Ben Selph Mercer COPHS, Class of 2012 SEGA Geriatrics NICE Guidelines for Hypertension

Importance of lowering blood pressure Lowering blood pressure can significantly decrease risk of CV disease. 61 prospective observational trials, nearly 1 million people, age bands from 40 to 89 Examined relationship between blood pressure level and 12,000 strokes, 34,000 heart disease events over an average of 13.2 years follow-up Reductions in systolic of 20mmHg and diastolic 10mmHg was associated with reductions in death from stroke and ischemic heart disease of about one half (~50%)

Importance of lowering blood pressure A similar analysis of 9 observational studies looking at relationship between BP level and strokes/coronary events found: Reductions in diastolic BP of 5, 7.5, and 10 was associated with reductions in stroke of 34%, 46%, and 56%, and coronary heart disease of 21%, 29%, and 37%, respectively

Cardiovascular risk assessment Important to determine presence of CV disease or high CV risk states (diabetes or CKD). Risk models have been developed for doctors to assess likelihood of patients developing cardiovascular disease. (10 year risk). Factors involved in risk assessment include: Gender, age, diabetic status, smoking status, total cholesterol, HDL cholesterol, and blood pressure. Allows for identification of patients under greatest overall risk and treatment of modifiable risk factors.

Target Organ Damage Medscape Cardiology Medscape.

Target Organ Damage Another important objective in assessing people with suspected hypertension is: To document presence of absence of target organ damage. Examples include: Left ventricular hypertrophy, hypertensive retinopathy, and increased albumin:creatinine ratio (kidney damage)

Clinical Tests Important to perform full CV assessment in patients with persistently high BP that do not have established CV disease. May detect diabetes and signs of developing target organ damage (damage to heart and kidneys) These include: urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total and HDL cholesterol, and 12 lead electrocardiogram

Diagnosis of Hypertension If clinic blood pressure is >140/90, offer AMBULATORY BLOOD PRESSURE MONITORING to confirm diagnosis. When ABPM is used, at least two measurements per hour should be taken during person’s waking hours. Use the average value of at least 14 measurements taken during person’s waking hours to confirm diagnosis of hypertension. The Oscar 2 monitor. The ambulatory blood pressure monitor gizmag.com

Diagnosis Another option is Home Blood Pressure Monitoring (HBPM). When this is used: For each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with person seated, Blood pressure is recorded twice daily, in morning and evening, Blood pressure recording continues for at least 4 days, ideally for 7 days. Measurements on first day are discarded Average of remaining measurements are used to confirm diagnosis Omron blood pressure monitor. BP monitor ratings effectsofhighbloodpressure.com

Diagnosis ABPM/HBPM <135/85 mmHg = Normal >135/85 mmHg = Stage 1 Hypertension >150/95 mmHg = Stage 2 Hypertension

Treatment algorithm

Lifestyle Modifications Dietary modifications and exercise Low calorie diets have modest effect on BP in overweight individuals (avg. 5-6 mm Hg). Aerobic exercise (brisk walking, jogging, or cycling) for min., 3-5 times/week, had small effect on BP (2-3 mm Hg). Relaxation therapies These activities (stress management, meditation, cognitive therapy, muscle relaxation) reduce by average of 3-4 mm Hg.

Lifestyle Modifications Limit alcohol consumption Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health. Reducing alcohol can lower BP 3-4 mm Hg. Limiting excessive consumption of coffee/caffeine (small benefit). Limit dietary sodium intake < 6 g/day, modest reduction of 2-3 mm Hg. Encourage smoking cessation (reduce risk of CV/pulmonary disease).

Initiating Treatment Offer antihypertensive drug treatment to people aged under 80 years with Stage 1 hypertension who have one or more of the following: Target organ damage, established cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater. Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

Initiating Treatment For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, CV disease, renal disease or diabetes, consider specialist evaluation of secondary causes of hypertension and more detailed assessment of potential target organ damage.

Step 1 Treatment > 55 years  CALCIUM CHANNEL BLOCKER Offer to people aged over 55 years and to black people of African or Caribbean family origin of any age. If CCB is not suitable (i.e. edema, intolerance, evidence of heart failure or risk of heart failure), offer a thiazide-like diuretic over conventional thiazide diuretics Chlorthalidone mg daily; indapamide mg once daily Calcium Channel Blockers examples—amlodipine, nifedipine, felodipine, verapamil, diltiazem.

Step 1 Treatment < 55 years  ACE INHIBITOR or ARB Offer people aged under 55 years an ACE inhibitor or a low- cost ARB. If ACE inhibitor is prescribed and is not tolerated (i.e. because of cough), offer a low-cost ARB. ACE inhibitor examples—benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Zestril), quinapril (Accupril), ramipril (Altace) ARB examples—candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)

Step 2 Treatment ACE inhibitor/ARB + Calcium Channel Blocker For those intolerant to CCBs or at high risk of heart failure: ACE inhibitor/ARB + Thiazide-like diuretic. ACCOMPLISH trial and updated cost-effectiveness analysis both favored A + C over A + D

Step 3 Treatment ACEi/ARB + CCB + Thiazide-like diuretic Based on the recommendations and analyses performed in the first two steps. Thiazide diuretic examples: chlorthalidone (Hygroton), indapamide (Lozol), hydrochlorothiazide (Hydrodiuril), metolazone (Zaroxolyn)

Resistant Hypertension: Step 4 treatment Person with confirmed hypertension in whom blood pressure is not controlled (<140/90mmHg) despite treatment with combination of optimum or best tolerated doses of three antihypertensive drugs (generally A+C+D).

Recommendations for Step 4 Addition of low-dose Spironolactone Considered when potassium level is <4.5 mmol/L Potassium, sodium, creatinine: checked 2 weeks after initiation and periodically thereafter. Higher-dose thiazide-like diuretic treatment Considered when potassium level is >4.5 mmol/L Other options for add-on therapy: alpha blockers or beta blockers

Blood Pressure Goals People aged < 80 years with treated hypertension: <140/90 (home: 135/85) People aged > 80 years with treated hypertension: <150/90 (home: 145/85) For people with “white coat effect”—difference of 20/10 mmHg between clinic and average daily reading—consider adjunt ambulatory or home BP measurement to monitor BP.

Comparing NICE with JNC7 (U.S.): Diagnosis NICE Hypertension signaled from clinic reading (>140/90 mm Hg). Officially diagnosed using Ambulatory Blood Pressure Monitoring (>135/85 mm Hg) JNC 7 (U.S.) Mainly based on office BP reading (>140/90) Ambulatory or Home Blood Pressure Monitoring mainly used for self- monitoring.

Comparing NICE with JNC7: Initiation of Medication Therapy NICE: Stage 1 (>135/85mmHg Ambulatory or Home BP) Offer antihypertensive to patients under 80 years if the patient has: Target organ damage, established cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater. Stage 2 (150/95 mmHg ABPM). Offer antihypertensive therapy to patients of any age with Stage 2 hypertension JNC7: After attempt of lifestyle modifications to lower BP, if still not at goal: Stage 1: diuretic or medication for compelling indication Stage 2: diuretic + additional medication considering compelling indication.

Comparing NICE with JNC7 (U.S.): First Medication Therapy Used. NICE: < 55 years: ACE inhibitor or ARB > 55 years: Calcium Channel Blocker If CCB not tolerated or contraindicated, use diuretic. JNC 7: Thiazide diuretic for most Unless diuretic cannot be used or if compelling indication requires use of another class of antihypertensive.

Comparing NICE with JNC7: Additional medication treatment NICE: Step 2: ACEi/ARB + Calcium Channel Blocker Step 3: ACEi/ARB + Calcium Channel Blocker + diuretic Step 4: add spironolactone if K 4.5 mmol/L. Also can add alpha blocker or beta blocker JNC 7: Stage 2 (>160/100 mmHg): Thiazide diuretic + ACEi or ARB or CCB or BB.

Level of Evidence: Class I, Level A

References Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Rocella EJ, and National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Amer Heart Assoc National Institute for Health and Clinical Excellence. Hypertension: clinical management of primary hypertension in adults. CG Medscape Cardiology. New Approaches to Managing Dyslipidemia: Risk Reduction Beyond LDL-C (Slides with Transcript) Available at: Accessed on April 12,