHAT Effect of Incident Diabetes on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) Incident Diabetes / No Diabetes HR (95% CI) CHD 1.64 ( ) Stroke 1.61 ( ) CCVD 1.04 ( ) Heart failure 1.37 ( ) ESRD 2.86 ( ) Total mortality 1.31 ( ) * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year BP, 2- year serum potassium, 2-year atenolol & statin treatment. Barzilay J et al: Arch Intern Med. 2006;166:2191

38 ALLHAT Effect of Change in Fasting Glucose on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) ΔFG to 2 Yr (per 10 mg/dl) HR (95% CI) CHD 1.02 ( ) Stroke 1.00 ( ) CCVD 1.00 ( ) Heart failure 1.02 ( ) ESRD 1.06 ( ) Total mortality 1.01 ( ) * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year serum potassium, 2-year atenolol atenolol & statin treatment. Barzilay J et al: Arch Intern Med. 2006;166:2191

39 ALLHAT Effect of Change in Fasting Glucose on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) ΔFG to 2 Yr (per 10 mg/dl) HR (95% CI) P compared with chlorthalidone CHD Total 1.02 ( ) 0.44 Chlorthalidone 1.00 ( ) 0.94 Amlodipine 0.99 ( ) 0.87 Lisinopril 1.09 ( ) 0.03 CCVD Total 1.00 ( ) 0.84 Chlorthalidone 0.99 ( ) 0.56 Amlodipine 1.00 ( ) 0.95 Lisinopril 1.06 ( ) 0.04 * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year serum potassium, 2-year atenolol atenolol & statin treatment.

40 ALLHAT CHD Black With Metabolic Syndrome Lisinopril/Chlorthalidone Relative Risk and 95% Confidence Intervals 6-year Rate per 100 Black 1.17 ( ) Without Metabolic Syndrome 1.07 ( ) All-cause Mortality 1.14 ( ) 1.02 ( ) Stroke 1.37 ( ) 1.31 ( ) Heart Failure 1.49 ( ) 1.09 ( ) Combined CVD 1.23 ( ) 1.09 ( ) ESRD 1.70 ( ) 0.75 ( ) Wright et al. Arch Int Med 2008; 168: Favors Lisinopril Favors Chlorthalidone Favors Lisinopril Favors Chlorthalidone

41 2010 Consensus Recommendations from the International Society of Hypertension in Blacks (ISHIB) A major recommendation of this consensus panel was the preference of the combination of a RAS-inhibitor with a calcium channel blocker over a RASinhibitor + a diuretic in Black hypertensives Flack J et al. Hypertens 2010; online

42 ACCOMPLISH Preliminary Results: Primary* and Secondary End Points End point Hazard ratio (95% CI) *Cardiovascular morbidity/mortality 0.80 ( ) Cardiovascular morbidity/mortality (excluding coronary revascularization) 0.79 ( ) Cardiovascular mortality 0.81 ( ) Nonfatal MI 0.81 ( ) Nonfatal stroke 0.87 ( ) Hospitalization for unstable angina 0.74 ( ) Coronary revascularization 0.85 ( ) Resuscitation for sudden death 1.75 ( ) Jamerson KA, et al. NEJM 2008;359:2117

43 Randomization ACCOMPLISH: Design Amlodipine 10 + benazepril 40 mg Free add-on antihypertensive agents* Amlodipine 5 mg + benazepril 40 mg Screening Amlodipine 5 mg + benazepril 20 mg Benazepril 20 mg + HCTZ 12.5 mg Benazepril 40 mg + HCTZ 12.5 mg Titrated to achieve BP<140/90 mmhg; <130/80 mmhg in patients with diabetes or renal insufficiency Benazepril 40 mg + HCTZ 25 mg Free add-on antihypertensive agents* 14 Days Day 1 Month 1 Month 2 Month 3 Year 5 *Beta blockers; alpha blockers; clonidine; (loop diuretics). Jamerson KA et al. Am J Hypertens. 2003;16(part2)193A

44 Thiazide-type Diuretic Doses in Hypertension Morbidity Trials Trial Drug Dose of Thiazide (mg/d) VA CSP M&M HCTZ 100 HDFP chlorthalidone MRC I bendroflumethiazide 10 HAPPHY bendroflumethiazide 5-10 HCTZ EWPHE HCTZ/triamterine MRC Elderly HCTZ/amiloride SHEP chlorthalidone ALLHAT chlorthalidone PATS indapamide 2.5 PROGRESS indapamide (+ACEI) 2.5 HYVET indapamide 1.5 ADVANCE BP indapamide (+ACEI) 1.25

45 Reduction in SBP (mmhg) Chlorthalidone vs HCTZ Estimated Dosing Equivalence based on Estimated Equivalent BP Reduction Current dosing of mg can be viewed as compromise between antihypertensive efficacy and kaliuresis HCTZ Chlor. 50 mg HCTZ ~ 25 to 37.5 mg chlorthalidone Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

46 Pharmacokinetics HCTZ Chlorthalidone Vd 3-4 L/kg 40% protein bound 3-13 L/kg 75% protein bound 98% distribution into RBC Relative Potency* Oral Bioavail Onset (h) Peak (h) Half-life (h) 1 ~70% (single dose) 8-15 (longterm dosing) 1 ~65% (single dose) (longterm dosing) Duration (h) 12 (single dose) (longterm dosing) (single dose) (longterm dosing) Indapamide 20 ~93% 1-2 <2 14 Up to 36 * per most pharmacology texts; research suggests otherwise Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

47 Perspective May be promoted by some to encourage use of CCBs over thiazide-type diuretics (each with RAS inhibitors). Calls for guidelines changes are premature. Dose of thiazide-type diuretic Doses of thiazide-type diuretics equivalent to <25-50 mg/day HCTZ have not been evaluated in clinical outcome trials demonstrating the benefits of HCTZ on CVD outcomes In ALLHAT, adequate dosage of diuretic was superior to both the CCB and ACE-inhibitor in preventing HF and unsurpassed for other CVDrenal outcomes, esp in Black patients 8/20/2008

48 Combination Therapy Needed to Achieve Target SBP Goals Trial/SBP Achieved UKPDS (144 mm Hg) RENAAL (141 mm Hg) ALLHAT (135 mm Hg) IDNT HOT (138 mm Hg) (138 mm Hg) INVEST (133 mm Hg) ABCD MDRD AASK (132 mm Hg) (132 mm Hg) (128 mm Hg) Updated from Bakris GL et al. Am J Kidney Dis. 2000;36: Number of BP meds

49 If most hypertensives (especially Black hypertensives) need 2-3 meds, which medications would these include CCB, DIURETICS, RAASI

50 RAS INHIBITOR USE IN HYPERTENSIVE BLACKS ACEIs/ARBs should be considered first in patients (including Blacks) with nephropathy (esp with proteinuria) and/or heart failure Available data suggest that RAS inhibitors are less effective in lowering BP in Black hypertensives in the absence of adequate doses of a diuretic or CCB (and in preventing clinical outcomes) ACEI also carry increased of angioedema, esp in Blacks In the absence of HF or CKD, particularly in Black hypertensives, beta blockers, ACEIs, and ARBs (and presently renin inhibitors) should be prescribed only in combination with thiazide-type diuretics or calcium channel blockers

51 The End

52 2010 Consensus Recommendations from the International Society of Hypertension in Blacks (ISHIB) Flack J et al. Hypertens 2010; online

53 POTENTIAL COSTS/RISKS OF LOWER THAN INDICATED BP TARGETS Increased cost of potentially unnecessary medications Increased risk of medication side effects Increased clinic visits if BP not at lower goal Increased monitoring required More complicated regimen that may jeopardize adherence to evidence-based treatment of other risk factors Potential increased risk of lower BP goals

54 Cumulative Incidence (%) TRIAL AND COHORT ALL PATIENTS Only Trial Mixed Trial and Cohort Only Cohort Low BP Usual BP Low BP vs. Usual BP Goal HR (95%CI) = 0.90 (0.77,1.07) p = Follow-Up Time (Months) AASK. NEJM 2010;363:10

55 Cumulative Incidence (%) TRIAL AND COHORT SUBGROUP WITH UP/Cr > Only Trial Mixed Trial and Cohort Only Cohort Low BP Usual BP Low BP vs. Usual BP Goal HR (95%CI) = 0.72 (0.57,0.92) p = Follow-Up Time (Months) AASK. NEJM 2010;363:10

56 Mean # Meds Intensive: Standard: Average after 1 st year: Standard vs Intensive, Delta = 14.2

57 ACCORD BP-Lowering: Reduction of SBP to <120 mmhg significantly Reduces the Rate of STROKE Outcome Intensive Therapy (n = 2363) Number of Events %/Year Standard Therapy (n = 2371) Number of Events %/Year Hazard Ratio (95% CI) Primary outcome* ( ) 0.20 Prespecified secondary outcomes Nonfatal MI ( ) 0.25 Any stroke ( ) 0.01 Nonfatal stroke ( ) 0.03 Death from any cause ( ) 0.55 Death from CV cause ( ) 0.74 Primary outcome plus revascularization or nonfatal heart disease ( ) 0.40 Major coronary disease event ( ) 0.50 Fatal or nonfatal heart failure ( ) 0.67 *Primary outcome: composite of nonfatal MI, nonfatal stroke, or death from CV causes Major coronary disease events included fatal coronary events, nonfatal MI, and unstable angina ACCORD: Action to Control Cardiovascular Risk in Diabetes Study P Value The ACCORD Study Group. N Engl J. Med. 2010;doi: /NEJMoa

58 Primary Outcome by Pre-defined Subgroups Also examined DBP tertiles (p=0.70) and number of screening meds (p=0.44) The ACCORD Study Group. N Engl J Med 2010;10

59 SUMMARY AND CONCLUSIONS 1/2-2/3 rd of Black hypertensives are above BP goal of 140/90 mmhg The evidence, including that in Black hypertensive patients, does not support BP goals substantially lower than 140/90 mmhg The increased cost in medications, clinic visits, monitoring, and potentially increased risk to achieve lower BP goals remains to be justified More definitive information should be forthcoming from the SPRINT trial In the meantime, efforts to control HTN in Blacks should focus on increasing the number of hypertensives controlled to <140/90 than on getting those already < 140/90 to lower goals

60 DIFFERENTIATION BETWEEN MARKETING AND EVIDENCE Who are you going to believe - me or the lying data?? Dr. Richard Pryor

61 Reduction in SBP (mmhg) Chlorthalidone vs HCTZ Estimated Dosing Equivalence based on Estimated Equivalent BP Reduction Current dosing of mg can be viewed as compromise between antihypertensive efficacy and kaliuresis HCTZ Chlor. 50 mg HCTZ ~ 25 to 37.5 mg chlorthalidone Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

62 Direct and Indirect Comparisons of Chlorthalidone and Nonchlorthalidone Treatments for 6 Outcomes Based on Placebo-Controlled Trials RR (95% CI) Indirect Outcome Chlorthalidone Nonchlorthalidone Comparison, SI (95% Cl)* Coronary disease 0.74 ( ) 0.72 ( ) 1.03 ( ) Stroke 0.64 ( ) 0.71 ( ) 0.90 ( ) Heart failure 0.53 ( ) NA NA CVD events 0.70 ( ) 0.76 ( ) 0.92 ( ) CVD mortality 0.80 ( ) 0.79 ( ) 1.01 ( ) Total mortality 0.89 ( ) 0.91 ( ) 0.98 ( ) Psaty BM, JAMA 2004; 292:42

ALLHAT. Major Outcomes in High Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic

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

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

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

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

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

APPENDIX D: PHARMACOTYHERAPY EVIDENCE

APPENDIX D: PHARMACOTYHERAPY EVIDENCE Página 1 de 7 APPENDIX D: PHARMACOTYHERAPY EVIDENCE Table D1. Outcome Trials of Antihypertensive Agents Study Drug Regimen N Duration Primary Outcomes Remarks Antihypertensive Therapy vs Placebo SHEP 1991

More information

Hypertension Update 2009

Hypertension Update 2009 Hypertension Update 2009 New Drugs, New Goals, New Approaches, New Lessons from Clinical Trials Timothy C Fagan, MD, FACP Professor Emeritus University of Arizona New Drugs Direct Renin Inhibitors Endothelin

More information

ALLHAT. ALLHAT Antihypertensive Trial Results by Baseline Diabetic & Fasting Glucose Status

ALLHAT. ALLHAT Antihypertensive Trial Results by Baseline Diabetic & Fasting Glucose Status ALLHAT Antihypertensive Trial Results by Baseline Diabetic & Fasting Glucose Status 1 Introduction and Background Clinical trials have reported reduction in CV events with diuretics, CCBs, ACE inhibitors,

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

Randomized Design of ALLHAT BP Trial

Randomized Design of ALLHAT BP Trial Outcomes in Hypertensive Black and Nonblack Patients Treated with Chlorthalidone, Amlodipine, and Lisinopril* *Wright JT, Dunn JK, Cutler JA et al. JAMA 2005:293:1595-1608. 42,418 High-risk hypertensive

More information

Preventing and Treating High Blood Pressure

Preventing and Treating High Blood Pressure Preventing and Treating High Blood Pressure: Finding the Right Balance of Integrative and Pharmacologic Approaches Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Blood Pressure

More information

ADVANCES IN MANAGEMENT OF HYPERTENSION

ADVANCES IN MANAGEMENT OF HYPERTENSION Advances in Management of Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Current Status of Prevalence 29%; Blacks 33.5%

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

Modern Management of Hypertension: Where Do We Draw the Line?

Modern Management of Hypertension: Where Do We Draw the Line? Modern Management of Hypertension: Where Do We Draw the Line? Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Blood Pressure

More information

Modern Management of Hypertension

Modern Management of Hypertension Modern Management of Hypertension Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Current Status of Hypertension Prevalence

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

ALLHAT Role of Diuretics in the Prevention of Heart Failure - The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial

ALLHAT Role of Diuretics in the Prevention of Heart Failure - The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial 1 ALLHAT Role of Diuretics in the Prevention of Heart Failure - The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial Davis BR, Piller LB, Cutler JA, et al. Circulation 2006.113:2201-2210.

More information

ADVANCES IN MANAGEMENT OF HYPERTENSION

ADVANCES IN MANAGEMENT OF HYPERTENSION Prevalence 29%; Blacks 33.5% About 72.5% treated; 53.5% uncontrolled (>140/90) Risk for poor control: Latinos, Blacks, age 18-44 and 80,

More information

Managing Hypertension in Diabetes Sean Stewart, PharmD, BCPS, BCACP, CLS Internal Medicine Park Nicollet Clinic St Louis Park.

Managing Hypertension in Diabetes Sean Stewart, PharmD, BCPS, BCACP, CLS Internal Medicine Park Nicollet Clinic St Louis Park. Managing Hypertension in Diabetes 2015 Sean Stewart, PharmD, BCPS, BCACP, CLS Internal Medicine Park Nicollet Clinic St Louis Park Case Scenario Mike M is a 59 year old man with type 2 diabetes managed

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

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

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

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

Diabetes and Hypertension

Diabetes and Hypertension Diabetes and Hypertension William C. Cushman, MD, FAHA, FACP, FASH Chief, Preventive Medicine, Veterans Affairs Medical Center Professor, Preventive Medicine, Medicine, and Physiology University of Tennessee

More information

New Lipid Guidelines. PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: Implications of the New Guidelines for Hypertension and Lipids.

New Lipid Guidelines. PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: Implications of the New Guidelines for Hypertension and Lipids. PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN: Implications of the New Guidelines for Hypertension and Lipids Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Disclosure No relevant

More information

Understanding the importance of blood pressure control An overview of new guidelines: How do they impact daily current management?

Understanding the importance of blood pressure control An overview of new guidelines: How do they impact daily current management? Understanding the importance of blood pressure control An overview of new guidelines: How do they impact daily current management? Slides presented during CDMC in Almaty, Kazakhstan on Saturday April 12,

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

Managing Hypertension in 2016

Managing Hypertension in 2016 Managing Hypertension in 2016: Where Do We Draw the Line? Disclosure No relevant financial relationships Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine baron@medicine.ucsf.edu

More information

Hypertension. Does it Matter What Medications We Use? Nishant K. Sekaran, M.D. M.Sc. Intermountain Heart Institute

Hypertension. Does it Matter What Medications We Use? Nishant K. Sekaran, M.D. M.Sc. Intermountain Heart Institute Hypertension Does it Matter What Medications We Use? Nishant K. Sekaran, M.D. M.Sc. Intermountain Heart Institute Hypertension 2017 Classification BP Category Systolic Diastolic Normal 120 and 80 Elevated

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

Pre-ALLHAT Drug Use. Diuretics. ß-Blockers. ACE Inhibitors. CCBs. Year. % of Treated Patients on Medication. CCBs. Beta Blockers.

Pre-ALLHAT Drug Use. Diuretics. ß-Blockers. ACE Inhibitors. CCBs. Year. % of Treated Patients on Medication. CCBs. Beta Blockers. Pre- Drug Use % of Treated Patients on Medication 60 50 40 30 20 10 0 1978 Diuretics ß-Blockers ACE Inhibitors Year CCBs CCBs Beta Blockers Diuretics ACE Inhibitors 1980 1982 1984 1986 1988 1990 1992 IMS

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

Hypertension Update Warwick Jaffe Interventional Cardiologist Ascot Hospital

Hypertension Update Warwick Jaffe Interventional Cardiologist Ascot Hospital Hypertension Update 2008 Warwick Jaffe Interventional Cardiologist Ascot Hospital Definition of Hypertension Continuous variable At some point the risk becomes high enough to justify treatment Treatment

More information

Update in Hypertension

Update in Hypertension Update in Hypertension Eliseo J. PérezP rez-stable MD Professor of Medicine DGIM, Department of Medicine UCSF 20 May 2008 Declaration of full disclosure: No conflict of interest (I have never been funded

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

Management of Lipid Disorders and Hypertension: Implications of the New Guidelines

Management of Lipid Disorders and Hypertension: Implications of the New Guidelines Management of Lipid Disorders and Hypertension Management of Lipid Disorders and Hypertension: Implications of the New Guidelines Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine

More information

How clinically important are the results of the large trials in hypertension?

How clinically important are the results of the large trials in hypertension? How clinically important are the results of the large trials in hypertension? Stéphane LAURENT, MD, PhD, FESC Pharmacology Department and PARCC / INSERM U970 Hôpital Européen Georges Pompidou, Université

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

Combination Therapy for Hypertension

Combination Therapy for Hypertension Combination Therapy for Hypertension Se-Joong Rim, MD Cardiology Division, Yonsei University College of Medicine, Seoul, Korea Goals of Therapy Reduce CVD and renal morbidity and mortality. Treat to BP

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

Management of High Blood Pressure in Adults

Management of High Blood Pressure in Adults Management of High Blood Pressure in Adults Based on the Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC8) James, P. A. (2014, February 05). 2014 Guideline for Management

More information

Outcomes and Perspectives of Single-Pill Combination Therapy for the modern management of hypertension

Outcomes and Perspectives of Single-Pill Combination Therapy for the modern management of hypertension Outcomes and Perspectives of Single-Pill Combination Therapy for the modern management of hypertension Prof. Massimo Volpe, MD, FAHA, FESC, Chair of Cardiology, Department of Clinical and Molecular Medicine

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

Outcomes in Hypertensive Black and Nonblack Patients Treated With Chlorthalidone, Amlodipine, and Lisinopril JAMA. 2005;293:

Outcomes in Hypertensive Black and Nonblack Patients Treated With Chlorthalidone, Amlodipine, and Lisinopril JAMA. 2005;293: ORIGINAL CONTRIBUTION Outcomes in Hypertensive and Patients Treated With, Amlodipine, and Lisinopril Jackson T. Wright, Jr, MD, PhD J. Kay Dunn, PhD Jeffrey A. Cutler, MD Barry R. Davis, MD, PhD William

More information

State of the art treatment of hypertension: established and new drugs. Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland

State of the art treatment of hypertension: established and new drugs. Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland State of the art treatment of hypertension: established and new drugs Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland First line therapies in hypertension ACE inhibitors AT

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

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

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

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

Talking about blood pressure

Talking about blood pressure Talking about blood pressure Mrs Khan 56 BP 158/99 BMI 32 Total cholesterol 5.4 (HDL 0.8) HbA1c 43 She has been promising to do more exercise and eat more healthily for the last 2 years but her weight

More information

Masked Hypertension. Why Should We Care? Dr. Peter J. Lin Director Primary Care Initiatives - Canadian Heart Research Centre

Masked Hypertension. Why Should We Care? Dr. Peter J. Lin Director Primary Care Initiatives - Canadian Heart Research Centre Masked Hypertension Why Should We Care? Dr. Peter J. Lin Director Primary Care Initiatives - Canadian Heart Research Centre PRESENTER DISCLOSURE Faculty: Dr. Peter Lin Relationships with commercial interests:

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

Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management

Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management Jeong Bae Park, MD,PhD Dept of Med/Cardiology, Cheil General Hospital, Kwandong University College of Medicine Apr

More information

Hypertension Pharmacotherapy: A Practical Approach

Hypertension Pharmacotherapy: A Practical Approach Hypertension Pharmacotherapy: A Practical Approach Ronald Victor, MD Burns & Allen Chair in Cardiology Director, The Hypertension Center Associate Director, The Heart Institute Hypertension Center 1. 2.

More information

MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure. No relevant financial relationships. Blood Pressure and Risk

MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure. No relevant financial relationships. Blood Pressure and Risk MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure No relevant financial relationships Robert B. Baron, MD MS Professor and Associate Dean UCSF School of Medicine baron@medicine.ucsf.edu

More information

Caring for Australians with Renal Impairment. BP lowering and CVD

Caring for Australians with Renal Impairment. BP lowering and CVD Caring for Australians with Renal Impairment BP lowering and CVD Questions: Conflicts of Interest: RH, TN, HHL- no conflict VP- level II conflict Speakers fees: Abbott, Astra Zeneca, Roche, Servier Grant

More information

Update in Cardiology Pharmacologic Management of Cardiovascular Risk. Christopher C. Roe, MSN, ACNP

Update in Cardiology Pharmacologic Management of Cardiovascular Risk. Christopher C. Roe, MSN, ACNP Update in Cardiology Pharmacologic Management of Cardiovascular Risk Christopher C. Roe, MSN, ACNP Objectives 1. Verbalize understanding of new pharmacologic guidelines in the treatment of hypertension

More information

Metabolic Consequences of Anti Hypertensives: Is It Clinically Important?

Metabolic Consequences of Anti Hypertensives: Is It Clinically Important? Metabolic Consequences of Anti Hypertensives: Is It Clinically Important?,FACA,FICA,MASH,FVBWG,MISCP CONSULTANT OF CARDIOLOGY DIRECTOR OF PORT-FOUAD HOSPITAL CCU Consideration of antihypertensive agents

More information

Drug-Induced Diabetes May Not Be Harmful But Should Be Prevented. Jeffrey A. Cutler, MD, MPH

Drug-Induced Diabetes May Not Be Harmful But Should Be Prevented. Jeffrey A. Cutler, MD, MPH Drug-Induced Diabetes May Not Be Harmful But Should Be Prevented Jeffrey A. Cutler, MD, MPH Overview Focus on thiazide-like diuretics (not BB) Diuretic-induced versus diureticassociated diabetes Role of

More information

Jared Moore, MD, FACP

Jared Moore, MD, FACP Hypertension 101 Jared Moore, MD, FACP Assistant Program Director, Internal Medicine Residency Clinical Assistant Professor of Internal Medicine Division of General Medicine The Ohio State University Wexner

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

Hypertension in 2015: SPRINT-ing ahead of JNC-8. MAJ Charles Magee, MD MPH FACP Director, WRNMMC Hypertension Clinic

Hypertension in 2015: SPRINT-ing ahead of JNC-8. MAJ Charles Magee, MD MPH FACP Director, WRNMMC Hypertension Clinic Hypertension in 2015: SPRINT-ing ahead of JNC-8 MAJ Charles Magee, MD MPH FACP Director, WRNMMC Hypertension Clinic Conflits of interest? None Disclaimer The opinions contained herein are not to be considered

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

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

Management of Hypertension in Women

Management of Hypertension in Women Management of Hypertension in Women Eliseo J. Pérez-Stable MD Professor of Medicine DGIM, Department of Medicine July 1, 2013 Declaration of full disclosure: No conflict of interest (I have never been

More information

2/10/2014. Hypertension: Highlights of Hypertension Guidelines: Making the Most of Limited Evidence. Issues with contemporary guidelines

2/10/2014. Hypertension: Highlights of Hypertension Guidelines: Making the Most of Limited Evidence. Issues with contemporary guidelines Hypertension: 214 Highlights of Hypertension Guidelines: Making the Most of Limited Evidence Michael A, Weber, MD Editor-in-Chief, The Journal of Clinical Hypertension, Professor of Medicine, Division

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

STANDARD treatment algorithm mmHg

STANDARD treatment algorithm mmHg STANDARD treatment algorithm 130-140mmHg (i) At BASELINE, If AVERAGE SBP 1 > 140mmHg If on no antihypertensive drugs: Start 1 drug: If >55 years old / Afro-Caribbean: Calcium channel blocker (CCB) 2 If

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

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

Hypertension in the Elderly. John Puxty Division of Geriatrics Center for Studies in Aging and Health, Providence Care

Hypertension in the Elderly. John Puxty Division of Geriatrics Center for Studies in Aging and Health, Providence Care Hypertension in the Elderly John Puxty Division of Geriatrics Center for Studies in Aging and Health, Providence Care Learning Objectives Review evidence for treatment of hypertension in elderly Consider

More information

Blood pressure treatment target in diabetes. Should it be <130 mmhg?

Blood pressure treatment target in diabetes. Should it be <130 mmhg? Blood pressure treatment target in diabetes Should it be

More information

New Antihypertensive Strategies to Improve Blood Pressure Control

New Antihypertensive Strategies to Improve Blood Pressure Control New Antihypertensive Strategies to Improve Blood Pressure Control Antonio Coca, MD, PhD,, FRCP, FESC Hypertension and Vascular Risk Unit Department of Internal Medicine. Hospital Clínic (IDIBAPS) University

More information

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

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

Hypertension (JNC-8)

Hypertension (JNC-8) Hypertension (JNC-8) Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 17, 2018, presented by Ezra Levy, Pharm.D.! The 8 th Joint

More information

Difficult-to-Control & Resistant Hypertension. Anthony Viera, MD, MPH, FAHA Professor and Chair

Difficult-to-Control & Resistant Hypertension. Anthony Viera, MD, MPH, FAHA Professor and Chair Difficult-to-Control & Resistant Hypertension Anthony Viera, MD, MPH, FAHA Professor and Chair Objectives Define resistant hypertension Discuss evaluation strategy for patient with HTN that appears difficult

More information

GOING BEYOND HYPERTENSION CONTROL

GOING BEYOND HYPERTENSION CONTROL From bench to practice: hypertension control GOING BEYOND HYPERTENSION CONTROL Prof. Dr. Maria DOROBANTU, FESC,FACC CAROL DAVILA UNIVERSITY OF MEDICINE OF BUCHAREST EMERGENCY HOSPITAL OF BUCHAREST, CARDIOLOGY

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

Hypertension Management Focus on new RAAS blocker. Disclosure

Hypertension Management Focus on new RAAS blocker. Disclosure Hypertension Management Focus on new RAAS blocker Rameshkumar Raman M.D Endocrine Associates of The Quad Cities Disclosure Speaker bureau Abbott, Eli Lilly, Novo Nordisk, Novartis, Takeda, Merck, Solvay

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

Disclosures. Hypertension: Nationwide Dilemma. Learning Objectives. What s Currently Recommended? Specific Concerns 3/9/2012

Disclosures. Hypertension: Nationwide Dilemma. Learning Objectives. What s Currently Recommended? Specific Concerns 3/9/2012 How Should We ACCOMPLISH Good Blood Pressure Control In Our VETS? Disclosures No conflicts of interest to disclose Updates in the Management of HypertensionIn the Elderly Antoine T. Jenkins, Pharm.D.,

More information

VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION

VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION Dr Catherine BESEME Paris 6 th December 2005 6 th International Congress of Bangladesh Society of Medicine Hypertension is a risk factor at the source, with

More information

Is there a mechanism of interaction between hypertension and dyslipidaemia?

Is there a mechanism of interaction between hypertension and dyslipidaemia? Is there a mechanism of interaction between hypertension and dyslipidaemia? Neil R Poulter International Centre for Circulatory Health NHLI, Imperial College London Daegu, Korea April 2005 Observational

More information

JNC-8. (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines

JNC-8. (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines JNC-8 (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines Derrick Sorweide, DO Assistant Professor of Family Medicine,

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

Management of The Patients with Hypertension and High Risk Cardiovascular Disease

Management of The Patients with Hypertension and High Risk Cardiovascular Disease Management of The Patients with Hypertension and High Risk Cardiovascular Disease Songsak Kiatchoosakun, MD. Cardiology, Medicine Khon Kaen University CVD and Hypertension: Worldwide Morbidity and Mortality

More information

First line treatment of primary hypertension

First line treatment of primary hypertension First line treatment of primary hypertension Dr. Vijaya Musini Assistant Professor, Dept. Anesthesiology, Pharmacology and Therapeutics Manager, Drug Assessment Working Group Therapeutics Initiative Editor,

More information

Hypertension Controversies: SPRINTing to New Goals

Hypertension Controversies: SPRINTing to New Goals Hypertension Controversies: SPRINTing to New Goals Diana Isaacs, PharmD, BCPS, BC-ADM, CDE Clinical Pharmacy Specialist Cleveland Clinic Lauren Wolfe, PharmD Primary Care Clinical Specialist Cleveland

More information

Management of Hypertension

Management of Hypertension Clinical Practice Guidelines Management of Hypertension Definition and classification of blood pressure levels (mmhg) Category Systolic Diastolic Normal

More information

Difficult to Treat Hypertension

Difficult to Treat Hypertension Difficult to Treat Hypertension According to Goldilocks JNC 8 Blood Pressure Goals (2014) BP Goal 60 years old and greater*- systolic < 150 and diastolic < 90. (Grade A)** BP Goal 18-59 years old* diastolic

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

Rationale for the use of Single Pill Combination. Yong Jin Kim, MD Seoul National University Hospital

Rationale for the use of Single Pill Combination. Yong Jin Kim, MD Seoul National University Hospital Rationale for the use of Single Pill Combination Yong Jin Kim, MD Seoul National University Hospital Unmet Need of Hypertension Treatment Hypertension # 1 Risk Factor for Global Mortality 0 1 2 3 4 5 6

More information

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

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

More information

RENAAL, IRMA-2 and IDNT. Three featured trials linking a disease spectrum IDNT RENAAL. Death IRMA 2

RENAAL, IRMA-2 and IDNT. Three featured trials linking a disease spectrum IDNT RENAAL. Death IRMA 2 Treatment of Diabetic Nephropathy and Proteinuria Background End stage renal disease is a major cause of death and disability among diabetics BP reduction is important to slow the progression of diabetic

More information

BLOOD PRESSURE-LOWERING TREATMENT

BLOOD PRESSURE-LOWERING TREATMENT BLOOD PRESSURE-LOWERING TRIALS NUMBER OF PARTICIPANTS NUMBER OF PERCENTAGE OF MEAN AGE MEAN - (YEARS) TRIALS WITH ANALYSIS BY GENDER N, (%) 69,473 28,008 40.3% 70.2 3.2 3/5 (60%) APPENDIX 2 1 BLOOD PRESSURE-LOWERING

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

Hypertension Management Controversies in the Elderly Patient

Hypertension Management Controversies in the Elderly Patient Hypertension Management Controversies in the Elderly Patient Juan Bowen, MD Geriatric Update for the Primary Care Provider November 17, 2016 2016 MFMER slide-1 Disclosure No financial relationships No

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