THE IMPACT OF HYPERTENSION GUIDELINES. Daniel Lackland

THE IMPACT OF HYPERTENSION GUIDELINES Daniel Lackland

Disclosures Member of NHLBI Risk Assessment Workgroup Member of 2014 Hypertension Guidelines (JNC 8) Member of Evidence Rating Committee for ACC/AHA Hypertension Guidelines No financial disclosures

Objectives To describe the population risk of elevated blood pressure To describe the evidence and impact of lowering of elevated blood pressure To describe the process and considerations of target blood pressures for clincal practice guidelines.

Stroke. 45(1):315-53, 2014 Stroke. 45(1):315-53, 2014. 4

EFFECT OF INTENSIVE BP REDUCTION ON THE RISK OF STROKE Stroke Study HOT, 1998 Adding UKPDS-38, 1998 Adding ABCD (H), 2000 Adding AASK, 2002 Adding ABCD (N), 2002 Adding JATOS, 2008 Adding Cardio-Sis, 2009 Adding ACCORD BP, 2010 Adding VALISH, 2010 Adding HOMED-BP, 2012 Adding SPS3, 2013 Adding Wei et al., 2013 Adding SPRINT, 2015 Cumulative estimate Random effects model Odds Ratio O R 95%-Cl 1.065 [0.832; 1.363] 0.793 [0.419; 1.504] 0.834 [0.516; 1.348] 0.864 [0.619; 1.204] 0.781 [0.534; 1.142] 0.855 [0.632; 1.158] 0.823 [0.610; 1.110] 0.770 [0.578; 1.024] 0.766 [0.591; 0.992] 0.800 [0.627; 1.022] 0.811 [0.665; 0.990] 0.787 [0.648; 0.955] 0.802 [0.676; 0.952] 0.802 [0.676; 0.952] Z=2.523; p=0.011 I 2 39.7%; p=.069 0. 0.7 More 5 Intensive Better 5 1. 0 1. Less Intensive 5 Better Verdecchia et al. Hypertension. 2016;68:642-653

Systolic and Diastolic Treatment Levels by Guidelines Report Systolic Blood Pressure Diastolic Blood Pressure JNC I No Systolic Level Identified 90 mmhg JNC II No Systolic Level Identified 90 mmhg JNC III 160 mmhg 90 mmhg JNC IV 160 mmhg 90 mmhg JNC V 140 mmhg 90 mmhg JNC VI 140 mmhg 90 mmhg JNC 7 140 mmhg 90 mmhg JNC 8 Panel 150 mmhg 90 mmhg

Population-Based Strategy SBP Distributions After Intervention Before Intervention Reduction in BP JAMA. 2003;289:2560-2572 Reduction in SBP mmhg 2 3 5 % Reduction in Mortality Stroke CHD Total 6 4 3 8 5 4 14 9 7

Median and 90 th Percentile Systolic BP Declined in 30-59 years 4.5 4.0 3.5 3.0 2.5 2.0 Figure 5c: Smoothed weighted frequency distribution, median, and 90th percentile of SBP: US 1959-2010, age 30-59 NHES (1959-1962) NHANES I (1971-1975) NHANES II (1976-1980) NHANES III (1988-1994) 1.5 1.0 0.5 0.0 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 Stroke. 45(1):315-53, 2014 2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. 9

Median and 90 th Percentile Systolic BP Declined in 60-74 years 4.5 4.0 3.5 3.0 2.5 2.0 Figure 5d: Smoothed weighted frequency distribution, median, and 90th percentile of SBP: US 1959-2010, age 60-74 NHES (1959-1962) NHANES I (1971-1975) NHANES II (1976-1980) NHANES III (1988-1994) 1.5 1.0 0.5 0.0 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 Stroke. 45(1):315-53, 2014 2013Stroke. Stroke. 45(1):315-53, 2014 45(1):315-53, 2014 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. 10

Actuaries Report VA Trials JNC I JNC III JNC V JNC 7 JNC II JNC IV JNC VI

Age-Adjusted Death Rates for Cerebrovascular Disease by Year United States, 1900-2010 Rates per 100,000 population, standardized to the U.S. 2000 standard population Diseases were classified to the International Classification of Disease codes in use at the time the deaths were reported. 2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. 12 Stroke. 45(1):315-53, 2014

Mean Systolic Blood Pressure (SBP) by Time Period NHANES I-IV TABLE 1 YEAR SBP (Hg) 1960-62 131 mm 1971-74 129 mm 1976-81 126 mm 1988-91 119 mm 1988-94 121 mm 1999-04 123 mm 2001-08 122 mm Stroke. 45(1):315-53, 2014 2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. 13

Mean and 90 th Percentile Systolic Blood Pressure by Time Period and Age Group 18 29 years 30 59 years 60 74 years Median 90 th Percentile Median 90 th Percentile Median 90 th Percentile 1960-1962 119 mmhg 137 mmhg 127 mmhg 155 mmhg 148 mmhg 188 mmhg 2001-2008 113 mmhg 126 mmhg 118 mmhg 138 mmhg 129 mmhg 156 mmhg

Age-adjusted Deaths per 100,000 46 44 42 40 38 36 34 32 30 Source: NVSS. Stroke: I60-I69 US Age-Adjusted Stroke Mortality Rates 2007-2015 Actual vs. 20% Impact Goal Scenario Actual 20% Target Scenario 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

JAMA. 2013;310(7):699-705. Select the subtitle text box above, copy, and paste it on to the slide that requires a subtitle Horizontal position setting for subtitle is 0.5" Vertical position setting for subtitle is 1.35" Keep subtitle to one line of text Follow these subtitle placement guidelines to ensure consistent positioning throughout the presentation 17

18 KPNC NCQA HEDIS Control Rate vs. National and California Rates

Falling CV Morbidity and Mortality - KPNC Since Year 2000: 30% reduction in mortality from CVD 42% reduction in mortality from stroke Sidney S, Jaffe M, Nguyen-Hyunha M, Kushi L, Young J, Sorel M, Selby J, Go A. Closing the Gap Between Cardiovascular and Cancer Mortality in an Integrated Health Care Delivery System, 2000-2008: The Kaiser Permanente Experience. Circulation 2011; 124: A13610 19

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 Writing Committee Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair

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. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults ACC/AHA Guideline Methodology Active participation of all Writing Committee members Comprehensive structured review of the literature Four questions referred to independent Evidence Review Committee for conduct of a systematic review and meta-analysis Evidence Review Committee David M. Rebouissin, PhD, Chair Norinna B. Allen, PhD, MPH, FAHA Edgar (Pete) R Miller III, PhD, MD Michael E. Griswold, PhD Tamar Polonsky, MD, MSCI Eliseo Guallar, MD Angela M Thompson-Paul, PhD, MSPH Yuling Hong, MD, MSc, PhD Suma Vupputuri, PhD, MPH, FAHA Daniel T Lackland, DrPH, FAHA, FASH

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Number Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) formatted Questions 1 Is there evidence that self-directed monitoring of BP and/or ambulatory BP monitoring are superior to office-based measurement of BP by a healthcare worker for 1) preventing adverse outcomes for which high BP is a risk factor and 2) achieving better BP control? 2 What is the optimal target for BP lowering during antihypertensive therapy in adults? 3 In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms? 4 In adults with hypertension, does initiating treatment with antihypertensive pharmacological monotherapy versus initiating treatment with 2 drugs (including fixed-dose combination therapy), either of which may be followed by the addition of sequential drugs, differ in comparative benefits and/or harms on specific health outcomes? ERC determined data insufficient to answer quest

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 III: No Benefit III: Harm Weak: Benefit Risk Moderate: Benefit = Risk Strong: Risk > Benefit B-NR C-LD Moderate quality evidence from 1 well designed/executed non-randomized, observational or registry studies or meta-analyses of such studies (Nonrandomized) Moderate quality evidence from randomized, observational or registry studies, meta-analyses of such studies, or physiological/mechanistic studies in humans (Limited Data) C-EO Consensus of expert opinion (Expert Opinion)

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Guideline Content 15 sections that provide 106 Recommendations Typical section format List of recommendations Supported by principal references Details of principal and other references in Data Supplement tables Synopsis and recommendation-specific supportive text Complete list of section-specific references accompanying each section

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

Blood Pressure (BP) and Cardiovascular Disease (CVD) Risk Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) 256 Age at risk: 80-89 years 256 Age at risk: 80-89 years IHD Mortality (Floating Absolute Risk and 95% CI) 128 64 32 16 8 4 2 1 70-79 years 60-69 years 50-59 years 40-49 years IHD Mortality (Floating Absolute Risk and 95% CI) 128 64 32 16 8 4 2 1 70-79 years 60-69 years 50-59 years 40-49 years 120 140 160 180 Usual SBP (mm Hg) 70 80 90 100 110 Usual DBP (mm Hg) Lewington et al. Lancet. 2002;360:1903-1913.

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

Changes in BP Categories from JNC7 to the New Guideline SBP DBP JNC7 2017 ACC/AHA <120 and <80 Normal BP 120 129 and <80 Prehypertension 130 139 or 80 89 Prehypertension 140 159 or 90-99 Stage 1 hypertension 160 or 100 Stage 2 hypertension The categorization of BP should be based on the average of 2 readings on 2 occasions following a standardized protocol.

Changes in BP Categories from JNC7 to the New Guideline SBP DBP JNC7 2017 ACC/AHA <120 and <80 Normal BP Normal BP 120 129 and <80 Prehypertension Elevated BP 130 139 or 80 89 Prehypertension Stage 1 hypertension 140 159 or 90-99 Stage 1 hypertension Stage 2 hypertension 160 or 100 Stage 2 hypertension Stage 2 hypertension The categorization of BP should be based on the average of 2 readings on 2 occasions following a standardized protocol.

Rationale for BP Categorization in the ACC/AHA Guideline Observational data related to the association between SBP/DBP and CVD risk. Randomized trials of lifestyle modification to lower BP. Treatment with antihypertensive medication to lower BP and prevent CVD.

Association between SBP/DBP and CVD risk Several meta-analyses have reported a gradient of progressively higher CVD risk going from normal BP to elevated BP to hypertension. Systolic/Diastolic blood pressure, mm Hg Outcome <120/80 120-129/80-84 130-139/85-89 Cardiovascular mortality Ref 1.24 (1.10 1.39) 1.56 (1.36 1.76) Stroke Ref 1.35 (1.10 1.66) 1.95 (1.69 2.24) Coronary heart disease Ref 1.11 (0.87 1.42) 1.33 (0.96 1.83) Myocardial infarction Ref 1.43 (1.10 1.86) 1.99 (1.59 2.50) Guo et. al. Current Hypertension Reports 2013; 15: 703-716. Guoet. al. PLoSOne, 2013; 8e61796. Huang et. al. Neurology, 2014; 82: 1153-1161. Huang et. al. American Journal of Kidney Diseases, 2014; 63: 76-83. Lee et. al., Neurology 2011; 77: 1330-1337. Shen, American Journal of Cardiology, 2013; 112: 266-271.

Randomized Trials Nonpharmacological interventions Trials have shown the benefit of lowering BP among those with SBP/DBP 130/80 mm Hg through: Weight loss among overweight/obese adults. Heart healthy diet (e.g., DASH diet) Sodium reduction Potassium supplementation Increased physical activity Alcohol reduction Whelton et. al. JAMA, 2002; 288: 1882-1888.

Randomized Trials Pharmacological interventions Three randomized trials have evaluated pharmacological antihypertensive treatment in adults without hypertension. ECG Index Baseline 18-months Change (95% CI) Sokolow-Lyon Voltage, mm Chlorthalidone/Amiloride 21.8 ± 7.5 20.7 ± 7.1 1.04 (0.45, 1.63) Placebo 21.5 ± 7.4 21.5 ± 7.2 0.03 (-0.61, 0.68) Duration product, µvms Chlorthalidone/Amiloride 229 ± 103 213 ± 84 15.4 (5.7, 25.2) Placebo 223 ± 99 224 ± 94-1.4 (-11.0, 8.2) p-value=0.02 comparing chlorthalidone/amiloride ver Fuchs et. al., Journal of the American Heart Association, 2016; 5: e004248 Julius et. al. New England Journal of Medicine, 2006; 354: 1685-1697. Luders et. al., Journal of Hypertension, 2008; 26: 1487-1496.

Distribution of US adults into BP Categories NHANES 2011-2014 Prevalence of hypertension: 45.6% Muntner et. al., Journal of the American College of Cardiology 2017 (in press) Muntner, et. al., Circulation 2017 (in press)

Prevalence of Hypertension 2017 ACC/AHA and JN7 Guidelines Prevalence of hypertension, % Number of US adults with hypertension, millions Muntner et. al., Journal of the American College of Cardiology 2017 (in press) Muntner, et. al., Circulation 2017 (in press)

Summary The 2017 ACC/AHA guideline uses lower BP thresholds to define hypertension: SBP 130 mm Hg DBP 80 mm Hg The prevalence of hypertension among US adults is 46% using this definition. Approximately 103 million US adults have hypertension according to the new guideline.

BP TREATMENT THRESHOLD AND THE USE OF ASCVD RISK ESTIMATION TO GUIDE DRUG TREATMENT OF HYPERTENSION Recommendations for BP Treatment Threshold and Use of ASCVD Risk Estimation* to Guide Drug Treatment of Hypertension COR LOE Recommendations I SBP: A DBP: C-EO 1. 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. I C-LD 2. 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 to estimate 10-y risk of ASCVD. ASCVD was defined as a first nonfatal MI or CHD death, or fatal or nonfatal stroke among adults free of CVD.

ACC/AHA POOLED COHORT EQUATIONS To estimate the 10-year risk of atherosclerotic CVD http://tools.acc.org/ascvd-risk-estimator/

IS THERE ANY DIFFERENCE IN EXPECTED BENEFIT FROM BP LOWERING ACCORDING TO CVD RISK? Yes Data from the BP Lowering Treatment Trialists Collaboration meta-analysis provided empirical evidence that the absolute benefits achieved with BPlowering therapy are driven by the combination of CVD risk factors determining risk of a CVD event rather than simply the BP level in isolation. Thus, the most intensive BP-lowering therapies should be directed to those at highest CVD risk. Sundstrom J et al. Blood Pressure Lowering Treatment Trialists. Lancet.2014;384;591-598.

DIFFERENCES IN CVD EVENTS ASSOCIATED WITH ANTIHYPERTENSIVE MEDICATIONS IN 11 TRIALS (>50,000 PATIENTS) Risk Ratios Relative Risk Reduction Absolute Risk Reduction 1.1 0 1-1 0.9-2 -3-1.4 0.8-4 -5 --2.0-2.4 0.7 0.6 0.82 0.85 0.87 0.85-6 -7-3.8 <11% 11%-15% 15%-21% >21% <11% 11%-15% 15%-21% >21% Blood Pressure Lowering Treatment Trialists Collaboration. Lancet.2014;384;591-598.

TEN-YEAR PREDICTED CVD RISK FOR HYPOTHETICAL LOW, INTERMEDIATE AND HIGH RISK ADULTS 10-Year Predicted CVD Risk 50% 40% 30% 20% 10% 0% Global ASCVD Risk Low Intermediate High 0.8% 12.3% 30.3% Muntner P, Whelton PK. JACC. 2017;69:2446-2456. 1.1% 16.2% 110 mm Hg 130 mm Hg Systolic Blood Pressure 38.4%

RISK-BASED TREATMENT OF HYPERTENSION Treating 1,000 hypertensuve people Events 5-Y ASCVD Risk (%) Prevented (5Y) NNT* < 11 14 71 11-15 20 51 15-21 24 41 >21 26 26 * Number needed to treat (NNT) to prevent 1 event: Blood Pressure Lowering Treatment Trialists. Lancet.2014;384;591-598.

CVD EVENTS AVOIDED BY BASELINE RISK AND MAGNITUDE OF SBP LOWERING Sundstrom et al. Lancet. 2014;384:591 598 Cardiovascular events avoided per 1000 70 60 50 40 30 20 10 0 1 69 57 54 44 36 31 28 20 18 14 10 16 2 12 Systolic blood pressure reduction (mm Hg) 3 8 37 5 4 4 10 16 19 >21 16-21 11-15 <11

BP & PREDICTED CVD RISK IN DRUG TREATMENT DECISION-MAKING The predicted risk of CVD between 2 people with the same SBP can differ by 20-fold based on the individual s global ASCVD risk. The increase in predicted CVD risk with higher BP is small among otherwise low-risk individuals but is much higher in those with higher ASCVD risk scores. Clinical trials and meta-analyses are based on participants with high ASCVD risk. CVD risk can be predicted by equations such as the AHA/ACC 2013 Pooled Cohort CVD Risk Equations** (based on BP, age, history of CVD, diabetes, LDL cholesterol and smoking). http://tools.acc.org/ascvd-risk-estimator Therefore, one can rationalize utilizing ASCVD risk calculations in antihypertensive drug treatment decisions. ** Goff DC Jr et al. 2013 AHA/ACC guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2013;1011.1005.

BOTTOM LINE Data from RCTs strongly suggest that patients with higher global ASCVD risk will receive a greater absolute risk reduction benefit from antihypertensive medication. Simulation studies suggest that employing ASCVD risk in conjunction with BP levels would result in treating fewer people with antihypertensive medication while preventing more CVD events and saving more quality-adjusted life years.

BP THRESHOLDS AND RECOMMENDATIONS FOR TREATMENT AND FOLLOW UP BP thresholds and recommendations for treatment and follow-up Normal BP (BP <120/80 mm Hg) Elevated BP (BP 120-129/<80 mm Hg) Stage 1 Hypertension (BP 130-139/80-89 mm Hg) Stage 2 Hypertension (BP >140/90 mm Hg) Promote optimal lifestyle habits (Class I) Non-pharmacologic therapy (Class I) Clinical CVD or estimated 10 y ASCVD risk 10% No Yes Reassess in 1 y (Class IIa) Reassess in 3-6 mo (Class I) Nonpharmacologic therapy (Class I) Non-pharmacologic therapy and BP lowering medication (Class I) Non-pharmacologic therapy and BP lowering medication (Class I) Reassess in 3-6 mo (Class I) Reassess in 1 mo (Class 1)

SUMMARY Benefits of using both BP and ASCVD risk assessment in determining BP thresholds for antihypertensive drug therapy Treatment is focused on patients most likely to have events More CVD events are prevented Larger absolute CVD risk reduction with treatment Lower number needed-to-treat to prevent one CVD event More quality-adjusted life years are saved Lower cost of care

Blood Pressure Goals for Patients Diagnosed with Hypertension

Approach to Determining the Optimal BP Target 1. The question was assigned to an independent evidence review committee for systematic review and meta-analysis in PICOT format. 2. Simultaneously, the writing group conducted a review of the literature

Meta Analysis of Trials of Intensive BP Targets Adapted from Thomopolus, Parati, and Zanchetti Journal pf Hypertension 2016

More intensive blood pressure lowering significantly reduced CV risk CV Event Relative Risk 95% CI MI 0.86 0.76-0.99 Stroke 0.77 0.65-0.91 Heart failure 0.75 0.56-0.99 CVD composite 0.83 0.75-0.92 A target of <130 mm Hg may significantly reduce the risk MI, stroke, heart failure, and major CVD events.

Summary Several large RTC s testing intensive BP targets have concluded since the JNC7 Report Systematic review, meta-analysis, and one RTC provide strong evidence for recommending SBP 130 mm Hg DBP 80 mm Hg for those with elevated risk for CVD (10 year risk 10%)

Significance of Out of Office BP Readings Guideline calls for greater use of out of office BP measurements (ABPM or HBPM) for both the diagnosis and management of hypertension. A major reason is to identify patients on no antihypertensive medication with: White Coat Hypertension (WCH) with elevated office BPs who may not require drug treatment and Masked Hypertension (MH) with normal office readings who should be considered for drug treatment In addition, in those on antihypertensive medications, to identify White Coat Effect (WCE) where office BPs are significantly higher than out of office readings Masked Uncontrolled Hypertension (MUCH) where office readings indicate adequate BP control but out of office readings are elevated

Recommendations for Patients (Not on Antihypertensive Drugs) to Identify WCH COR LOE RECOMMENDATIONS IIa IIa B-NR In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ambulatory blood pressure monitoring (ABPM) or HBPM before diagnosis of hypertension. C-LD In adults with white coat hypertension, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension.

Cohort, sex, and age-standardized incidence of cardiovascular events in untreated and treated normotensive (NT) and masked hypertensive (MHT) nondiabetic subjects that are derived from an IDACO (International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes) meta-analysis. 17 Fully adjusted hazard ratios (HRs) for treated vs untreated masked hypertensives are as follows: HR, 2.27 (95% confidence interval, 1.6 3.2; P<0.0001). Stanley S. Franklin et al. Hypertension. 2015;65:16-20 Copyright American Heart Association, Inc. All rights reserved.

Recommendations for Patients (Not on Antihypertensive Drugs) to Identify MH COR LOE RECOMMENDATIONS IIa B-NR In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ambulatory blood pressure monitoring (ABPM) or HBPM before diagnosis of hypertension. IIa C-LD In adults with white coat hypertension, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension.

Recommendations for Patients on Antihypertensive Drug Treatment COR LOE RECOMMENDATIONS IIb C-LD In adults on multiple drug therapies for hypertension and office BPs within 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM (or ABPM). IIa C-LD In adults being treated for hypertension with office BP readings not at goal and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful. IIb C-EO In adults being treated for hypertension with elevated HBPM readings suggestive of masked uncontrolled hypertension, confirmation of the diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment.

Detection of White Coat Hypertension or Masked Hypertension in Patients not on Drug Therapy

Detection of White Coat Hypertension or Masked Hypertension in Patients on Drug Therapy

Recommendations for BP Goal for Patients with Hypertension

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 JNC7 2017 ACC/AHA <120 and <80 Normal BP Normal BP 120 129 and <80 130 139 or 80 89 140 159 or 90-99 160 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

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults BP Thresholds for Treatment SBP DBP <120 and <80 120 129 and <80 130-139 or 80-89 130 139 or 80 89 130 or 80 130 140 or 90 CVD Risk/other circumstances N/A N/A No CVD/10-yr ASCVD risk <10% CVD/10-year ASCVD risk 10% Diabetes or CKD Age 65 years N/A Recommended Treatment Healthy Lifestyle 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

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults High BP Treatment Target SBP DBP <120 and <80 120 129 and <80 130-139 or 80-89 130 139 or 80 89 130 or 80 140 or 90 130 CVD Risk N/A 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 Recommended Treatment N/A N/A SBP <130 and DBP <80 mm Hg SBP <130 mm Hg

Summary 2013: NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA ACC/AHA partnered with nine professional organizations to sponsor new BP CPG 2014: 21 member multidisciplinary Writing Committee charged to develop the CPG 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

MMWR January 8, 2016 / Vol. 64 / No. 52

Effect of Sodium Reduction (Higher to Lower) in African-Americans and Non-African-Americans on the Control Diet Change in BP 0-2 -4-6 -8-10 -12 African-Americans - 4.5 P<.001-8.0 P<.001 0 P-interaction < 0.05 Non-African-Americans - 2.2 P<.001-5.1 P<.001 Systolic BP Diastolic BP

Most Salt Comes from Processed and Restaurant Foods Processed and restaurant foods Naturally occurring 77% 12% While eating 6% Home cooking 5% Source: Mattes, RD. Journal of American College Nutrition, 1991, 10:383-393.

Most Salt Comes from Processed and Restaurant Foods How much sodium is in a Chicken Cesar Salad at the Costco Food Court? A. 2680mg B. 725 mg C. 1130 mg D. 2060 mg

Most Salt Comes from Processed and Restaurant Foods How much sodium is an order of PF Chang s, double pan fried noodles with pork? A. 1500 mg B. 7900 mg C. 2700 mg D. 4300 mg

2/3 LB** Double Bacon Cheese Thickburger Serving size (grams) = 462 Calories = 1300 Calories from fat = 860 Total fat = 96 grams Saturated fat = 40 grams Cholesterol = 205 mg Sodium = 2110 mg Total Carbohydrates = 51 grams

Diabetes, Black Pooling Project Caucasians African Americans 12 10 8 6 4 2 0 < 50 years 50-59 years 60+ years

Hypertension and Diabetes, Black Pooling Project Percent of Hypertensvies 8 7 6 5 4 3 2 1 0 Normal Prehypertension Stage 1 Stage 2 Level of Hypertension

STRIKE OUT STROKE