Hypertension Beyond JNC7

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Hypertension Beyond JNC-7

• Richard Derby, LtCol, USAF, MC
• Malcolm Grow Medical Center
• Andrews AFB

2
Focus Points

• Current Snapshot
• clinical impact
• treatment success
• Guidelines of care
• JNC 7 key points
• Emerging data
• beyond JNC 7

3
Stats of interest

• 72 million affected in the U.S.
  (1 in every 3 Americans / over a billion
  worldwide)
• 90 lifetime risk for those gt 55 yrs (Framingham
  data applicable to U.S.)
• Up to 5 of adolescents in the U.S. (small
  cohort data)
• Most common Primary Care
  Diagnosis in U.S.
  (more than 35 million office visits)

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Impact

• Hypertension elevates cardiovascular disease risk
  independent of other risk factors

CVD Risk Doubles each elevation of 20mm Hg SBP
or 10mm Hg DBP (starting from 115/75)
MI
Stroke
CHF
CKD
5
2004 National Death Stats

• All causes ...................................
  ..................................................
  ........ 2,397,615
• 1. Diseases of heart .............................
  .............. 652,486
• 2. Malignant neoplasms .........................
  ..................................................
  .553,888
• 3. Cerebrovascular diseases ......................
  ........150,074
• 4. Chronic lower respiratory diseases
  ..................................................
  .... 121,987
• 5. Accidents (unintentional injuries)
  ..................................................
  ....... 112,012
• 6. Diabetes mellitus ...........................
  ..................................................
  .......73,138
• 7. Alzheimers disease .........................
  ..................................................
  ....65,965
• 8. Influenza and pneumonia .....................
  ..................................................
  59,664
• 9. Nephritis, nephrotic syndrome and nephrosis
  ........................................42,480
• 10. Septicemia ...................................
  ..................................................
  ...... .33,373
• 11. Intentional self-harm (suicide)
  ..................................................
  ............ 32,439
• 12. Chronic liver disease and cirrhosis
  ..................................................
  ...... 27,013
• 13. Essential (primary) hypertension...
  23,076
• hypertensive renal disease
• 14. Parkinsons disease ..........................
  ..................................................
  .. 17,989
• 15. Assault (homicide) ...........................
  ..................................................
  ... 17,357
• All other causes ...........................
  ..................................................
  ..... 414,674

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Can we make a difference?

• Antihypertensive therapy
• 35-40 Stroke
• 20-25 MI
• 50 Heart failure
• 12mm Hg decrease in SBP for 10 years
• prevents 1 death for every 11 treated

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Do we make a difference?

• Age-adjusted CAD death rates

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Do we make a difference?
Age-adjusted Stroke death rates
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In practice

• National Health and Nutrition Examination Survey
  (18 to 74 y/o)
• 1976-80 1988-91
  1991-94 1999-00
• Awareness 51 73 68
  70
• Treatment 31 55 54
  59
• Control 10 29
  27 34

BP CONTROL Canada 17 European countries lt 10
Healthy people 2010 goal 50 control
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Snapshot review

• A disease of enormous scope
• Effective treatments with meaningful outcomes
• Treatments poorly executed (34 control)

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JNC 7 review

• A guideline source to help with
• Detection
• Evaluation
• Treatment

5 writing teams Commissioned by NHBPEP MeSH
search 1997-2003 386 reference review
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Detection - current definitions

• Classification Systolic Diastolic
• Normal lt 120 and lt 80
• Prehypertension 120-139 or 80-89
• Stage I HTN 140-159 or 90-99
• Stage 2 HTN gt 160 or gt 100
• (2 or more readings)

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Detection - methods

• 24 hour ambulatory
• Assesses white coat effect
• Better measure of CVD risk
• Assesses BP drop during sleep

• In office
• At least 2 readings
• Proper measurement technique
• Avoid caffeine, exercise, tobacco prior to visit

• Self measurement
• Equipment / technique check
• Fosters patient involvement
• Assesses white coat effect and response to
  therapy

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Evaluation

• Three objectives
• Assess lifestyle identify other CV risk factors
  or concomitant disorders affecting prognosis and
  treatment
• Reveal identifiable causes of high BP
• - Secondary cause of hypertension
• Assess the presence or absence of target organ
  damage and CVD
• - labs/tests

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CV risk factors
Cigarette smoking
Obesity (BMI gt 30kg/m²
Physical inactivity
Dyslipidemia
Microalbuminuria or GFR lt 60 ml/min
Age (men gt 55, women
gt 65)
Family History of premature CVD (men lt
55 or women lt 65)
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Treatment

• Establish goals of therapy
• Lifestyle modifications
• Pharmacologic
• Follow up care/monitoring

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Treatment Goals
SBP gt 140 more important CVD risk factor than
DBP in those gt 50 years old

• Bottom line reduce morbidity mortality from
  disease related to hypertension
• BP measures
• lt 140/90
• lt 130/80
• in diabetic and CKD patients

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Lifestyle modification

• Start with all prehypertensive patients
• Weight loss (10kg) 5-20 mm Hg
• DASH diet 8-14 mm Hg
• Low Na diet 2-8 mm Hg
• Physical activity 4-9 mm Hg
• Moderate Etoh 2-4 mm Hg
• - Effects time and dose/degree dependent
• - Always recommend tobacco cessation

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Medication therapy

• Think thiazide-type diuretics first for
  uncomplicated hypertension
• Consider compelling indications in using
  specific antihypertensive drug class
• Most patient will ultimately require 2 or more
  medication classes to reach goal
• Consider initial 2 agent therapy if BP more than
  20/10 mm Hg above goal (one being
  thiazide-type diuretic)

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Compelling indications

• Ischemic Heart Disease
• Stable angina
• Acute Coronary syn.
• Post MI
• Heart Failure
• Class I-II
• Class III-IV
• Diabetes

• b-blocker, long acting CCB
• b-blocker, ACE-I
• ACE-I, b-blocker, aldosterone blocker
• ACE-I, b-blocker
• ACE-I, b-blocker, ARBs aldo - blocker, loop
  diuretics
• ACE-I and ARBs prevent nephropathy
• Thiazide diuretic, b-blocker, ACE-I, ARBs, CCBs -
  all reduce CVD/Stroke

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Compelling indications

• ACE-I and ARBs prevent nephropathy
• ACE-I and thiazide diuretic combination reduce
  recurrence

• Chronic Kidney disease
• Cerebrovascular disease

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Special Populations

• Minorities (blacks)
• Older Patients gt 65 y/o
• group with lowest BP control
• Pregnancy
• Children/adolescents

• Better response with diuretics and CCBs (ACE-I
  induced angioedema 2-4x more frequent)
• Thiazides first line. All classes open, consider
  medication side effect profile.
• Methydopa, b-blockers, vasodialators (NO ACE-I,
  ARBs)
• BP gt 95th percentile (age, ht, sex)
• All classes open if needed

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Follow up at goal? If not why not?

• Improper BP measurement
• Volume overload
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Non-compliance
• Inadequate doses
• Drug actions and interactions (e.g., NSAIDS,
  illicit drugs, sympathomimetics, oral
  contraceptives)
• Over-the-counter drugs and herbal supplements
• Excess alcohol intake
• Obesity
• Secondary causes

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Partner with patient

• Effective therapy will control hypertension
  only if the patient is motivated. Positive
  physician experience and trust improve patient
  motivation. Empathy builds trust.
• - JNC 7

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JNC-7 Review
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Whats new

• Diuretic therapy is gold standard
• Beta blockers shrinking role
• ARBs expanding role
• Optimal control redefined

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Grimm, R. Diuretics Are Preferred Over
Angiotensin II-Converting Enzyme Inhibitors For
Initial Therapy of Uncomplicated Hypertension.
American Journal of Kidney Diseases, Vol 50, No 2
(August), 2007 pp 188-196.

• 50 years after their introduction, diuretics
  remain the single best drug for initiating the
  treatment of hypertension.
• In head-to-head comparisons with placebo and
  other antihypertensives in major trials,
  diuretics have consistently proven to be superior
  for lowering BP.

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Wiysonge CS, Bradley H, Mayosi BM, Maroney R,
Mbewu A, Opie LH,Volmink J.. Beta-blockers for
hypertension. Cochrane Database of Systematic
Reviews 2007, Issue 1.

• Available evidence does NOT support
• the use of beta-blockers as first-line drugs
• in the treatment of hypertension.
• Atenolol accounted for 75 of med taken in these
  studies
• Effect unknown for different ages and beta
  blocker sub-types

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Expanding ARB role

• PPAR-?
  (Peroxisome Proliferator-Activated Receptor?)
• Therapeutic target for metabolic syndrome for
  improving glucose and lipid metabolism
• Pioglitazone and Rosiglitazone act as PPAR-?
  activators
• Telmisartan (ARB) is found to significantly
  activate PPAR-?

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Clinical effect of PPAR-? activation

• Lower serum glucose
• Lower serum triglycerides
• Does this equate with better outcomes in regard
  to CVD?

Clinical trials pending Ongoing Telmisartan
Alone and in Combination with Ramipril Global
Endpoint Trial (ONTARGET) Telmisartan Randomized
Assessment Study in ACE-Intolerant Subjects with
Cardiovascular Disease (TRANSCEND)
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Optimal BP control

• Lower BP lower CV events
• regardless of antihypertensive agent
• lt 130/80 vs. lt140/90
• Daily BP changes/variation have significant
  impact on outcomes
• Night vs. Daytime
• BP measures in different settings (office, home,
  24 hour)

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• Office, home, and 24-hour mean daytime and
  nighttime systolic blood pressure at entry as
  predictors of 11-year risk for cardiovascular
  death in the Pressioni Arteriose Monitorate E
  Loro Associazioni (PAMELA) study.
  (Circulation 111. 1777-1783.2005)

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• Kaplan-Meier curves for all-cause and
  cardiovascular deaths with no blood pressure (BP)
  elevations, or with elevations in 1, 2, or 3 BP
  measurements (office, home, and 24-hour
  ambulatory). (Hypertension 47. 846-853. 2006)

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Home monitoring

• Question Does home monitoring improve blood
  pressure control in people with hypertension?
• Answer YES! (Review of 18 RCTs shows mean
  of 4mm SBP 2.5mm DBP)

Cappuccio FP, Kerry SM, Forbes L, Donald A. Blood
pressure control by home monitoring
meta-analysis of randomised trials. BMJ 2004
329145.
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Will Paradigms of BP control shift?

• Minimum goal for all patients lt 130/80
• More aggressive and earlier use of
  anti-hypertensives
• More intensive monitoring to ensure adequate
  control
• Use of long acting meds as a rule to achieve 24
  hour control

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In Summary we

• Took a current snapshot of hypertensive disease
• Reviewed key points of JNC-7
• Looked at emerging information beyond JNC-7

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References

• JNC 7 Report Hypertension 2003421206-1252
  (http//hyper.ahajournals.org/cgi/content/full/42/
  6/1206)
• Khan N McAlister F. Review Re-examining the
  efficacy of ß-blockers for the treatment of
  hypertension a meta-analysis. Canadian Medical
  AssociationJournal - Vol 174, Issue 12 (June
  2006)  
• Mancia G. Blood Pressure Reduction and
  Cardiovascular Outcomes Past, Present, and
  Future. The American Journal of Cardiology - Vol
  100, Issue 3A (August 2007)
• National Vital Statistics Reports. Vol 54,
  Number 19, June 28, 2006
• Grimm, R. Diuretics Are Preferred Over
  Angiotensin II-Converting Enzyme Inhibitors For
  Initial Therapy of Uncomplicated Hypertension.
  American Journal of Kidney Diseases, Vol 50, No 2
  (August), 2007 pp 188-196.
• Kurtz T. W. New Treatment Strategies for
  Patients with Hypertension and Insulin
  Resistance. The American Journal of Medicine
  (2006) Vol 119 (5A), 24S-30S
• Wiysonge CS, Bradley H, Mayosi BM, Maroney R,
  Mbewu A, Opie LH, Volmink J.. Beta-blockers for
  hypertension. Cochrane Database of Systematic
  Reviews 2007, Issue 1.

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Routine Labs / Tests prior to initating therapy

• 12-lead ECG
• urinalysis
• blood glucose
• hematocrit
• serum potassium calcium
• creatinine (estimated GFR)
• Lipid profile (fasting) that includes HDL, LDL
  triglycerides
• urinary albumin excretion or
  albumin/creatinine ratio

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Stay tunedcoming up next

• Dr. Jim Scott Secondary
  Causes of Hypertension