JNC 8 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Dr. Asif Mehmood R.Ph Pharm. D

HTN patients estimated by 2025 Hypertension (HTN) is a major public health concern, affecting 26% of adults worldwide1 972 million Number of people with HTN worldwide in 20001 60% Increase in the number of adults with HTN globally by 20251 10% Percent of all global healthcare spending attributable to high blood pressure2 1.6 Billion HTN patients estimated by 2025 1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. 2. Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477. $370 billion Annual worldwide cost of hypertension2 1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23. Gaziano TA, Asaf B, S Anand, et.al. The global cost of nonoptimal blood pressure. J Hypertens 2009; 27(7): 1472-1477.

EU Prevalence of Hypertension ~81 Million Adults have elevated Blood Pressure Patients with HTN Diagnosed HTN Treated HTN EU Patients with HTN 81.0M Diagnosed HTN 78% Treated HTN 68% Uncontrolled HTN 38% Resistant HTN 9% - $7.2M Uncontrolled HTN Lloyd-Jones D: Circulation 2010;121:e46 – e215 Persell SD: Hypertension 2011;57:1076-1080 HTN=Hypertension

Hypertension in Pakistan % age of Pakistani adults with HTN 18% %age of Pakistani above 45 years of age 33% are only adequately controlled HTN Cases. 12.5% Time to take some serious action Fahad Saleem et al; Br J Gen Pract. 2010 June 1; 60(575): 449–450. doi: 10.3399/bjgp10X502182

HTN leads to an increased risk of death from stroke and heart disease 8x Cardiovascular Mortality Risk 4x 2x Hypertension is a serious health issue Hypertension significantly increases ones risk of CV mortality For every 20mm Hg, one doubles their CV mortality risk CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2 Systolic BP / Diastolic BP (mmHg) Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913

Risk Factors for Cardiovascular Disease Smoking Hyperlipidaemia High salt intake Homocysteinaemia Lack of exercise Obesity Diabetes Alcohol >4pints of beer/day Genetic

Accurate Reading of Blood Pressure Cuff bladder encircle >80% pts arm sphygmomanometer Deflate 2-3mm per second Siting comfortably Back supported Legs uncrossed Upper arm bared Arm at heart level SBP INACCURATELY HIGH IF: patient is supine, crossed legs, arm below the heart, arm unsupported, undersized cuff. AHA guidelines

Questions Guiding the Evidence Review

Question-1 Specific BP thresholds for Improvement in health outcomes? Start of antihypertensive pharmacologic therapy Improvement in health outcomes? 1) > 160 mm Hg 2) > 150 mm Hg 3) > 140 mm Hg 4) > 130 mm Hg

Question-2 Does a specified BP goal lead to improvements in health outcomes? 1) 130/80 mm Hg in a diabetic 2) < 140/90 in an 84 year old female 3) < 140/90 in a patient with CKD 4) < 120/80 in a 38 year old male

Question-3 Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on Specific health outcomes

Level of Recommendation Strength of Recommendation Grade Strength of Recommendation A Strong Recommendation B Moderate Recommendation C Weak Recommendation There is at least moderate certainty based on evidence that there is a small net benefit. D Recommendation against There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh benefits. E Expert Opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends.”) Net benefit is unclear. JAMA. 2013;():. doi:10.1001/jama.2013.284427

JNC 8 (2014 Hypertension Guideline Management Algorithm) JAMA. 2013;():. doi:10.1001/jama.2013.284427 2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan.

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