Hypertension Guidelines 2014

Jason A. Smith, DO
Associated Cardiovascular Consultants at
Lourdes Cardiology Services
Disclosures

No disclosures
Hypertension

• Hypertension is the most common

condition in primary care.

• 1 in 3 patients have hypertension

according to NHLBI

• Risk factor for MI, CVA, ARF, death

Hypertension
Case

• A 58 year old African-American woman

with diabetes and dyslipidemia has a
BP of 158/94 confirmed on several
office visits. Other than obesity, the
exam is normal. Labs show normal
renal function, well-controlled lipids on
atorvastatin and well-controlled
diabetes on metformin. Urine micro-
albumin is mildly elevated.
Case Question 1

• What goal BP is most appropriate for

this patient?
1. <150/90 mmHg
2. <130/80 mmHg
3. <140/90 mmHg
4. <140/80 mmHg
5. <140/85 mmHg
Case Question 2

• What is the drug of choice to start?

1. HCTZ
2. Norvasc
3. Lisinopril
4. Losartan
5. Bystolic
6. Combination therapy
Classification of BP – JNC 7

Systolic Diastolic
Category
(mmHg) (mmHg)
Normal < 120 and < 80

Pre-HTN 120-139 or 80-89

Hypertension

Stage I 140-159 or 90-99

Stage II > 160 or > 100

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions and classification of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg ± DBP >90 mmHg

Category Systolic Diastolic

Optimal <120 and <80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension ≥180 and/or ≥110

Isolated systolic hypertension ≥140 and <90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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JNC 8

• 2014 Evidence-Based Guidelines for

the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
– December 18, 2013
JNC 8: Hypertension Management
Questions Guiding Review
• In adults with HTN:
1. Does initiating antihypertensive
pharmacologic therapy at specific BP
thresholds improve health outcomes?
2. Does treatment with antihypertensive
pharmacologic therapy to a specified goal
lead to improvements in health outcomes?
3. Do various antihypertensive drugs or drug
classes differ in comparative benefits and
harms on specific health outcomes?
JNC 8: Hypertension Management
Evidence Review
• Limited to RCT’s
– Hypertensive adults > 18 years old
– Sample size > 100
– Follow-up > 1 year
– Reported effect of treatment on important
health outcomes (mortality, MI, HF, CVA,
ESRD)
• January 1966 to December 2009
– Separate criteria used of RCT’s published
after December 2009
JNC 8: Hypertension Management
Evidence Review
• RCT’s December 2009 – August 2013
1. Major study in hypertension
• ACCORD, NEJM 2010
2. > 2,000 participants
3. Multicentered
4. Met all other inclusion/exclusion criteria
JNC 8: Graded Recommendations

A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
 JNC 8: Drug Treatment
Thresholds and Goals
• Age > 60 yo
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A
 JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yo
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for ages 40-59; Grade E for ages 18-
39
 JNC 8: Drug Treatment
Thresholds and Goals
• Age > 18 yo with CKD or DM
– JNC 7: < 130/80 (MDRD NEJM 1994)
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E

– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade E
JNC 8: Initial Drug Choice

• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B

• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
JNC 8: Initial Drug Choice

• Age > 18 yo with CKD and HTN

(regardless of race or diabetes)
– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria
• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo
• Diuretic is an option for initial therapy
JNC 8: Subsequent Management

• Reassess treatment monthly

• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
– Consider referral to HTN specialist
– LOE: Grade E
Dissenting Editorial

• Ann Intern Med. January 14, 2014

• 5/17 authors (29%)

• “Insufficient evidence” to increase

target SBP to 150 mmHg.

• Expertise vs. Scientific Evidence

Recent HTN Guideline Statements

• 2013 ESH/ESC Guidelines for the

management of arterial hypertension.
• J Hypertnsion 2013;31:1281-1357.
• An Effective Approach to High Blood
Pressure Control: A Science Advisory
From the AHA, ACC, and CDC.
• Hypertension online November 15, 2013.
• Clinical Practice Guidelines for the
Management of HTN in the Community
A Statements by the ASH/ISH.
• J Hypertension 2014;32:3-15
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for “most” <140 mmHg
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD

SBP goal for elderly 140-150 mmHg

•Ages <80 years
•Initial SBP ≥160 mmHg

SBP goal for fit elderly <140 mmHg

Aged <80 years

SBP goal for elderly >80 years with SBP 140-150 mmHg
•≥160 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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BP goal in the elderly
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations Additonal considerations
Mandatory: initiate drug treatment in patients • Strongly recommended: start drug treatment
with SBP ≥160 mmHg when SBP ≥140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg

All hypertension treatment agents are • RAS blockers may be preferred

recommended and may be used in patients with • Especially in presence of preoteinuria or
diabetes microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not • Avoid in patients with diabetes

recommended

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with nephropathy

Recommendations Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria • Monitor changes in eGFR

RAS blockers more effective to reduce • Indicated in presence of microalbuminuria or

albuminuria than other agents overt proteinuria

Combination therapy usually required to reach BP • Combine RAS blockers with other agents
goals

Combination of two RAS blockers • Not recommended

Aldosterone antagonist not recommended in CKD • Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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What is the goal BP?
 Comparison of Recent
Guideline Statements

JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90
Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr
for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr
140-150 if <80 yr

B-blocker No Yes No No
First line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100

w/ 2 drugs elevated BP"
 Goal BP
Group BP Goal (mm Hg)
General DM* CKD**
JNC 8: <60 yr: <140/90 < 140/90 < 140/90
>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)
ASH/ISH < 140/90 < 140/90 < 140/90
>80 yr: <150/90 (Consider < 130/80 if proteinuria)
AHA/ACC < 140/90 < 140/90 < 140/90

**KDIGO: <140/90 w/o albuminuria

*ADA: < 140/80 or lower
<130/80 if >30 mg/24hr
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)

Quit smoking

* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Thank you for your attention!

smithj@lourdesnet.org