RECOMENDACIONES JNC8

7/28/2019 RECOMENDACIONES JNC8

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20thAnnual Primary Care Conference

Hypertension 2012: What Will The JNC 8Guideline Look Like?

Annual Primary Care Kiawah ConferenceKiawah Island, South Carolina

July 3, 2012

Jan Basi le, MDSeinsheimer Cardiovascular Health ProgramProfessor of Medicine

Medical University of South CarolinaRalph H. Johnson VA Medical CenterCharleston, South Carolina

DISCLOSURE OF FINANCIAL RELATIONSHIPS

Jan N. Basile, MD

Grant/Research support: NHLBI (SPRINT)

Consultant: Daiichi-Sankyo, Forest, Takeda

Speakers Bureau: Daiichi-Sankyo , Forest, Takeda,Boehringer Ingelheim, Lilly

Major stock shareholder: None

Other: None


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Why Are We Still Talking About HTN?

Its prevalent

Over 74 milli on in U.S. have HTN

Abou t 70 mi ll ion in U.S. have prehypertens ion

Increasing p revalence with aging of popu lation and

epidemic of overweight/obesity

Control of BP leads to a reduction in events

Approx imately 50% reduction in heart fai lu re

Approx imately 40% reduction in stroke

Approx imately 20%25% reduction in MI

Ong KL et al. Hypertension. 2007;49:69.Hebert PR et al.Arch Inten Med. 1993;153:578.Kannel WB. JAMA. 1996;275:1571.Moser M, Hebert P. J Am Coll Cardiol. 1996;27:1214.

HTN, hypertension; BP, blood pressure

j22

20-Year Trends in Hypertensionin the U.S.: 19882008

Hajjar I et al. JAMA. 2003;290:199.Egan BM et al. JAMA. 2010;303:2043.

0

10

20

30

40

50

60

70

80

90

Prevalence Awareness Treatment Control(With RX)

Control (AllHypertension)

%

19881991 19911994 19992000 20072008


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Slide 6

22 NOTE: Our reference format includes only first page number of article (not full page range). Also, nocomma before "et al" and refs flush right. Abbreviations and footnotes should not appear in the sametext box as refs.simmons, 7/31/2010


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It's tough to make predictions,especially about the future.

Y. Berra (1925- )

Trying to Predict JNC 8

Is it the Antihypertensive Class or theBP Achieved That Best Improves

Outcome in Those with Hypertensionand No Compelling Indication?

Question 1


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0.5 1.0 2.0

BP-Lowering Treatment TrialistsComparisons of different active treatments

Lancet 2003; 360:1903

Relative Risk RR (95% CI)

BP Difference

(mm Hg)

FavorsFirst Listed

FavorsSecond Listed

Major CV Events

CV Mortalit y

Total Mor tality

1.02 (0.98, 1.07)2/0ACE vs. D/BB

1.03 (0.95, 1.11)2/0ACE vs. D/BB

1.00 (0.95, 1.05)2/0ACE vs. D/BB

1.04 (0.99, 1.08)1/0CA vs. D/BB

1.05 (0.97, 1.13)1/0CA vs. D/BB

0.99 (0.95, 1.04)1/0CA vs. D/BB

0.97 (0.95, 1.03)1/1ACE vs. CA

1.03 (0.94, 1.13)1/1ACE vs. CA

1.04 (0.98, 1.10)1/1ACE vs. CA

FavorsFirst Listed

FavorsSecond Listed

0.5 1.0 2.0

BP-Lowering Treatment TrialistsComparisons of different active treatments

Lancet 2003; 360:1903

Relative Risk RR (95% CI)BP Difference

(mm Hg)

CA vs. D/BB 1.33 (1.21, 1.47)1/0

0.93 (0.86, 1.01)CA vs. D/BB 1/0

1.01 (0.94, 1.08)CA vs. D/BB 1/0

ACE vs. CA 0.82 (0.73, 0.92)1/1

1.12 (1.01, 1.25)ACE vs. CA 1/1

0.96 (0.88, 1.05)ACE vs. CA 1/1

Stroke

Coronary Heart Disease

Heart Failure

1.09 (1.00, 1.18)ACE vs. D/BB 2/0

0.98 (0.91, 1.05)ACE vs. D/BB 2/0

1.07 (0.96, 1.19)ACE vs. D/BB 2/0


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Question 2

What Is The Optimal BP For OutcomeImprovement in Special Populations?

DiabeticCKD

Elderly

One Million Adults, 61 Prospective Studies

Ischemic Heart Disease Mortality Stroke Mortality

Lewington S, et al. Lancet. 2002;360:1903-1913.

Increasing Systolic Blood Pressure and Age

Elevates Risk of Ischemic Heart Disease (IHD) andStroke Mortality

Usual Systolic BP (mm Hg)

256

128

64

32

16

8

4

2

1

120 140 160 180

IHDMortality

(AbsoluteRiskand95%

CI)

Age at Risk (y)

80-89

70-79

60-69

50-59

40-49

Usual Systolic BP (mm Hg)

256

128

64

32

16

8

4

2

1

120 140 160 180

StrokeMortality

(AbsoluteRiskand95%

CI)

Age at Risk (y)

80-89

70-79

60-69

50-59


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Chobanian AV et al. JAMA. 2003;289:2560.Arauz-Pacheco C et al. Diabetes Care. 2003;26:S80.

Flack JM et al. Hypertension 2010;56:780.Bakris GL et al.Am J Kidney Dis. 2000;36:646.

Condition mm Hg

Essential HTN


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DiabeticCKD

Elderly

HOT Trial Events byTarget DBP Groups*

0

30

60

90

120

150

180

210

240

270

Majorcardiovascular

events

AllmyocardialInfarction

All stroke CardiovascularMortality

TotalMortality

Hansson L, et al. Lancet. 1998;351:17551762.

*The outcomes for different BP groups were not statistically significant

90 85 80

Numberofevents

N =18,790

DBP Target:


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Hansson L et al. Lancet . 1998;351:17551762.

HOT: Results in High-Risk Subgroup(Diabetic Patients)

p=0.005 for

trend

MajorCVEvents

Per1,0

00PatientYears

Target DBP, mmHg

(n=501) (n=501) (n=499)

RR=1.32

RR=1.56

RR=2.06

05

1015202530

808590

Major CV Event Reduction by Target Blood Pressure

UKPDS:

Effect of Tight Glucose Control vsTight BP Control on CV Events

* P


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Trial N

Mean SBP

less intense

Mean SBP

more intense

CVD Risk

Reduction

SHEP 583 155 143 22-56%

Syst-EUR 492 162 153 62-69%

HOT 1,501 148 142 30-67%

UKPDS 1,148 154 144 32-44%

ABCD 470 138 132 No CVD

ADVANCE 11,140 140 135 14% mortality

Cushman, et al. Am J Cardiol 2007;99[suppl]:44i55i;

Patel, et al. Lancet. 2007;370:829840

ACCORD: Achieved SBP

Mean no. of medications prescribed:Intensive 3.2 3.4 3.4 3.5 3.5 3.5 3.4 3.4Standard 1.9 2.1 2.1 2.2 2.2 2.3 2.3 2.3

No. of patients:Intensive 2,174 2,071 1,973 1,792 1,150 445 156 156Standard 2,208 2,136 2,077 1,860 1,241 504 203 201

Years Since Randomization876543210

SBP(mmHg)

Standard

Intensive

140

130

120

110

0

Average : 133.5 standard vs. 119.3 int ensiv e, Delta = 14.2 at year 1

The ACCORD Study Group. New Engl J Med. 2010;362:1575.


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ACCORD Blood Pressure Trial:Primary Outcome and Total Stroke

Primary OutcomeNonfatal MI, Nonfatal Stroke, or CVD Death

Total Stroke

HR = 0.8895% CI (0.731.06)P=0.20

HR = 0.5995% CI (0.390.89)P=0.01


PatientsWithEvents(%)

0

5

10

15

20

Years Postrandomization

0 1 2 3 4 5 6 7 8

PatientsWithEvents(%)

0

5

10

15

20

Years Postrandomization

0 1 2 3 4 5 6 7 8

ACCORD Blood PressureTrial: Conclusions

Intensive antihypertensive therapy did notreduce the primary composite outcome(nonfatal stroke, nonfatal MI, and CV death) vsstandard therapy in patients with type 2 DM athigh risk of CV events

Intensive antihypertensive therapy did reduceboth total strokes (P=0.01) and nonfatal stroke

(P=0.03) vs standard therapy, which weresecondary end points, and there were moreadverse events in the intensive group



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SBP

UKPDSADV

UK Prospective Diabetes Study, BMJ Volume 321, August 12, 2000.

ACCORD

Standards of Medical Care inDiabetes, 2012: HTN/BP Control

Diabetes Care. 2012;Vol 35: Suppl 1,S6.

A systol ic BP goal


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DiabeticCKD

Elderly

BP Targets in Chronic Kidney Disease:Proteinuria as an Effect Modifier

3 RCTs (8 reports) with a total of 2272 participants

MDRD (Modif ication o f Diet in Renal Disease) Study

AASK (African American Study of Kidney Disease and

Hypertension) Trial

REIN-2 (Ramipril Efficacy in Nephropathy 2) trial

Mostly no diabetes

2- to 4-year trial follow-up

[Renal outcomes (not CVD) ]

MDRD Study and AASK Trial also posttrial observational

follow-up

All tr ials with subgroup analyses by baseline proteinuria levels

Upadhyay A, et al. Annals Intern Med 3/2011


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Standard control 300 mg/dayStandard control 176 165 134 113 81 66 45 32 26 22 13

Intensive control 181 172 151 128 109 87 67 56 47 40 25

300 mg/dayStandard control 376 373 362 353 332 302 267 234 214 196 128Intensive control 357 350 335 321 306 282 254 228 206 189 128

Adap ted wi th permi ssi on fro m Appel LJ et al fo r the AA SK Coll abor ativ e Research Group . N Engl J Med. 2010;363:918929.


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Systematic Review: BP Target in CKDProteinuria as an Effect Modifier

Evidence does not conclusively show that the currentlyrecommended BP target of < 130/80 mm Hg improvesclinical outcomes more than a conventional target of 300 to 1000 mg/d.

We suggest that practitioners use discretion inpatients with CKD and proteinuria and base the

BP target on individualized risk-benefit assessment.Treatment to a lower target may require greatervigilance to monitor for and avoid possib le symptomsand adverse events from hypotension.

Upadhyay, A et al.Ann In tern Med 2011;154:541-548.

CKD is a major risk factor for CVD; however, patients withCKD have been under represented in most CV trials that testinterventional strategies, such as BP lowering.

Reducing SBP to levels 4,000 participants with eGFR

20-59 and comparing < 120 mm Hg to < 140 mm Hg.

CKD in SPRINT


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DiabeticCKD

Elderly

BP Targets and Achieved BP in HTNIntervention Studies in Elderly

1. SHEP Cooperative Researc h Group. JAMA. 1991;265(24):3255-3264. 2. Staessen JA, et al. Lancet. 1997;

350(9080):757-764. 3. Beckett NS, et al; for HYVET Study Group. N Engl J Med. 2008;358(18):1887-1898.

SHEP1 Syst-Eur2 HYVET3

Subjects, n 4736 4695 3845

Inclusion BP

Criteria, mm Hg160-219/


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Systolic BP values


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Question 3

What Antihypertensive MedicationsShould Be Recommended as Init ial

Therapy?

Compelling Indications for

Individual Drug Classes

Diuretic

-blocker ACEI ARB CCB

Aldo

Antag. Clin ical Trial Basis

HF

ACC/AHA HF guideline;

MERIT-HF; COPERNICUS,CIBIS, SOLVD; AIRE, TRACE,Val-HeFT; RALES

Post-MI ACC/AHA post-MI guideline;BHAT; SAVE, CAPRICORN,EPHESUS/VALIANT

High CAD

Risk

ALLHAT; HOPE, ANBP2; LIFE;CONVINCE, ONTARGET

Diabetes NKF-ADA guideline; UKPDS;

ALLHAT

CKD NKF guideline; CAPPP;RENAAL; IDNT, REIN, AASK

Stroke PROGRESS, LIFE

Chobanian AV et al. JAMA. 2003;289:2560-2572.

MI=myocardial infarction

CKD=chronic kidney disease


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Stage 1 Hypertension

(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for m ost

May cons ider ACEI, ARB,-blocker, CCB, or c ombination

In Patients With Hypertension

INITIAL DRUG CHOICES

LIFESTYLE MODIFICATIONS

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most

(usually thiazide-type diuretic and

ACEI or ARB or-blocker or CCB)

Management of Blood Pressure

Adapted f rom Cho banian AV et al. Hypertension. 2003;42:12061252.

Years to CHD Event

0 1 2 3 4 5 6 7

C

umulativeCHDEventRate

0

0.04

0.08

0.12

0.16

0.20RR (95% CI) p value

A/C 0.98 (0.901.07) 0.65

L/C 0.99 (0.911.08) 0.81

ChlorthalidoneAmlodipine

Lisinopril

Cumulative Event Rates for the Primary Outcome

(Fatal CHD or Non-fatal MI) by ALLHAT Treatment Group

Adapted with per mission from ALLHAT Of fic ers and Coo rdi nator s for the ALLHAT Collaborat iv e

Research Group. JAMA. 2002;288:29812997.


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ALLHAT Secondary Endpoints: Heart Failure*Rate Lower in Diuretic vs. ACEI or CCB

*Heart failure is a component of combined cardiovascular disease.

Adapted f rom ALLHAT Co llaborativ e Research Grou p. JAMA. 2002;288:29812997.

1.38 (1.251.52)

RR (95% CI)

Favors Am lodipineFavors Li sinopril

Heart failure (fatal, non-fatal,

hosp italized or treated)

1.19 (1.071.31)

Amlod ip ine

Lisinopril

Hospitalized/fatal heart failure

1.35 (1.211.50)

1.10 (0.981.23)Amlod ip ine

Lisinopril

FavorsChlorthalidone

0.5 2.01

JNC-8: What Might Be Expected?

Either a thiazide-type diuretic, CCB,ACEI/ARB will be recommended as ini tialdrug therapy for most patients. Direct renininhibitors wil l be recommended as anadditive but not first l ine agent

Chlorthalidone or indapamide should be

highl ighted as the evidence-based thiazide-type diuretic of choice

Moser M, Basile J, Kaplan M, and Victor R. Med Roundtable Cardiovasc Ed. 2010 pg 267-275.


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Dose-Response Curve With HCTZ: HaveWe Gone Too Far With Low-Dose HCTZ?

Compared w ith HCTZ 25 mg ABP: P = NS vs 12.5 mg (both systolic and diastolic), P=0.0001 vs50 mg systolic, and P = NS vs 50 mg diastolic. N indicates number of patients.

24-HrBPChange

(mmHg)

0

-6

-12

-14

-4

-8

-10

-2

5 Studies(N=123)

50 mg

9 Studies(N=503)

25 mg

4 Studies(N=129)

12.5 mg

-3.3

-5.7

Systolic ambulatory BP (ABP)

Diastolic ABP

-5.4

-7.6

-5.4

-12

Messerli FH et al. J Am Coll Cardiol. 2011:57:590.

NS, not significant

Evidence for Chlorthalidone

MRFIT C or HCTZ vs usual care

TOMHS C vs enalapril, amlodipine (A)doxazosin (D), acebutolol, andplacebo

SHEP C vs placebo

ALLHAT C vs lisinopril, A, and D

1.MRFIT Grimm RH J r et al.Arch Intern Med . 1985;145:1191.2.MRFIT Ci rc ulation1990;82:1616.3.MRFIT Hypert ension 2011;57;689.4.TOMHS Neaton JD et al. JAMA. 1993;270:713.5.SHEP Cooperativ e Res Group. J AMA 1991; 265:3255.6.ALLHAT Col laborativ e Research Group. J AMA 2002; 288: 2981.


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12.411.4

13.5

7.48.1

6.4

-16

-14

-12

-10

-8

-6

-4

-2

0

CLD 25 mg HCTZ 50 mg

Chlorthalidone Has Greater BP-LoweringEfficacy vs HCTZ, Especially at night

CLD=chlorthalidon e; HCTZ=hydrochlorothiazide.

ReductioninMeanSBP

BaselinetoWeek8,mmHg

24-hour Mean SBP Dayt ime Mean SBP Night-time Mean BP

Daytime was 6:00 AM to 10:00 PM; nigh t-t ime, 10:00 PM to 6:00 AM.

P=0.009

P=0.054 P=0.230

Ernst ME, et al. Hypertension. 2006;47:352-358.

Chlorthalidone Has a Longer Half-lifeand Duration of Action vs. HCTZ

Half-life, hours Duration of Action, hours

Single doseLong-term

dosingSingle dose

Long-term

dosing

HCTZ 6-9 8-15 12 16-24

CLD 40 45-60 24-48 48-72

Carter BL, et al. Hypertension. 2004;43:4-9


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Al iskerin

FDA Approved at 150 or 300 mg as initial or additional therapy

ALiskerin Trial In Type 2 Diabetes Using CV

and Renal Disease Endpoints (ALTITUDE)

- Aliskerin vs placebo on top of ACEI or ARB

in type 2 diabetes with renal impairment

- stopped early when DMSB noted more

nonfatal strokes, renal complications,

hyperkalemia, and hypotension over 18-24months follow-up

- still awaiting final publication

No outcomes available as initial antihypertensive

Future Evidence for Aliskerin

ASTRONAUT AliSkerin TRial ON Acute HeartFailure oUTcomes

ATMOSPHEREAliskerin Trial to Minimize

OutcomeS in Patients with

HEart failuRE

APOLLOAliskerin in the Prevention OfLater

Life Outcomes

Gheorghiade M, et al. Eur J Heart Fail. 2011; 13: 100-106.Krum H, et al. Eur J Heart Fail. 2011; 13: 107-14.


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Lifestyle ModificationEspecially Diet and Exercise

Algori thm for BP Contro l in Non-Compell ing Situation(May Start with 2-Drug Combination)

Not at Goal

All Patients

(ACEI or ARB) orThiazideDiuretic

(Use alternative not used above)

(Mineralocortico id Receptor Blocker)

(Vasodilatory BB)

Not at Goal

or Amlod ip ine orNon-Atenolol

BB

Primary Prevention MRC Older AdultsCoronary Events

Cumulative% of events

Follow-up (y)

Atenolol

Placebo

Hctz +Amiloride

MRC Working Party, Br Med J. 1992;304:405-12.

P=0.0009

10

8

6

4

2

0

0 1 2 3 4 5 6 7


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ASCOT-BPLA

ELSA

INVEST

LIFE

MRC Old

UKPDS

Total events

0.5 0.7 1 1.5 2

Atenolol Other drug RR RR(n/N) (n/N) (95% Cl) (95% Cl)

422/9618

14/1157

201/11309

309/4588

56/1102

17/358

1019/28132

327/9639

9/1177

176/11267

232/4605

45/1081

21/400

810/28169

1.29 (1.121.49)

1.58 (0.693.64)

1.14 (0.931.39)

1.34 (1.131.58)

1.22 (0.831.79)

0.90 (0.481.69)

1.26 (1.151.38)

Favorsatenolol Favorsother drug

-Blocker Meta-analysisStroke: Atenolol vs Other Antihypertensive Agents

ASCOT-BPLA, Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure Lowering Arm; CI,confidence interval; ELS A, European Lacidipine Study on Atherosclerosis; INVEST, InternationalVerapamil-Trandolapril Study; L IFE, Losartan Intervention For Endpoint reduction; MRC, MedicalResearch Council; RR, relative risk; UKPDS, United Kingdom Prospective Diabetes Study.

Lindholm LH et al. Lancet. 2005;366(9496):1545-1553.

NICE Treatment of HypertensionUpdate 2011New Cost-Effectiveness Review

of Drug Therapy for Hypertension

NICE. Clinical gui delines (CG127). August 2011. Availabl e at:http://www.nice.org.uk /nicemedia/liv e/13561/56007/56007.pdf. Access ed May 8, 2012.


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Cost Effectiveness ofAntihypertensive Treatment 2011

No intervention Thiazide-type diuretics Calcium-channel blockers

B et a-bl oc ker s ACE i nh ibi to rs /ang iot ens on -II rec ep to r an tag on is ts

4,800

4,600

4,400

4,200

4,000

3,800

9.40 9.60 9.80 10.00 10.20 10.40

Mean Effect (QALYsPer Person, Discounted)

MeanCost(2009UK

PerPerson,Discounted)

1,960

5,400

5,200

4,800

4,600

4,400

4,200

9.80 10.00 10.20 10.40 10.60 10.80

Mean Effect (QALYs

Per Person, Discounted)

1,520

5,000

Men Women

Treating high blood pressure is cheaper than doing nothing

Beta-blockers are the least cost-effective treatment.

apart from no treatment at all Bryan Williams 2011

Base case results (65-year-old, 2% cardiovascular risk, 1.1% diabetes risk, 1% HF risk)

NICE. Clinical gui delines (CG127). August 2011. Availabl e at:http://www.nice.org.uk /nicemedia/liv e/13561/56007/56007.pdf. Access ed May 8, 2012.

Antihypertensive Drug Treatment AlgorithmNICE 2011

Age


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National Institute for Health and Clinical Excellence (NICE)

Places -Blockers as Fifth-Line Treatment for

Uncomplicated Hypertension

NICE Clinical Guideline 127, August 2011.

Beta-blockers are not a preferred initial therapy for uncomplicatedhypertension.

If treatment with three drugs is required, the combination of ACEinhibitor or ARB, calcium-channel blocker and thiazide-like diuretic should beused.

Beta-blockers may be considered in younger people, particularly:-those with an intolerance or contraindication to ACE inhibitors and ARBs-women of child-bearing potential

-people with evidence of increased sympathetic drive.

If therapy is initiated with a beta-blocker and a second drug isrequired, add a calcium-channel blocker rather than a thiazide-likediuretic to reduce the persons risk of developing diabetes.

Question 4

When should 2 or more antihypertensive agents be

recommended as initial therapy, either as a fixed-dose

combination (FDC) or as 2 individual agents?

Which 2 drug combinations have the greatest BP-

lowering effect?


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0.19

In

crementalSBPreductionratio

ofobservedtoexpectedadditiveeffects

Thiazide

Wald DS et al.Am J Med. 2009;122:290-300.

Betablocker

Calciumchannelblocker

Adding a drug from another class (on average standard doses)Doubling dose of same drug (from standard dose to twice standard)

1.04

1.00

1.16

0.89

1.01

0.20.23

0.37

ACEinhibitor

Allclasses

0.22

Combining Drugs from Different Classes is

Approximately 5 Times More Effective in Lowering

BP than Doubling the Dose of 1 Drug

1.00

0.60

0.40

0.20

0

1.40

0.80

1.20

Guideline Recommendations Regarding

Initial Use of Combination Therapy

JNC 7 >20/10 mm Hg

ISHIB >15/10 mm Hg

ESH >20/10 mm Hg OR high cardiovascular risk

AHASBP 160 mm Hg or DBP 100 mm Hgirrespective of the BP goals

NKF K/DOQISBP >20 mm Hg above goal according to

the stage of CKD and CVD risk

J NC 7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.ISHIB, International Society on Hypertension in Blacks.ESH, European Society of Hypertension.

AHA, American Heart Association.NKF K/DOQI , National Kidney Foundation Kidney Disease Outcomes Quality Initiative.

1. Chobanian AV, et al. Hypertension. 2003;42:1206-1252. 2. Douglas J G, et al.Arch Intern Med. 2003;163: 525-541.3. K/DOQI.Am J Kidney Dis. 2004;43 (suppl 1):S65-S230. 4. Mancia G, et al.J Hypertens. 2007;25:1105-1187.

5. Rosendorff C, et al. Circulation. 2007;115;2761-2788.


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45 practices (2048 patients) in southern Ontario randomized to:

Guideline-based stepped care

Based on Canadian Health System Guidelines(similar to J NC 6)

STITCH care algorithm

Start tab single-pill fixed-dose combination of ACEI-diureticor ARB-diuretic

Increase dose of combination tablet

Add calcium channel blocker

Add a peripheral alpha blocker, beta blocker or spironolactone

Primary Outcome = Proportion at BP target at 6 months

The Simpl ified Therapeutic Intervention To

Control Hypertension (STITCH) TrialMethods

Feldman RD, et al. Hypertension. 2009;53(4):646-653.

STITCH STUDY: Main Results

(Summary)Variable Usual Care STITCH P-Value

# of patients 1246 802

Baseline

SBP, mmHg 153.4 155.1 NS

DBP, mmHg 87.7 88.1 NS

Diabetic, % 15.9 15.1 NS

FDC, % 9.3 11.2 NS

BP control, % 0 0 NS

Final visi t

SBP, mmHg -17.5 -22.6


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The Simpl ified Therapeutic Intervention To

Control Hypertension (STITCH) TrialResults

95% CI: 1.5% to 22.4%P=0.026

Feldman RD, et al. Hypertension. 2009;53(4):646-653.

52.764.7

0

10

20

30

40

50

60

70

Guideline-Based Care STITCH-Based Care

Contro l Rates (%)

6-Month Follow-up

Gradman AH, Basile JN, Carter BL, Bakris GL; American Society of Hypertension Writing Group. J Am Soc Hypertens. 2010;4:42.

Drug Combinations in HTN:Recommendations

Preferred

ACE inhibit or /diu ret ic*ARB/d iur etic *ACE inhibit or /CCB*ARB/CCB*

Acceptable

BB/diuretic* CCB (dihydropyridine)/BB CCB/diuretic Renin inhibitor/diuretic* Renin inhibitor/ARB*

Thiazide diuretics/K+ sparing diuretics*

Less effective

ACE inhibit or /ARBACE inhibit or /BBARB/BB CCB (nondihydropyridine)/BB Centrally acting agent/BB

*Single-pill comb inations available in the United States.


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Hermida et al. Hypertension. 2009.

Bedtime Dosing of One BP Medication

in Resistant Hypertension

3 drugs onawakening

One of the drugsat bedtime

ChangeinSBP(mmHg)

-12

-15

-8

-6

-4

-2

0

2

Diurnal mean Nocturnal mean 24-hr mean

P


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Tuesday, July 3, 2020thAnnual Primary Care Conference

Clinical Points

Most patients will require 2 or moreantihypertensive agents to get BP effectivelycontrol led which may be best approached withinitial combination therapy, either as a fixed-dose combination (FDC) or as 2 individual initialagents

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