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Blueprint for Change: Defining and Promoting a Single, Effective System of
Care for Patients with Hypertension
Robert M. Carey, MD, MACP, FRCP, FRCPI, FAHADean, Emeritus, and Professor of Medicine
University of Virginia School of MedicineCharlottesville, VA
AMERICAN COLLEGE OF MEDICAL QUALITY
Bethesda, MD12 April 2019
I have nothing to disclose.
HYPERTENSION
• World’s leading risk factor for morbidity and mortality.
• Ranks first worldwide in disability-adjusted life years (7%).
• Affects 27% of the world’s adult population –approximately one-billion people.
• Prevalence 34.0% in U.S. (2011-2014 NHANES data; 85.7 million adults).
• The most common reason for visiting a physician for ongoing care in the U.S.
Recent BP Guidelines
KDIGO JNC 8 Panel ACP/AAFP ADA
2012 2014 2017 2017
Kidney Int (Supp) JAMA Ann Intern Med Diabetes Care (2003 GL Update)
Areas of Focus
Renal disease(Adults & children)
≥ 18 y Older adults (≥ 60 y)
Diabetes Mellitus(Adults)
Treatment(Lifestyle & Drug)
Treatment (Drug)Limited to:1) BP threshold2) BP goal3) Drug class diffs.
Treatment (Drug)Limited to: 1) BP goal
Diagnosis and Treatment(Lifestyle & Drug)
JNC 7 Australia Canada ACC/AHA ESC/ESH
2003 2016 2016 2017 2018
Hypertens/JAMA AHF website Can J Cardiol Hypertens/JACC J Hypertens/EHJ
≥18 y ≥18 y Adults Adults Adults
Update (1997 JNC VI) Update (2010 GL) Update (Annual) Update (JNC 7) Update (2013 GL)
Focused
Comprehensive
DiagnosisJNC 7 Australia Canada ACC/AHA ESC/ESH
Office SBP ≥ 140 DBP ≥ 90
OfficeSBP ≥ 140DBP ≥ 90
Office (Non AOBP)SBP ≥ 140DBP ≥ 90
OfficeSBP ≥130DBP ≥80
OfficeSBP ≥140DBP≥90
Office (AOBP) PreferredSBP ≥135/DBP ≥85SBP ≥130/DBP ≥80 in DM
ABPM Day:≥ SBP 135 or DBP ≥ 8524 hrs:≥ SBP 130 or DBP ≥ 80
HBPM≥ SBP 135 or DBP ≥ 85
5
KDIGO JNC 8 Panel ACP/AAFP ADA
Not defined(Focus on BP)
Not defined Presumably assumes:
SBP ≥140DBP ≥90
Not definedPresumably assumes:
SBP ≥140DBP ≥90
OfficeSBP ≥140DBP ≥90
Focused Guidelines
Comprehensive Guidelines
Threshold
JNC 7 Australia Canada ACC/AHA ESC/ESH
LifestyleSBP ≥120DBP ≥80
LifestyleAll adults
Lifestyle Lifestyle Lifestyle
DrugsSBP≥140DBP ≥90
DrugsSBP ≥140DBP ≥90
(Consider CVD risk)
DrugsNon-AOBPSBP ≥140DBP ≥ 90
DrugsBP ≥140/90for all adults;BP ≥130/80 for those with CVD or high ASCVD risk
DrugsAdd drugs if;
SBP ≥140DBP ≥90
Comprehensive Guidelines
KDIGO JNC 8 Panel ACP/AAFP ADA
Office BPSBP≥140DBP ≥90
Drug therapy (only)<60y: SBP ≥140/DBP ≥90>60y: SBP ≥150/DBP ≥90
Drug therapy ≥60YAll: SBP ≥150Stroke/TIA: SBP ≥140High CVD risk: SBP ≥140
Not specifically stated
Presumably office BPSBP ≥140/DBP ≥90
Focused Guidelines
TargetJNC 7 Australia Canada ACC/AHA ESC/ESH
SBP <140DBP <90
SBP <140DBP <90High CVD risk: SBP <120
SBP <140DBP <90
High CVD risk:SBP <120
SBP <130DBP <80
COR higher forhigh ASCVD risk
SBP ≤130 but not less than 120 in adults 18-65 years; <140 - 130 if tolerated.
7
Not based CVD risk Treatment target influenced by CVD risk
KDIGO JNC 8 Panel ACP/AAFP ADA
SBP ≤140DBP ≤90
≥60 ySBP/DBP <150*/90
≥60 ySBP <150
SBP <140DBP <90
Albuminuria
>300 mg/24 hr>30 mg/24 hr in DM
30 – 59 y<DBP 90 mm Hg
High CVD risk(not defined)
SBP <140
High CVD risk (not defined)
SBP <130/DBP <80
*Minority report favoring SBP <140
H/O stroke or TIASBP < 140(moderate evidence forSBP 130-139)
Comprehensive Guidelines
Focused Guidelines
No explicit influence by CVD risk Treatment target influenced by CVD risk
Not based CVD risk
ACCURACY OF BP MEASUREMENT
• Statement calls for greater use of out-of-office BP measurements (ABPM or HBPM) for both the diagnosis and management of hypertension.
• AOBP devices (attended or unattended) should be considered for use in measuring office BP.
• Office BP should be measured ≥2 times at each clinic visit.
• Training of personnel is crucial for BP measurement, even when AOBP is employed.
• HBPM by itself is ineffective in BP control but is effective when used in combination with supportive interventions (eg. web-based/telephone feedback).
• The main indications for ABPM are to detect white coat and masked hypertension.
• HBPM can be employed to assess out-of-office BP when ABPM is unavailable or unaccepted by the patient and can be used to detect WCH and MH.
Muntner P et al. Hypertension. 2019;73: DOI:10.1161/HYP.0000000000000087
BP MEASUREMENT BY AOBP
• Automated oscillometric device records multiple BP readings automatically.
• Allows the patient to have BP measured alone without talking in absence of a health care provider, improving the quality of the readings.
• Meta-analysis of 31 studies comprising 9,279 participants demonstrated that research/office SBP readings were 14.5 mmHg higher than AOBP readings.
• AOBP readings were demonstrated to be equivalent to daytime ABPM readings and essentially eliminating the white coat effect.
• The data suggest that unattended AOBP readings are more accurate than office BP readings and are devoid of any white coat effect.
Roerecke M et al. JAMA Intern Med. 2019;179:351-362.
BP CLASSIFICATION (JNC 7 and ACC/AHA Guidelines)
SBP DBP
<120 and <80
120–129 and <80
130–139 or 80–89
140–159 or 90-99
≥160 or ≥100
2003 JNC7
Normal BP
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
2017 ACC/AHA
Normal BP
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
Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.
Area ofdifference
11
Estimated Risk of BP-related Coronary Heart Disease by Level of Systolic Blood Pressure
Experience during an average of 11.6 years of follow-up in 347,978 adults
screened for entry into the Multiple Risk Factor Intervention Trial
Adapted from Stamler J et al. Arch Intern Med. 1993;153:598-615.
130-139 category> 20% of BP-related risk
130-139 categoryalmost double riskof CHD (and stroke)vs. normal BP
130-139 categoryhigh prevalence
2017 ACC/AHA BP Guideline: Thresholds for Treatment
CVD Risk/other
circumstances
N/A
N/A
- No CVD- 10-yr ASCVD risk <10%*
- CVD, or- 10-year ASCVD risk ≥ 10%
Diabetes or CKD
Age ≥65 years
N/A
Recommended Treatment
Healthy Lifestyle
Nonpharmacological therapy
Nonpharmacological therapy
Nonpharmacological therapy
and
Antihypertensive drug therapy
* AHA/ACC 2013 Pooled Cohort CVD Risk Equations
Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.
+
SBP DBP
<120 and <80(Normal)
120–129 and <80(Elevated)
130-139 or 80-89(Stage 1 Hypertension)
130-139(Stage 1 Hypertension)
≥140 or ≥90(Stage 2 Hypertension)
http://tools.acc.org/ASCVD-Risk-Estimator/APP Store: ASCVD Risk Estimator Plus
ACC/AHA POOLED COHORT EQUATIONS
To estimate the 10-year risk of ASCVD
Based on age, race, sex, total cholesterol, LDL cholesterol, HDL cholesterol, treatment with a statin, systolic BP, treatment for hypertension, history of diabetes, current smoker, aspirin therapy
Validated for adults 40-79 years of age.
Car
dio
vasc
ula
r ev
en
ts a
void
ed
pe
r 1
00
0
0
10
20
30
40
50
60
70
1
2
3
4
1612
84
Systolic blood pressure reduction (mm Hg)
<11
11-15
16-21
>21
18
69
54
37
19
57
44
31
16
36
28
20
1014
10
5
CVD EVENTS AVOIDED BY BASELINE RISK AND MAGNITUDE OF SBP LOWERING
Sundstrom et al. Lancet. 2014;384:591–598
Lifestyle
Intervention Dose
Impact on SBP
Hypertension Normotension
Weight loss 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.
-5 mm Hg -2/3 mm Hg
Healthy diet Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
-11 mm Hg -3 mm Hg
Reduced intake
of dietary
sodium
Optimal goal is <1500 mg/d, but aim
for at least a 1000-mg/d reduction in
most adults.
-5/6 mm Hg -2/3 mm Hg
Enhanced intake
of dietary
potassium
Aim for 3500–5000 mg/d, preferably
by consumption of a diet rich in
potassium.
-4/5 mm Hg -2 mm Hg
LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND TREATMENT OF HYPERTENSION
All 4 Recommendations COR:1; LOE:A
Nonpharmacological
Intervention Dose
Effect on SBP
Hypertension Normotension
Physical
activity
Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
-5/8 mm Hg -2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
-4 mm Hg -2 mm Hg
Isometric
resistance
● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction,
3 sessions/wk
● 8–10 wk
-5 mm Hg -4 mm Hg
Moderation
in alcohol
intake
Alcohol
consumption
In individuals who drink alcohol,
reduce alcohol to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
-4 mm Hg -3 mm
LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND
TREATMENT OF HYPERTENSION
Both Recommendations COR:1; LOE:A
0
20
40
60
80
45.6%
13.7%
31.9%
36.2%1.9%
34.3%
53.4%
14.4%
39.0%
0
20
40
60
80
100
120
140
Hypertension Recommended
pharmacological
treatment
Blood pressure
above goal among
pharmacologically
treated US adults
103.3
31.1
72.2
81.94.2
77.7 29.2
7.9
21.3
Perc
en
tag
e o
f U
S a
du
lts
Nu
mb
er
of
US
ad
ult
s in
mil
lio
ns
2017 ACC/AHA guideline but not JNC7
2017 ACC/AHA guideline and JNC7
PREVALENCE OF HYPERTENSION, RECOMMENDATIONS FOR ANTIHYPERTENSIVE DRUG TREATMENT AND BP ABOVE GOAL
Muntner et al. Circulation. November, 2017
2017 ACC/AHA BP Guideline: Treatment Targets
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-yearASCVD risk <10%
Clinical CVD or 10-year ASCVD risk ≥ 10%
Diabetes or CKD
N/A
Age ≥65 years
Recommended BP Target
N/A
N/A
SBP <130 (DBP <80 mm Hg)
SBP <130 mm Hg
Whelton PK et al. Hypertension. 2018;71:1269-1324./J Am Coll Cardiol. 2018;71:2199-2269.
ASSOCIATION OF HYPERTENSION GUIDELINES WITH CVD EVENTS AND DEATH IN THE US
Bundy JD et al. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.1240
Characteristic 2014 Evidence-Based Guideline
2017 ACC/AHA Guideline
BP threshold for definition of hypertension
≥140/90 ≥130/80
BP threshold for initiation of antihypertensive drugs
≥140/90 (<age 60)≥150/90 (≥age 60)
≥140/90 (gen. population)≥130/80 (high CVD risk)
BP goal of treatment <140/90 (<age 60)<150/90 (≥age 60)
<130/80
Annual CVD event reduction (adults ≥age 40)
270,000 610,000 (NNT=70)
Annual reduction in death(adults ≥age 40)
177,000 334,000 (NNT=129)
(1) Incidence of major CVD events & all-cause mortality by modeling 4 community-based cohort studies
(2) Network meta-analysis (42 RCTs) to estimate HRs for outcomes and determine population-attributable risks and events reduced.
SUMMARY
• Hypertension is, arguably, the most significant medical and public health problem in the United States today.
• Evidence-based clinical practice guidelines from several organizations have appeared during the past 2 years.
• Although recommendation differences do exist, these are relatively minor compared with the overall similarities of the guidelines.
• Although we may not be able to reach complete consensus on the guideline recommendations, the hope is that we can reach conclusions about the way BP is controlled that will benefit our patients and communities.
Thank you for your kind attention!
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