8/19/2016. No Conflicts. I struggled with everything cardiac in nursing school.

Transcription

1 Cindy Weston, DNP, RN, CCRN, CNS CC, FNP BC Assistant Professor, Texas A&M Health Science Center College of Nursing Describe and define epidemiology and pathophysiology of hypertension Differentiate JNC8 and the SPRINT Trial recommendations in the treatment of hypertension Review pharmacologic and non pharmacologic treatments for hypertension Outline the mechanism of action, efficacy and safety issues in the categories of antihypertensive medications Apply current evidence and guidelines to the appropriate prescription of antihypertensive medications No Conflicts I struggled with everything cardiac in nursing school. 1

2 Booth, J. (1977). Section of the history of medicine. Procedures from the Royal Society of Medicine, 70, % US adults > 18 year old 6% undiagnosed 47.5% Uncontrolled Health disparity black women Overall Death rate: 18.8 per 1000 per year Cost = $46.4 Billion $274 billion Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28 e

3 Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), HDS 4Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high HDS 5 Reduce the proportion of persons in the population with hypertension HDS 9Increase the proportion of adults with prehypertension who meet the recommended guidelines HDS 10 Increase the proportion of adults with hypertension who meet the recommended guidelines HDS 11 Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure HDS 12 Increase the proportion of adults with hypertension whose blood pressure is under control HDS 25 Increase the proportion of patients with hypertension in clinical health systems whose blood pressure is under control objectives/topic/heart disease and stroke/objectives 3

4 Mediterranean (low evidence) DASH (high evidence) Reduce dietary Sodium (high evidence) Exercise Blood Pressure If DM or 3 risk factors < 6 7/2 3 mmhg Healthy < 2 3/1 2 mmhg Lipids No change < 5 6/3 mmhg < LDL 11mg/dL <HDL 4 mg/dl No change TG Lowers BP 1150mg/d < 3 4/1 2 mmhg < 2 5/1 4 mmhg (high evidence) No change < LDL 2.5 mg/dl < non HDL 6 mg/dl No change TG No change HDL (moderate evidence) EXERCISE: at least 12 weeks duration, 3 to 4 sessions per week, lasting on average 40 minutes per session, and involving moderate to vigorous intensity physical activity. Strength of evidence: High Eckel, R.H.. et al. (2013) AHA/ACC Guideline on lifestyle management to reduce cardiovascular risk. Circulation. Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15),

5 Diuretics ACEI: Angiotensin Converting Enzyme Inhibitors ARB: Angiotensin Receptor Blockers Calcium Channel Blockers Beta Blockers Alpha Blockers Central Acting Vasodilators Potassium Channel Activators Diuretics Drug Class Drug Dose Interval Benzophenone Chlorthalidone (Hygroton) mg Daily Benzothiadiazine HCTZ mg Daily Indapamide (Lozol) mg Daily Quinazolinones Metolazone (Zaroxolyn) mg Daily 5

6 ACEIs Renin Inhibitor ARBs Aldosterone Antagonist Captopril (Capoten) Lisinopril (Zestril, Prinivil) Enalapril (Vasotec) Ramipril (Altace) Fosinopril (Monopril) Benazepril (Lotensin) Quinapril (Accupril) Trandolapril (Mavik) Perindopril (Aceon) Losartan (Cozaar) Candesartan (Atacand) Valsartan (Diovan) Telmisartan (Micardis) Irbesartan (Avapro) Omesartan (Benicar) Eprosartan (Teveten) 6

7 Aliskiren (Tekturna) CYP3A4! Avoid grapefruit juice, azoles Dihydropyridines Non dihydropyridines Amlodipine (Norvasc) Verapamil (Isoptin, Calan) Felodipine (Plendil) Diltiazem (Cardizem, Dilacor) Isradipine (DynaCirc) Nifedipine (Procardia XL, AdalatCC) Nisoldipine (Sular) Avoid grapefruit juice Metoprolol (Lopressor, Toprol) Atenolol (Tenormin) Bisoprolol (Zebeta) Esmolol (Brevibloc) Carvedilol (Coreg) Propranolol (Inderal) Labetalol (Trandate) Nadolol (Corgard) Nebivolol (Bystolic) 7

8 Terazosin (Hytrin) Prazosin (Minipress) Doxazosin (Cardura) Phentolamine (Regitine) Clonidine Methyldopa Hydralazine Sodium Nitroprusside Minoxidil (Loniten) Diazoxide (Proglycem) 8

9 1977 JNC JNC JNC JNC JNC JNC 6 AHA/ACC/CDC advisory algorithm 2013 ASH/ISH 2013 Canadian 2011 British 2012 European JNC 7 (delayed wait for ALLHAT) 2014 JNC 8 Chopra,. & Nanda, N. (2013). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers. Study Yr n Criteria Result Conclusion HOT Hypertension Optimization Treatment Study ALLHAT Antihypertensive and Lipidlowering Treatment to Prevent Heart Attack Trial ACCOMPLISH Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension HYVET Hypertension in the Very Elderly Trial ACCORD Action to Control Cardiovascular Risk in Diabetes AASK African American Study of Kidney Disease and Hypertension Trial ,790 Age HTN DBP ,357 HTN + 1 risk factor (1/3 DM) ,000 HTN, High CV risk , years old , year old DM II x 10 yrs with CAD or 2+ RF ,094 Black, HTN, nephrosclerosis, NO DM 3 groups: DBP < 80 DBP <85 DBP <90 All received Felodipine + 4 groups: Chlorthalidone Lisinopril Amlodipine Doxazosin **stopped CHF/Stroke 2 groups: Benazepril + Amlodipine Benazepril + HCTZ 2 groups Indapamide SR Placebo 2 groups Goal SBP < 140 mmhg Goal SBP < 120 mmhg 3 groups Metoprolol Ramipril Amlodipine Lowest CV event DBP = 82.6 mmhg, Lowest mortality DBP = 86.5 mmhg No difference in primary outcome or mortality Less CV events (9.6 % vs 11.8%) with ACEI/CCB combo Lower BP associated with risk reduction No difference in CV events No difference in GFR BUT ACEI more effective in slowing decline of GFR than BB or CCB DBP < 90 mmhg No difference in CV event or stroke ACEI/CCB combo in thin, high risk Small decrease in stroke with intensive control group ACEI best, Lower BP may be benefit with proteinuria 9

10 BP Classification Treatment Age JNC 7 JNC 8 Normal 120/80 PreHTN Stage Stage HTN < /90 150/90 DM RD /80 140/90 E BP Goal JNC JNC ASH/ISH 2013 ESC/ESH 2013 CHEP 2013 Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90 Age <140/90 <150/90 <140/90 <140/90 <140/90 Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90 Diabetes <130/80 <140/90 <140/90 <140/85 <130/80 CKD <130/80 <140/90 <140/90 <130/90 <140/90 Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9),

11 JNC Non black Thiazide No DM/CKD Black No DM/CKD Diabetes Without CKD Thiazide ACEI, ARB, CCB, BB, Thiazide JNC Thiazide, ACEI, ARB, CCB Thiazide CCB Thiazide, ACEI, ARB, CCB ASH/ISH 2013 < 60 ACEI, ARB > 60 CCB, Thiazide Thiazide CCB ACEI, ARB, CCB, Thiazide ESC/ESH 2013 Thiazide, ACEI, ARB, CCB, BB Thiazide, ACEI, ARB, CCB, BB ACEI, ARB CHEP 2013 Thiazide, ACEI, ARB (BB if < 60) Thiazide, ARB (BB if < 60) ACEI, ARB, CCB, Thiazide CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Prospective Randomized Trial Intensive BP control N= GROUPS= goal SBP < 120 vs SBP < 140 Overall mortality decreased 27% 4 5 agents to achieve goal Increased side effects, orthostasis, low K+, CrCl No DM! No frail elderly 11

12 Rest 5 minutes Took 3 readings at 2 minute intervals Omron 907XL $ Correlated with ambulatory BP measurements NSAID use Belief System Medication Adherence Medication Affordability 12

13 Home Blood Pressure Monitoring Self Titration Patient Selection BP Goals: < 140/90 vs < 120/80 Automated Office BPs Patient Centered Care Self Titration in select populations Facilitate healthy lifestyle modification QUESTIONS?? 13

14 Eckel, RH, et al. (2013) AHA/ACC guideline on lifestyle management to reduce cardiovascular risk, Circulation. Salvo, M. & White CM (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Egan, B., Li, J., Hutchison, F. & Ferdinand, K. (2014). Hypertension in the United States : Progress toward Healthy People 2020 Goals. Circulation. Caboral Stevens, M. & Rosario Sim, M. (2014). Review of the Joint National Committee s recommendations in the management of hypertension. JPN, 10(5), James, P. et al. (2014) Evidence based guideline management of high blood pressure in adults: Report from the panel members appointed to the eighth Joint National Committee (JNC8). JAMA, 311(5), Wright, JT, et al. (2015). A randomized trial of intensive versus standard blood pressure control. NEJM 373, Leung AA, et al. Hypertension Canada s 2016 CHEP Guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention and treatment of hypertension. Can J Cardiol. 2016; 32: Healthy People 2020 Heart Disease and Stroke. objectives/topic/heart diseaseand stroke/objectives. Accessed August 16, Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28 e292. Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), Chopra,. & Nanda, N. (2013). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. (2008). Treatment of hypertension in patients 80 years of age or older. NEJM;358(18): B. Cushman WC, Evans GW, Byington RP, et al; (2010). ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. NEJM;362(17): Chobanian AV. Bakris GL. Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; (2003). National High Blood Pressure Education Program Coordinating Committee The JNC 7 report. JAMA. 289(19):256O