Summary, Scope, BP Classification, BP thresholds and Targets

Transcription

1 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ PCNA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Summary, Scope, BP Classification, BP thresholds and Targets American College of Medical Quality January 17, 2018 Don Casey MD, MPH, MBA, FACP, FAHA, FAAPL, DFACMQ President-elect, American College of Medical Quality Chief of Clinical Affairs, Medecision Rush Medical College, Jefferson College of Population Health Conflicts of interest: None

2 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Background Clinical practice guidelines (CPGs) well-suited for care of patients with high BP High BP very prevalent Can is expensive (individual and society) Large variation in clinical practice patterns Substantial evidence for recommendations In 1977, NHLBI released first CPG for detection and management of high BP In subsequent years, NHLBI sponsored a series of JNC high BP CPGs In 2013, NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA

3 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Background Initiative led and managed by: American College of Cardiology American Heart Association Major professional organizations invited to partner Nine accepted invitation American Academy of Physician Assistants American College of Preventive Medicine American Geriatrics Society American Pharmacists Association American Society of Hypertension American Society of Preventive Cardiology Association of Black Cardiologists National Medical Association Preventive Cardiovascular Nurses Association

4 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults In 2014, a 21 member multidisciplinary Writing Committee appointed to develop the guideline: Cardiologists, epidemiologists, internists, endocrinologist, geriatrician, nephrologist, neurologist, nurse, pharmacist, physician assistant, 2 lay/patient representatives Representation for each of the 11 participating professional organizations No Writing Committee member had a relevant relationship with industry Wilbert S. Aronow, MD, FACC, FAHA Donald E. Casey, Jr, MD, MPH, MBA, FAHA Karen J. Collins, MBA Cheryl Dennison Himmelfarb, RN, ANP, PhD Sondra M. DePalma, MHS, PA-C, CLS, AACC Samuel Gidding, MD, FACC, FAHA Kenneth A. Jamerson, MD Daniel W. Jones, MD, FAHA Eric J. MacLaughlin, PharmD Paul Muntner, PhD Writing Committee Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair Bruce Ovbiagele, MD, MSc, MAS, MBA FAHA Sidney C. Smith, Jr, MD, MACC, FAHA Crystal C. Spencer, JD Randall S. Stafford, MD, PhD Sandra J. Taler, MD, FAHA Randal J. Thomas, MD, MS, FACC, FAHA Kim A. Williams, Sr, MD, MACC, FAHA Jeff D. Williamson, MD, MHS Jackson T. Wright, Jr, MD, PhD

5 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Focus on adults Scope of the Guideline Intended to be: Resource for clinical and public health communities Comprehensive (therefore long) but easy to use (each section in a stand alone format) Provide recommendations for: Classification of BP Diagnosis, prevention, evaluation, and treatment of hypertension Nonpharmacological interventions Antihypertensive drug therapy Management of hypertension in patients with comorbidities, special groups and different clinical situations Strategies to improve hypertension treatment and control

6 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Guideline Review and Approval Process Peer review: Five ACC/AHA official reviewers Nine organizational reviewers representing the partner professional organizations 38 content reviewers with special expertise in high BP Writing Committee responded to every reviewer comment Final document approved by ACC/AHA and nine partner professional organizations

7 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Scope of the Guideline: Content 15 sections that provide 106 Recommendations Typical section format List of recommendations, supported by: Class of Recommendation (COR), indicating the strength of the recommendation Level of Evidence (LOE), indicating the quality of the supporting evidence Principal references supporting each recommendation Synopsis and recommendation-specific supportive text Details of principal and other references in 448 supplementary Evidence Tables Complete list of references accompanying each section

8 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Class (Strength) of Recommendation Level (Quality) of Evidence I Strong: Benefit >>> Risk A High quality evidence from >1 RCT or meta-analysis IIa Moderate: Benefit >> Risk B-R Moderate quality evidence from 1 RCT or meta-analysis (Randomized) IIb Weak: Benefit Risk B-NR Moderate quality evidence from 1 well designed/executed non-randomized, observational or registry studies or metaanalyses of such studies (Nonrandomized) III: No Benefit Moderate: Benefit = Risk C-LD Moderate quality evidence from randomized, observational or registry studies, meta-analyses of such studies, or physiological/mechanistic studies in humans (Limited Data) III: Harm Strong: Risk > Benefit C-EO Consensus of expert opinion (Expert Opinion)

9 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults BP measurement New BP classification system Selected Highlights New approach to treatment decisions for management of hypertension Lower targets for BP during treatment of hypertension Strategies to improve BP control during treatment of hypertension

10 2017 Hypertension Guideline Classification of BP

11 Recommendation Recommendation for Definition of High Blood Pressure (BP) COR LOE Recommendations I B-NR 1. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension in order to prevent and treat high BP

12 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults BP Classification (JNC 7 and ACC/AHA Guidelines) SBP DBP JNC ACC/AHA <120 and <80 Normal BP Normal BP and < or or or 100 Prehypertension Prehypertension Stage 1 hypertension Stage 2 hypertension Elevated BP Stage 1 hypertension Stage 2 hypertension Stage 2 hypertension Blood Pressure should be based on an average of 2 careful readings on 2 occasions Adults with SBP or DBP in two categories should be designated to the higher BP category

13 Prevalence of Hypertension Based on 2 SBP/DBP Thresholds* SBP/DBP 130/80 mm Hg or Self-Reported Antihypertensive Medication SBP/DBP 140/90 mm Hg or Self- Reported Antihypertensive Medication Overall, crude 46% 32% Men (n=4717) Women (n=4906) Men (n=4717) Women (n=4906) Overall, age-sex adjusted 48% 43% 31% 32% Age group, y % 19% 11% 10% % 44% 33% 27% % 63% 53% 52% % 75% 64% 63% % 85% 71% 78% Race-ethnicity Non-Hispanic White 47% 41% 31% 30% Non-Hispanic Black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32% The prevalence estimates have been rounded to the nearest full percentage. *130/80 and 140/90 mm Hg in 9623 participants ( 20 years of age) in NHANES BP cutpoints for definition of hypertension in the present guideline. BP cutpoints for definition of hypertension in JNC 7. Adjusted to the 2010 age-sex distribution of the U.S. adult population. BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.

14 Distribution of US adults into BP Categories NHANES Prevalence of hypertension: 45.6% Normal BP Elevated BP Muntner et. al., Journal of the American College of Cardiology 2017 (in press) Muntner, et. al., Circulation 2017 (in press)

15 2017 Hypertension Clinical Practice Guidelines BP and CVD Risk

16 Coexistence of Hypertension and Related Chronic Conditions COR I LOE B-NR Recommendation for Coexistence of Hypertension and Related Chronic Conditions Screening for and management of other modifiable CVD risk factors are recommended in adults with hypertension.

17 IHD Mortality (Floating Absolute Risk and 95% CI) IHD Mortality (Floating Absolute Risk and 95% CI) Blood Pressure (BP) and Cardiovascular Disease (CVD) Risk Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) 256 Age at risk: years 256 Age at risk: years years years years years years years years years Usual SBP (mm Hg) Usual DBP (mm Hg) Lewington et al. Lancet. 2002;360:

18 CVD Risk Factors Common in Patients With Hypertension Modifiable Risk Factors* Current cigarette smoking, secondhand smoking Diabetes mellitus Dyslipidemia/hypercholesterolemia Overweight/obesity Physical inactivity/low fitness Unhealthy diet Relatively Fixed Risk Factors CKD Family history Increased age Low socioeconomic/educational status Male sex Obstructive sleep apnea Psychosocial stress *Factors that can be changed and, if changed, may reduce CVD risk. Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress). CKD indicates chronic kidney disease; and CVD, cardiovascular disease.

19 2017 Hypertension Guideline Measurement of BP

20 Accurate Measurement of BP in the Office COR I LOE C-EO Recommendation for Accurate Measurement of BP in the Office For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP.

21 Checklist for Accurate Measurement of BP Key Steps for Proper BP Measurements Step 1: Properly prepare the patient. Step 2: Use proper technique for BP measurements. Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension. Step 4: Properly document accurate BP readings. Step 5: Average the readings. Step 6: Provide BP readings to patient.

22 Out-of-Office and Self-Monitoring of BP COR I LOE A SR Recommendation for Out-of-Office and Self- Monitoring of BP Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. SR indicates systematic review.

23 BP Patterns Based on Office and Out-of-Office Measurements Office/Clinic/Healthcare Setting Home/Nonhealthcare/ ABPM Setting Normotensive No hypertension No hypertension Sustained hypertension Masked hypertension White coat hypertension Hypertension No hypertension Hypertension Hypertension Hypertension No hypertension ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.

24 2017 Hypertension Guideline Nonpharmacological Interventions

25 Nonpharmacological Interventions COR I I I I LOE A A A A Recommendations for Nonpharmacological Interventions Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension. Sodium reduction is recommended for adults with elevated BP or hypertension. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.

26 Nonpharmacological Interventions (cont.) COR I I LOE A A Recommendations for Nonpharmacological Interventions Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively. *In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

27 Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* Weight loss Healthy diet Reduced intake of dietary sodium Enhanced intake of dietary potassium Nonpharmacologi -cal Intervention Dose Weight/body fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. DASH dietary pattern Dietary sodium Dietary potassium Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. Aim for mg/d, preferably by consumption of a diet rich in potassium. Approximate Impact on SBP Hypertension Normotension -5 mm Hg -2/3 mm Hg -11 mm Hg -3 mm Hg -5/6 mm Hg -2/3 mm Hg -4/5 mm Hg -2 mm Hg *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Resources: Your Guide to Lowering Your Blood Pressure With DASH How Do I Make the DASH? Available at: Top 10 Dash Diet Tips. Available at:

28 Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.) Physical activity Moderation in alcohol intake Nonpharmacologica l Intervention Aerobic Dynamic resistance Isometric resistance Alcohol consumption Dose min/wk 65% 75% heart rate reserve min/wk 50% 80% 1 rep maximum 6 exercises, 3 sets/exercise, 10 repetitions/set 4 2 min (hand grip), 1 min rest between exercises, 30% 40% maximum voluntary contraction, 3 sessions/wk 8 10 wk In individuals who drink alcohol, reduce alcohol to: Men: 2 drinks daily Women: 1 drink daily Approximate Impact on SBP Hypertension Normotension -5/8 mm Hg -2/4 mm Hg -4 mm Hg -2 mm Hg -5 mm Hg -4 mm Hg -4 mm Hg -3 mm *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. In the United States, one standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

29 2017 Hypertension Guideline Treatment of High BP

30 BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension COR I I LOE SBP: A DBP: C-EO C-LD Recommendations for BP Treatment Threshold and Use of Risk Estimation* to Guide Drug Treatment of Hypertension Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher. Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher. *ACC/AHA Pooled Cohort Equations ( Risk-Estimator/) to estimate 10-year risk of atherosclerotic CVD.

31 Age-Related Issues COR LOE I A Recommendations for Treatment of Hypertension in Older Persons Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults ( 65 years of age) with an average SBP of 130 mm Hg or higher. IIa C-EO For older adults ( 65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.

32 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults BP Thresholds for Treatment SBP DBP <120 and <80 CVD Risk/other circumstances N/A Recommended Treatment Healthy Lifestyle and < or or or or 90 N/A No CVD/10-yr ASCVD risk <10% CVD/10-year ASCVD risk 10% Diabetes or CKD Age 65 years N/A Nonpharmacological therapy Nonpharmacological therapy Antihypertensive drug therapy (plus nonpharmacological therapy) Blood Pressure should be based on an average of 2 careful readings on 2 occasions Adults with SBP or DBP in two categories should be designated to the higher BP category

33 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults High BP Treatment Target SBP DBP <120 and <80 CVD Risk N/A Recommended Treatment N/A and < or or or or N/A No CVD and 10-year ASCVD risk <10% Clinical CVD or 10-year ASCVD risk 10% Diabetes or CKD N/A Age 65 years N/A SBP <130 and DBP <80 mm Hg SBP <130 mm Hg

34 Follow-Up After Initial BP Evaluation COR LOE I B-R I B-R I B-R Recommendations for Follow-Up After Initial BP Elevation Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months. Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month. Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in 1 month.

35 Summary 2013: NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA 2017 ACC/AHA BP CPG Comprehensive report 15 sections: 106 recommendations, each characterized by COR and LOE Extensive referencing and provision of 448 supplementary evidence tables Selected areas of interest: BP measurement New system for BP classification New thresholds for initiation of antihypertensive drug therapy In stage1 hypertension, use of ASCVD risk estimation to determine whether to treat with: Nonpharmacological therapy alone ( low risk patients) Antihypertensive drug therapy, in addition to nonpharmacological therapy ( high risk patients) New target for BP control during treatment of hypertension ACC/AHA partnered with nine professional organizations to sponsor new BP CPG 2014: 21 member multidisciplinary Writing Committee charged to develop the CPG

36 Thank You Additional details: Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension /HYP J Am Coll Cardiol. 2017; :