DR. IDOWU AKOLADE EDM DIVISION LUTH EVIDENCE-BASED GUIDELINE FOR THE MANAGEMENT OF HIGH BLOOD PRESSURE IN ADULTS. REPORT FROM JNC 8 DR. IDOWU AKOLADE EDM DIVISION LUTH

Hypertension remains one of the most important preventable contributor to disease and death. It is the most common condition seen in primary care and leads to MI, RF, and death if not detected early and treated appropriately. Patients want to be assured that BP treatment will reduce their disease burden while Clinicians wants guidance on HTN management using the best scientific evidence. The report of JNC8 is long overdue, expected date mid 2011.

The panel members appointed to the 8th joint national committee (JNC8) used rigorous evidence based methods, developing evidence statements and recommendations for BP treatment based on a systematic review of literature to meet user needs.

QUESTIONS GUIDING EVIDENCE REVIEW In adult with HTN, does initiating antihypertensive pharmacological therapy at specific BP thresholds improve health outcomes? In adults with hypertension, does treatment with antihypertensive pharmacological therapy to a specified BP goal lead improvement in health outcomes? In adult with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcome?

WHAT IS KNOWN-CURRENT RECOMMENDATIONS FOR BP GOALS JNC7 <140/90 in general population, in diabetics or CKD <130/80. AHA/ACC 2007, <130/80 in high risk population- CVD,CKD and DM. ADA- DM<130/80 WHO/ISH-<140/90 in general population. In DM, CVD or CKD <130/80 NDOQI CKD<130/80 BHS<140/90 in general population, <130/80 DM,CVD and CKD. ESH ‘’ at least’’ <130/80 in DM, CVD and CKD.

9 recommendations were made based on evidence review. JNC8 recommendation for management of HTN Recommendation 1-5- thresholds and goals for BP treatment Recommendation 6,7,8 – selection of antihypertensive drugs. Recommendation 9- starting and adding antihypertensive drugs.

R 1 In the general population aged ≥60, initiate pharmacologic treatment to lower BP at SBP of ≥150 or DBP ≥90 and treat to a goal of SBP <150 and DBP <90mmhg.   Corollary recommendation- if treatment results in lower achieved SBP e.g <140mmhg and treatment is not associated with adverse effect on health or QOL, treatment does not need to be adjusted. High quality evidence from various rct that in general population greater than 60 yrs , treating bp to a goal lower than 150/90 reduces stroke, HF and CAD and a goal less than 140 provides no additional benefits.

R2 In general population <60yrs, initiate pharmacologic treatment to lower BP at DBP≥90mmhg and treat to a goal DBP <90mmhg(HOT trial). Adults aged 30-59 with elevated bp, initiation of antihypertensive at dpb greater or equal to 90 and treatment to less than 90 reduces cerebrovascular events and overall mortality, while in HOT trial patients were randomised to this 3 goal without any significant statistical difference.

R3-ISH In the general population <60yrs, initiate pharmacologic treatment to lower BP at SBP ≥140mmhg and treatment to a goal of SBP <140mmhg In the absence of any rct that compared the current sbp standard of 140 with another higher or lower standard, there was no compelling reason to change current recommendation and many study participant who achieved dbp less than 90 are also likely to have achieve sbp less than 140.

R4 TARGET In the general population aged ≥18yrs with CKD, initiate pharmacologic treatment to lower BP SBP ≥140mmhg a DBP ≥ 90 mmhg and treat to a goal of SBP<140mmhg or a goal DBP <90mmhg. (AASK & MDRD trials) Relevant clinical trial: AASK or MDRD. No benefit overall in CV or renal outcome. Non of the trials shows that treatment to a lower bp goal of less than 130/80 significant lower kidney or cardiovascular disease end point compared with a goal of 140/90

R5 18+DM In the population aged ≥18yrs with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140mmhg or DBP ≥90mmhg and treat to a goal SDP <140mmhg and goal DBP<90mmhg. (ACCORD-BP trial, UKPDS) The accord BP trial evaluated the effect of targeting a SBP goal of 120mmhg compared to a goal of 140mmhg in patients with T2DM. The result provide no conclusive evidence that the intensive BP control strategy reduces the rate of a composite of major CVD events in such patients.

R6 : WHICH ONE TO START WITH In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide type diuretic, CCB, ACEI and ARB. Each of the four drug classes recommended by the panel yielded comparable effects on the overall mortality and cardiovascular, cerebrovascular and kidney outcome with one exception. Initial treatment with thiazide was more effective than CCB or ACEI ACEI was more effective than CCB in improving heart failure outcomes Panel did not recommend B blocker for initial treatment of HTN because in one study , use of B blocker resulted in higher rate of cardiovascular death , MI or stroke.

R7: INITIAL IS THIAZIDE In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide type diuretic or CCB.( ALLHAT) Thiazide more effective in improving cardiovascular, Heart failure and combined cardiovascular outcome compared to an ACEI in the black patient subgroup. Benedict trial

R8 : CKD In the population aged ≥18yrs with CKD, initial ( or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with HTN regardless of the race or diabetes status. AASK study shows the benefit of ACEI on kidney outcome in black patients with ckd and provide additional evidence that support ACEI use in that population

R9: ADD ONE AT A TIME Attain and maintain goal BP If goal BP is not reached within one month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in R6 Access BP and adjust the regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs , add and initiate a third drug form the list provided . Do not use ACEI and ARB together.

If goal BP cannot be reached using only the drugs in Recommendation 6 because of a contraindication to the need to use more than 3 drugs to reach BP goal, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom BP goal cannot be attained using the above strategies or for the management of complicated patients for whom additional clinical consultation is needed.

COMPARISON OF CURRENT RECOMMENDATIONS WITH JNC7 GUIDELINES Definitions Defined hypertension and prehypertension Definitions of hypertension and prehypertension not addressed, but thresholds for pharmacologic treatment were defined Treatment goals Separate treatment goals defined for “uncomplicated” hypertension and for subsets with various comorbid conditions (diabetes and CKD) Similar treatment goals defined for all hypertensive populations except when evidence review supports different goals for a particular subpopulation Lifestyle recommendations Recommended lifestyle modifications based on literature review and expert opinion Lifestyle modifications recommended by endorsing the evidencebased Recommendations of the Lifestyle Work Group Drug therapy Recommended 5 classes to be considered as initial therapy but recommended thiazide-type diuretics as initial therapy for most patients without compelling indication for another class Specified particular antihypertensive medication classes for patients with compelling indications, ie, diabetes, CKD, heart failure, myocardial infarction, stroke, and high CVD risk Included a comprehensive table of oral antihypertensive drugs including names and usual dose ranges Recommended selection among 4 specific medication classes (ACEI or ARB, CCB or diuretics) and doses based on RCT evidence Recommended specific medication classes based on evidence review for racial, CKD, and diabetic subgroups Panel created a table of drugs and doses used in the outcome trials Scope of topics Addressed multiple issues (blood pressure measurement methods, patient evaluation components, secondary hypertension, adherence to regimens, resistant hypertension, and hypertension in special populations) based on literature review and expert opinion Evidence review of RCTs addressed a limited number of questions, those judged by the panel to be of highest priority.

CONCLUSION Evidence based guideline has not redefined high BP and the panel believes that the 140/90mmhg definition of JNC7 remains reasonable. For all patients with HTN, the potential benefits of healthy diet, weight control and regular exercise cannot be overemphasized. These recommendations are not a substitute for clinical judgement and decision about care must carefully consider and incorporate the clinical characteristic circumstances of each individual patient.

References ICSI Hypertension evidence 2010 version. Treatment blood pressure targets for HTN : Cochicine review 2009. ACCORD- BP study march 14, 2010, effect of intensive BP control in T2DM INVEST diabetes study group : tight blood pressure control and cardiovascular outcome among hypertensive patients with diabetes and CAD, JAMA vol 304,1, 61-67. Hypertension in the very elderly trial ( HYVET) 2010. N Engl J Med 2008: 358 (18): 1887-98. Staessen JA, Fagard R, Thijs L, et al; The Systolic Hypertension in Europe (Syst-Eur) Trial

References 7. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887-1898. 8. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265(24):3255-3264. 9. Institute of Medicine. Clinical Practice Guidelines We Can Trust.Washington, DC: National Academies Press; 2011. http://www.iom.edu/Reports/2011 /Clinical-Practice-Guidelines-We-Can-Trust.aspx. Accessed November 4, 2013. 10. Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval. 2007;12(10). http://pareonline.net/pdf/v12n10.pdf. Accessed October 28, 2013. 11. Institute of Medicine. Finding WhatWorks in Health Care: Standards for Systematic Reviews.