Hypertensierichtlijnen, quo vadis? Wilko Spiering, internist-vasculair geneeskundige Afd. Vasculaire Geneeskunde

Transcription

1 Hypertensierichtlijnen, quo vadis? Wilko Spiering, internist-vasculair geneeskundige Afd. Vasculaire Geneeskunde RadboudHypertensieSymposium 2015,

2 Disclosure Geen

3 Outline presentation Case Landscape of hypertension guidelines Definition of hypertension Diagnosis of hypertension When to start therapy? Blood pressure goal Which drug to choose? Treatment algorithm Conclusions

4 Case

5 Mr. O. 74 years old Type 2 diabetes, dyslipidemia Previous visit RR 156/98 Current visit RR 154/92 Current medication: Metformin Simvastatin egfr 56 ml/min/1.73m2, ACR 2.7 mg/mmol

6 Mr. O. BP goal? A. <150/90. B. <140/90. C. <140/85. D. <130/80. First line drug? A. ACEI. B. Thiazide. C. CCB. D. All three are equal.

7 Landscape of hypertension guidelines

8 Recent hypertension guidelines 2011 Dutch CVRM 2011 NICE 2012 KDIGO 2013 ESH/ESC 2013 AHA/ACC/CDC 2014 ASH/ISH 2014 CHEP 2014 ADA 2014 JNC 8

9 Which one to follow in the Netherlands?

10 JNC 8

11 Development of JNC 8 Commissioned by the NHLBI in 2008 Panel members appointed Developed focused critical questions relevant to practice Systematic search of pertinent literature Limited to RCTs between 1966 and 2009 Adults 18 years with hypertension Sample size 100 patients Follow-up 1 year Only relevant outcomes (death, MI, stroke, HF, ESRD) Subsequent search from 2009 to 2013 with 2000 patients

12 Main questions Does initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes? =>When to start therapy? Does treatment with antihypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes? =>Which BP goal? Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? =>Which drug to choose?

13 Graded recommendations A: Strong B: Moderate C: Weak D: Against E: Expert Opinion N: No recommendation

14 Dissenting editorial 5/17 (29%) authors JNC 8 Insufficient evidence to increase target SBP to 150 mmhg Expertise vs. scientific evidence Wright, Ann Intern Med 2014

15 Development of JNC 8 Report sent by NHLBI for external review Revision report and resubmission to NHLBI NHLBI decides that it will no longer publish clinical guidelines Report handed over to AHA/ACC Appointed panel members for JNC 8 decided not to wait and publish their findings independently Published online in JAMA in December 2013

16 Definition of hypertension

17 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 and/or High normal and/or Grade 1 hypertension and/or Grade 2 hypertension and/or 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: Medical Education & Information for all Media, all Disciplines, from all over the World Powered by

18 Definitions Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmhg or higher and ABPM or HBPM average is 135/85 mmhg or higher. Stage 2 hypertension: Clinic BP 160/100 mmhg is or higher and ABPM or HBPM daytime average is 150/95 mmhg or higher. Severe hypertension: Clinic BP is 180 mmhg or higher or Clinic diastolic BP is 110 mmhg or higher.

19 Diagnosis of hypertension

20 2013 ESH/ESC Guidelines for the management of arterial hypertension Office BP measurement When measuring BP in the office, care should be taken: To allow the patients to sit for 3 5 minutes before beginning BP measurements To take at least two BP measurements, in the sitting position, spaced 1 2 min apart, and additional measurements if the first two are quite different. Consider the average BP if deemed appropriate To take repeated measurements of BP to improve accuracy in patients with arrhythmias, such as atrial fibrillation To use a standard bladder (12 13 cm wide and 35 cm long), but have a larger and a smaller bladder available for large (arm circumference >32 cm) and thin arms, respectively To have the cuff at the heart level, whatever the position of the patient When adopting the auscultatory method, use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively To measure BP in both arms at first visit to detect possible differences. In this instance, take the arm with the higher value as the reference To measure at first visit BP 1 and 3 min after assumption of the standing position in elderly subjects, diabetic patients, and in other conditions in which orthostatic hypotension may be frequent or suspected To measure, in case of conventional BP measurement, heart rate by pulse palpation (at least 30 s) after the second measurement in the sitting position BP, 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: Medical Education & Information for all Media, all Disciplines, from all over the World Powered by

21 2013 ESH/ESC Guidelines for the management of arterial hypertension Definitions of hypertension by office and out-of-office BP levels Category Systolic BP (mmhg) Diastolic BP (mmhg) Office BP 140 and 90 Ambulatory BP Daytime (or awake) 135 and/or 85 Nighttime (or asleep) 120 and/or h 130 and/or 80 Home BP 135 and/or 85 BP, 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: Medical Education & Information for all Media, all Disciplines, from all over the World Powered by

22 Diagnosis (1) If the clinic blood pressure is 140/90 mmhg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

23 Costs and savings for total population of England Costs and savings of using ABPM to confirm diagnosis of hypertension Year Change in diagnosis cost ( m) Change in treatment cost ( m) Net resource impact ( m) Year Year Year Year Year Cost data correct at August This has not been updated for this 2nd edition

24 When to start therapy?

25 Risk-driven?

26 2013 ESH/ESC Guidelines for the management of arterial hypertension Initiation of lifestyle changes and antihypertensive drug treatment Other risk factors, asymptomatic organ damage or disease High normal SBP or DBP Blood pressure (mmhg) Grade 1 HT SBP or DBP Grade 2 HT SBP or DBP Grade 3 HT SBP 180 or DBP 110 No other RF No BP intervention Lifestyle changes for several months Then add BP drugs targeting <140/90 Lifestyle changes for several weeks Then add BP drugs targeting <140/90 Lifestyle changes Immediate BP drugs targeting <140/ RF Lifestyle changes No BP intervention Lifestyle changes for several weeks Then add BP drugs targeting <140/90 Lifestyle changes for several weeks Then add BP drugs targeting <140/90 Lifestyle changes Immediate BP drugs targeting <140/90 3 RF Lifestyle changes No BP intervention Lifestyle changes for several weeks Then add BP drugs targeting <140/90 Lifestyle changes BP drugs targeting <140/90 Lifestyle changes Immediate BP drugs targeting <140/90 OD, CKD stage 3 or diabetes Lifestyle changes No BP intervention Lifestyle changes BP drugs targeting <140/90 Lifestyle changes BP drugs targeting <140/90 Lifestyle changes Immediate BP drugs targeting <140/90 Symptomatic CVD, CKD stage 4 or diabetes with OD/RFs Lifestyle changes No BP intervention Lifestyle changes BP drugs targeting <140/90 Lifestyle changes BP drugs targeting <140/90 Lifestyle changes Immediate BP drugs targeting <140/90 BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DBP, diastolic blood pressure; HT, hypertension; OD, organ damage; RF, risk factor; SBP, systolic 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: Medical Education & Information for all Media, all Disciplines, from all over the World Powered by

27 JNC 8: initiation of therapy 1. In the general population 60 years initiate pharmacologic treatment to lower BP at SBP 150 mm Hg or DBP 90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mmhg (A). 2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP 90 mm Hg and treat to a goal DBP <90 mm Hg (30-59 years: A; years: E). 3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg and treat to a goal SBP <140mmHg (E).

28 JNC 8: initiation of therapy 4. In the population 18 years with CKD, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg (E). 5. In the population 18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg (E).

29 Blood pressure goal

30 2013 ESH/ESC Guidelines for the management of arterial hypertension Blood pressure goals in hypertensive patients Recommendations SBP goal for most 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 Ages <80 years Initial SBP 160 mmhg SBP goal for fit elderly Aged <80 years SBP goal for elderly >80 years with SBP 160 mmhg DBP goal for most DB goal for patients with diabetes <140 mmhg mmhg <140 mmhg mmhg <90 mmhg <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: Medical Education & Information for all Media, all Disciplines, from all over the World Powered by

31 JNC 8: BP goal years

32 Hypertension in the elderly (60-80) Systolic Hypertension in the Elderly Program (SHEP): 4736 patients aged >60 (average age 72) Randomized to active treatment vs. placebo Achieved BP 143/68 vs. 155/72 Significant reductions in stroke, CV events, and death Systolic Hypertension in Europe (Syst-Eur): 4695 patients aged >60 (average age 70) Randomized to active treatment vs. placebo Achieved BP not reported Significant reductions in stroke, CV events, and CV death JAMA 1991 Staessen, Lancet 1997

33 Hypertension in the elderly (60-80) Japanese Trial to Assess Optimal SBP (JATOS): 4416 patients aged (average age 74) Randomized to SBP <140 vs. SBP Achieved BP 136/75 vs. 146/78 No difference in CV events or renal failure Valsartan in elderly isolated systolic hypertension (VALISH): 3079 patients aged (average age 76) Randomized to SBP <140 or SBP Achieved BP 137/75 vs. 142/77 No difference in stroke, CV events, or renal failure Overall event rates were lower than anticipated in both trials JATOS Study Group, Hypertens Res 2008 Ogihara, Hypertension 2010

34 BP Goal BP goal in different guidelines CVRM 2011 NICE 2011 ESC/ESH 2013 ASH/ISH 2014 Age <60 <140 <140/90 <140/90 <140/90 (<130/80) Age <140 <140/90 <140/90 (<150/90) Age >80 <150 <150/90 < /90 Diabetes <140 (<130) CKD - - <140/90 (<130/90) JNC <140/90 <140/90 <150/90 <150/90 <150/90 - <140/85 <140/90 <140/90 <140/90 <140/90

35 Which drug to choose?

36 JNC 8: first line drug 6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide, CCB, ACEI or ARB (B). 7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide or CCB (general black population: B; black patients with diabetes: C). 8. In the population 18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes (B).

37 First line drug in different guidelines BP Goal CVRM 2011 NICE 2011 ESC/ESH 2013 ASH/ISH 2014 JNC Non-black (no DM or CKD) <50: ACEI, ARB >50: CCB, thiazide <55: ACEI, ARB >55: CCB Thiazide, ACEI, ARB, CCB, BB <60: ACEI, ARB >60: CCB, thiazide Thiazide, ACEI, ARB, CCB Black (no DM or CKD) Thiazide, CCB Thiazide, CCB Thiazide, CCB Thiazide, CCB Thiazide, CCB Diabetes Thiazide - ACEI, ARB ACEI, ARB, CCB, thiazide ACEI, ARB, CCB, thiazide CKD ACEI, ARB - ACEI, ARB ACEI, ARB ACEI, ARB

38 Treatment algorithm

39 Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C 2 Step 1 Summary of antihypertensive drug treatment A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5

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41 Conclusions Landscape of sometimes confusing hypertension guidelines Mandatory use of ambulatory BP measurements still lacking BP goal in general: years: <140/90 >80 years: <150/90 Most patients need 2 drugs, so combination of thiazide, ACEI/ARB, CCB often needed Use guidelines as framework and keep thinking!

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43 Mr. O. 74 years old Type 2 diabetes, dyslipidemia Previous visit RR 156/98 Current visit RR 154/92 Current medication: Metformin Simvastatin egfr 56 ml/min/1.73m2, ACR 2.7 mg/mmol

44 Mr. O. BP goal? A. <150/90. B. <140/90. C. <140/85. D. <130/80. First line drug? A. ACEI. B. Thiazide. C. CCB. D. All three are equal.