Comparative review of NICE, JNC8, SAHS and ISHIB Brian Rayner, Division of Hypertension, University of Cape Town
Scope of Problem Deaths attributable to high blood pressure in males, South Africa 2000 7000 6000 5000 4000 3000 2000 1000 0 30-44 45-49 60-69 70-79 80+ Stroke Hypertensive disease Ischaemic heart disease other cardiovascular Prevalence of Hypertension in SA men Bradshaw et al MRC and CDiA 2011 Norman et al. 2007 BOD at the MRC
Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1 25 million people Eleni Rapsomaniki, PhD, Adam Timmis, FRCP, Julie George, PhD, Mar Pujades-Rodriguez, PhD, Anoop D Shah, MRCP, Spiros Denaxas, PhD, Ian R White, PhD, Mark J Caulfield, MD, John E Deanfield, FRCP, Liam Smeeth, FRCGP, Bryan Williams, FRCP, Aroon Hingorani, FRCP and Harry Hemingway, FRCP The Lancet Volume 383, Issue 9932, Pages 1899-1911 (May 2014) DOI: 10.1016/S0140-6736(14)60685-1 Copyright 2014 Rapsomaniki et al. Open Access article distributed under the terms of CC BY Terms and Conditions
Figure 5 Source: The Lancet 2014; 383:1899-1911 (DOI:10.1016/S0140-6736(14)60685-1) Terms and Conditions
Figure 6 Source: The Lancet 2014; 383:1899-1911 (DOI:10.1016/S0140-6736(14)60685-1) Terms and Conditions
Principles Go et al, Effective approach to HT management, Hypertension 2014
Algorithm Development Go et al, Effective approach to HT management, Hypertension 2014
Awareness, Treatment and Control of USA Canada UK Germany Greece Spain China Japan Taiwan Mexico Hypertension Aware* Treated Controlled # 0 20 40 60 80 Proportion of patients (%) *Prior diagnosis by health professional Use of BP medication # On BP medication, with SBP/DBP<140/90mmHg Whelton. J Clin Hypertens 2004;6:636 42
Kaiser Permanente Model Between 2001-2009 number of patients with HT increased from 349,937 to 652763. Target BP from 44% to 80% In 2011 > 87% reached target Go et al, Effective approach to HT management, Hypertension 2014
PURE STUDY The PURE study enrolled 155,245 subjects between 35 and 70 years old, from both rural and urban areas in 17 countries to assess the influence of cardiovascular risk factors on cardiovascular disease and mortality. Overall, CV risk factors high-> middle-> lowincome countries Treatment and preventive measures also followed this pattern (p<0.0001). Yusuf, S, ESC 2013
Fatal CV Events Yusuf, S, ESC 2013
Wendy Hoy
Key Issues Thresholds for diagnosis and intervention First line therapy How to initiate? Treatment resistance
Non-controversial Life style modification Treat all CV risk factors as appropriate Compelling indications and contra-indications BP measurement Assessment of TOD
> 80 years > 160/90, target < 150/90 NICE -DIAGNOSIS
ISHIB - Risk stratification and treatment algorithm for blacks with hypertension. Risk Stratification No TOD or CVD BP > 135/85 Initiate treatment TOD or CVD BP > 130/80 Initiate treatment Target < 135/85 Target < 130/80 Adapted - Flack J et al. Hypertension 2010;56:780-800 Copyright American Heart Association
Death rates for diseases of the heart and stroke by race/ethnicity and sex, United States, 1980 to 2001. Mensah G A et al. Circulation 2005;111:1233-1241 Copyright American Heart Association
* # SAHS, NICE > 80 years, >160/90 Goal < 150/90 # Level E evidence
JNC-8 Minority View increasing the target will probably reduce the intensity of antihypertensive treatment in a large population at high risk for cardiovascular disease the evidence supporting increasing the SBP target from 140 to 150 mm Hg in persons aged 60 years or older was insufficient the higher SBP goal in individuals aged 60 years or older may reverse the decades-long decline in CVD, especially stroke mortality Wright JT Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Ann Intern Med 2014; 160(7): 499-503.
Indications for antihypertensive medication by age. Murthy V L et al. Hypertension. 2014;64:275-280 Copyright American Heart Association, Inc. All rights reserved.
Blood pressure treatment status by age. Murthy V L et al. Hypertension. 2014;64:275-280 Copyright American Heart Association, Inc. All rights reserved.
NICE/SA/JNC/ISHIB GUIDELINES Diuretics ACEi ARB CCB Diuretic/CCB preferred in black patients
Figure 1. Risk stratification and treatment algorithm for blacks with hypertension. Copyright American Heart Association Flack J et al. Hypertension 2010;56:780-800
Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C* Step 1 Summary of antihypertensive drug treatment A + C* A + C + D Resistant hypertension A + C + D + consider further diureticor alpha- or beta-blocker Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensinii receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) *D Thiazide-like diuretic See slide notes for details of footnotes 1-5
JNC-8 SAHS 2014
2014 Hypertension Guideline JNC-8 Dosing Strategies 1. Start low dose monotherapy and titrate to maximum dose before considering 2 nd drug 2. Start low dose monotherapy and add second drug at low dose 3. Start 2 drugs especially if BP > 160/100 mmhg or 20/10 mmhg above goal
Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C* Step 1 Summary of antihypertensive drug treatment A + C* A + C + D Resistant hypertension A + C + D + consider further diureticor alpha- or beta-blocker Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensinii receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) *D Thiazide-like diuretic See slide notes for details of footnotes 1-5
Figure 1. Risk stratification and treatment algorithm for blacks with hypertension. Copyright American Heart Association Flack J et al. Hypertension 2010;56:780-800
SAHS Practice Guidelines, CVJA, in press
Stepped care BP > 160/100 Start low dose diuretic, dose Not at target FDC with RAS inhibitor + CCB or diuretic Add ACE inhibitor/arb 6-12 months Not at target Add CCB, β blocker 4-8 weeks Not at target Optimise dose of FDC or combine RAS, CCB, diuretic
VALUE: Outcome and SBP Differences at Specific Time Periods: Primary Endpoint Time Interval (months) SBP mmhg Overall study 0 3 3 6 2.2 3.8 2.3 6 12 2.0 12 24 1.8 24 36 1.6 36 48 1.4 48 end 1.7 PRIMARY ENDPOINT Odds Ratios and 95% CIs 0.5 1.0 2.0 4.0 Favours valsartan Favours amlodipine Julius S et al. Lancet. June 2004;363:2022 31.
NICE RESISTANT HT Beta blocker, alpha blocker
JNC -8
Figure 2. Guide to multidrug antihypertensive therapy in blacks with hypertension. Flack J et al. Hypertension 2010;56:780-800 Copyright American Heart Association
SAHS Beta blocker Aldosterone antagonist Vasodilator e.g. minoxidil Centrally acting Furosemide twice daily if egfr < 45mls/min
CONCLUSIONS Hypertension is major world wide epidemic There are substantial differences in awareness, prevalence and control rates, and CV outcomes Broad consensus for BP thresholds for intervention Consensus on BP targets/goals less aggressive than before Much closer agreement on optimal drug treatment (ACE or ARB, CCB, diuretic or all 3) Recognition for the wider use of drug combinations for optimal BP control, and earlier initial use of combinations in high risk e.g. > 160/100
Aldosterone and PRA in normotensive populations in SA/USA 6 5 4 3 2 Black White 1 0 PRA Aldosterone Rayner et al, S Afr Med J 2002 Tu W et al. Hypertension. 2014;63:1212-1218
Changes from baseline parameters in response to 2 week of treatment with 9-α fludrocortisone (ENaC) Tu W et al. Hypertension. 2014;63:1212-1218 Copyright American Heart Association, Inc. All rights reserved.
24,000 mmol Na Gordon s syndrome Gitelman s syndrome Na-Cl, WINK Thiazide GRK4 ENaC pseudohypoaldosteronism Liddle s syndrome SCNN1B, SCNN1G Na- K or H Amiloride 10-200 mols Barter s syndrome KCNJ1 CASR Uromodulin ROMK Na-K-2Cl Furosemide Loss or gain of function leads to either hypotension or hypertension