Todd S. Perlstein, MD FIFTH ANNUAL SYMPOSIUM

Faculty Disclosure I have no financial interest to disclose No off-label use of medications will be discussed FIFTH ANNUAL SYMPOSIUM

Recognize changes between new JNC 8 and prior JNC guidelines Apply the JNC 8 hypertension guidelines to clinical practice Discuss the contradictions between the new JNC 8 guidelines and other societal guidelines for the treatment of hypertension Comfortably swim in the pool of ambiguity that continues to surround the treatment of hypertension

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

In the general population aged 60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) 150 mm Hg or diastolic blood pressure (DBP) 90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation Grade A)

In the general population aged 60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion Grade E)

In the general population aged < 60 years, initiate pharmacologic treatment to lower BP at SBP > 140 mm Hg or DBP 90 mm Hg and treat to a goal SBP < 140 mm or DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation Grade A; For ages 18-29 years, Expert Opinion Grade E)

In the population aged 18 years with chronic kidney disease (CKD) or diabetes, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion Grade E)

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation Grade B)

In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation Grade B; for black patients with diabetes: Weak Recommendation Grade C)

In the population aged 18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation Grade B)

There is no evidence that ACEI or ARB improve cardiovascular outcomes or mortality in hypertensives with CKD

If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation #6 (thiazide-type diuretic, CCB, ACEI, or ARB). If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. If goal BP cannot be reached using only the drugs in recommendation #6, antihypertensive drugs from other classes can be used. (Expert Opinion Grade E)

These recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Adults >60: 150/90 Adults < 60: 140/90 Adults with CKD or DM: 140/90 Adults with CKD: Nonblack adults: Black adults: Not at target BP: ACEI/ARB CCB, diuretic, ACEI/ARB CCB, diuretic titrate every month, CCB, diuretic, ACEI/ARB

SBP > 150 mm Hg treatment initiation threshold and SBP < 150 mm Hg treatment target applies to adults > 80 years of age (not > 60 years) For nonblack patients < 60 years of age, ACEI or ARB recommend as first line therapy (not CCB or thiazide-type diuretic)

SBP > 150 mm Hg treatment initiation threshold and SBP < 150 mm Hg treatment target applies to adults > 80 years of age (not > 60 years)

In fact, the JNC 8 guidelines disagree with American Society of Hypertension, American Heart Association, Canadian, British and European guidelines with regard to the treatment of hypertension in persons aged 60-79 years of age

Hypertension treatment guidelines: Initiate treatment based upon blood pressure Cholesterol treatment guidelines: Initiate treatment based upon estimated risk for cardiovascular disease (risk estimator includes blood pressure!)

Neaton JD, Wentworth D; Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152:56-64.

Level of Evidence Strength of Recommendation Number A Strong High quality trials B Moderate Weaker trials C Weak Observational data D Against Harm! E Expert opinion No data

Level of Evidence Strength of Recommendation Number A Strong 1 B Moderate 2 C Weak 1 D Against 0 E Expert opinion 5

Level of Evidence Strength of Recommendation Number A Strong 1 B Moderate 2 C Weak 1 D Against 0 E Expert opinion 5 THE ONLY GRADE A RECOMMENDATION IS THE ONE THAT DISAGREES WITH EVERY OTHER GUIDELINE!

How good are you at measuring blood pressure?

Manual sphygmomanometer Correct cuff size (bladder > 80% of arm circumference) Seated quietly 5 min, back supported, feet on floor Arm supported at heart level Palpate SBP first At least 2 measurements, both arms, + one leg Sometimes this is not good enough The 7 th Report of the Joint National Committee on the Detection, Prevention, Evaluation and Treatment of High Blood Pressure, JAMA. 2003.

A 75-year old woman with hypertension. For 10+ years she has had office SBPs of 160+ mmhg, but she refuses antihypertensives. No angina, dyspnea, or claudication. No other cardiovascular risk factors or cardiovascular disease. Exam: BP 166/90 HR 94. BMI 22. Anxious. Fundoscopic exam normal. Carotids normal. Lungs clear. Heart: PMI nl, S1S2, no gallop, basal early 2/6 SEM, extremity pulses normal, no edema, neurological exam normal. ECG NSR & no evidence of LVH. egfr > 60. Urinalysis normal. Next step? Re-check BP in your office in 4 weeks, Order 24-hour ambulatory blood pressure monitor Initiate antihypertensive therapy Refer for cardiac stress test Trial of anti-anxiety medication

Option B is the correct choice. It would be unusual for a patient to have a 10-year history of severe hypertension and no evidence of target organ damage. This case is suspicious for white coat hypertension, even more so given the anxiety and relative tachycardia, and an ambulatory BP monitor should be ordered to determine the patient s 24-hour mean BP.

Indications For the Use of Ambulatory Blood Pressure Monitoring White coat hypertension Informing equivocal treatment decisions Evaluation of nocturnal hypertension Evaluation of drug-resistant hypertension Determining efficacy of treatment over 24 hours Evaluation of symptomatic hypotension Evaluation of unusual variability* JNC 7, JAMA 2003. *Peter Rothwell, Lancet 2010. Thomas G Pickering. 1940-2009.

24-hour Ambulatory BP > 135/85 > 125/75 < 135/85 < 125/75 Pickering TG et al. J Am Soc Hypertens. 2010;4(2)56-61. Masked Hypertension True Normotension True Hypertension White Coat Hypertension < 140/90 > 140/90 < 130/80 > 130/80 Office Blood Pressure

Sensitivity Specificity Hodgkinson J, Mant J, Martin U, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011; 342: d3621.

Sensitivity 86% (95% CI 81 89) Specificity 46% (95% CI 33 59) Hodgkinson J, Mant J, Martin U, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011; 342: d3621.

Sensitivity Specificity masked HTN white coat HTN Hodgkinson J, Mant J, Martin U, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011; 342: d3621.

Schettini et al. Hypertension 1999;34:818-825.

The current use of clinic BP measurements results in high rates of misclassification Results in younger people who are at risk for complications of HTN being undertreated Results in older people who are at risk for complications of HTN treatment being overtreated

Medicare, United Health Care: White coat hypertension BCBS, Aetna: White coat hypertension, resistant hypertension, hypertensive individuals with hypotensive symptoms, episodic hypertension, suspected autonomic dysfunction

Relying solely on office pressures overtreats the elderly and undertreats the young Consider in cases of white coat hypertension, resistant hypertension, hypertensive individuals with hypotensive symptoms, episodic hypertension, suspected autonomic dysfunction

Todd S. Perlstein, MD FIFTH ANNUAL SYMPOSIUM