1. 2017 Guideline for High Blood Pressure in Adults
What should we do in LTC?

2. 2014 Evidence-Based Guideline for Management of HTN in Adults Report From the Panel Members Appointed to JNC 8
Hypertension is the most common condition seen in primary care and leads to MI, CVA, renal failure, and death if not detected early and treated appropriately
Evidence was drawn from RCTs, which represent the gold standard for determining efficacy and effectiveness
Evidence quality and recommendations were graded based on their effect on important outcomes

3. 2014 Evidence-Based Guideline for Mgmt of HTN in Adults
There is strong evidence to support treating hypertensive persons >60 to a BP goal of <150/90 and HTN persons 30 –59 years to a diastolic goal of <90
There is insufficient evidence in HTN persons <60 years for a systolic goal or in those <30 for a diastolic goal, so the panel recommends a BP of <140/90 for those groups
The same thresholds and goals are recommended for HTN adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general HTN population <60
There is moderate evidence to support initiating drug treatment with an ACEI, ARB, Ca++ Channel blocker or thiazide diuretic in nonblack hypertensives, including those with DM
In black hypertensives, including those with diabetes, a Ca++ Channel blocker or thiazide diuretic is recommended as initial therapy
There is moderate evidence to support initial or add-on HTN therapy with an ACEI or ARB in persons with CKD

4. Pharmacologic Treatment of HTN in Adults >60 to Higher vs Lower BP Targets: A CPG from the ACP and AAFP; March 2017
The target patient population includes all adults >60 with HTN
Based on a systematic review of published RCTs for primary outcomes and observational studies for harms through 9/ 2016
Evaluated outcomes included all-cause mortality, M&M related to CVA, major cardiac events (fatal & nonfatal MI & sudden cardiac death), and harms

5. Recommendation 1
Initiate treatment in adults >60 with systolic BP persistently >150 to achieve a target systolic BP of <150 to reduce risk for mortality, stroke, and cardiac events. (Grade: strong rec, high-quality evidence)
Clinicians should select treatment goals for adults >60 based on a periodic discussion of the benefits and harms of specific BP targets with the patient

6. Recommendation 2
Clinicians should consider initiating or intensifying pharmacologic treatment in adults >60 with a history of CVA or TIA to achieve a target systolic BP of <140 to reduce risk for recurrence (Grade: weak recommendation, moderate-quality evidence)
Clinicians should select treatment goals for adults >60 based on a periodic discussion of benefits and harms of specific blood pressure targets with the patient.

7. Recommendation 3
Clinicians should consider initiating or intensifying pharmacologic treatment in adults >60 at high cardiovascular risk, based on individualized assessment, to achieve a target systolic BP of <140 to reduce the risk for CVA or cardiac events (Grade: weak recommendation, low-quality evidence
Clinicians should select treatment goals for adults >60 years based on a periodic discussion of the benefits and harms of specific BP targets with the patient

8. Clinical Update on Nursing Home Medicine: 2017 Updates from the AMDA meeting (Morley, et al)
HTN guidelines don’t reflect the heterogeneity of the older population
The 2017 guideline published by the ACP and AAFP does not have a separate recommendation for frail elders, or specific recommendations for elders > 80, regardless of frailty
Clarity regarding heterogeneity of the older population may soon be possible, since design of the recently published Systolic Blood Pressure Intervention Trial (SPRINT), incorporates at least some of the heterogeneity of the older adult population

9. Clinical Update on Nursing Home Medicine: 2017 Updates from the AMDA meeting (Morley, et al)
Current HTN guidelines are driven by major studies published over the past 3 decades preceding SPRINT. The large 2X-blind, placebo-controlled legacy trials enrolled older adults with stage 2 HTN (sBP >160) and targeted a systolic BP of 140
Interestingly, mean final BP in treatment arms of the 3 major trials SHEP, Systolic HTN in Europe & HTN in Very Elderly Trial, studies did not actually reach the intended targets
Nevertheless, primary outcome of incident CVA was reduced 30–42%
Secondary outcomes (HF & mortality) were reduced in SHEP & HYVET trials, which used diuretic antihypertensives

10. Clinical Update on Nursing Home Medicine: 2017 Updates from the AMDA meeting (Morley, et al)
A nonplacebo controlled trial of antihypertensives in older adults suggested a sBP nadir of 130 for adverse cardiovascular outcomes
Based on that finding, the ACC Foundation and AHA updated their guideline to recommend against lowering sBP & dBP below 130 & 65, respectively, for persons >80
SPRINT trial enrolled 9361 older participants with few comorbidities, but tracked important geriatric outcomes such as gait speed, cognition, and overall frailty
Research question was whether a target sBP of <120 would have superior cardiovascular outcomes compared with the standard target sBP of <140

11. SPRINT INCLUSION CRITERIA
>50 years old
sBP 130–180, and 1 or more of the following:
Cardiovascular disease, cardiovascular disease risk of at least 15%,
CKD with estimated GFR of 20–59;
Age >74
Major exclusions:
Past CVA;
DM;
Clinical HF or ejection fraction <35%;
Proteinuria >1 g / 24 hours;
eGFR <20;
Dementia or nursing home residence without documented dementia;
Life expectancy <3 years; and
Standing sBP <110

12. SPRINT RESULTS
The intense target sBP was not met. On average, 3 antihypertensives were required to achieve a mean sBP of The control group required 2 antihypertensives to achieve a mean sBP of 134.6
The trial was discontinued early after a median follow-up of 3.3 years, because of a cumulative hazard ratio for cardiovascular events of (95% CI 0.64–0.89), and a mortality hazard ratio of 0.73 (95% CI 0.60–0.90)
This risk reduction translates to a number needed to treat (NNT) of 61 to prevent 1 cardiovascular event and 90 to prevent 1 death
Statistically significant serious adverse events included:
Hypotension: Statistically less likely in treatment group;
Electrolyte abnormalities Higher in intense group (5% vs 3.6%)
Acute kidney injury or failure Higher in intense group (5.9% vs 4.2%)
Injurious Falls: Lower in the intense group (12 v 14.6%)

13. PARTAGE study [Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population]
Looked at relationship between sBP, antihypertensive use, and mortality in French and Italian nursing homes
Multivariate analysis examined mortality in persons treated with HTN Rx
Average age = 88
Most had HTN and a substantial number had DM 2, CHD & CHF
Mortality was higher in the more intensely controlled population, those participants with sBP <130 and on at least 2 antihypertensives
Relationship held when adjusted for age, sex, BMI & other characteristics

14. 2017 Guideline for High BP in Adults
An update of JNC 7 (2003)
Incorporates new information regarding BP-related risk of CVD, ambulatory and home BP monitoring, BP thresholds to initiate anti- HTN treatment, BP goals of treatment, strategies to improve HTN treatment and control, and various other important issues
Providers should follow standards for accurate BP measurement
BP should be categorized as:
Normal [<120 / <80]
Elevated [ / <80]
Stage 1 [ or 80-89]; and
Stage 2 [>140 / >90];

15. 2017 Guideline for High BP in Adults
Risk for CVD increases in a log-linear fashion; from SBP levels <115 to >180, and from DBP levels <75 to >105
A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in risk of death from stroke, heart disease, or other vascular disease
In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, MI, HF, CVA, PAD & AAA
It is important to screen for and manage other CVD risk factors, e.g., smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea

16. 2017 Guideline for High BP in Adults
Screening for secondary causes of HTN is necessary for new-onset or uncontrolled HTN
<2 drugs
Abrupt onset
Age <30
Excessive target organ damage for age
Diastolic HTN in seniors with unprovoked / excessive hypokalemia
Nonpharmacologic interventions to reduce BP include:
Weight loss with a heart healthy diet,
Sodium restriction, and potassium supplementation within the diet; and
Increased physical activity with a structured exercise program

17. 2017 Guideline for High BP in Adults
Benefits of pharmacologic Rx for BP reduction is related to atherosclerotic CVD risk
For a given magnitude reduction of BP, fewer people with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower NNT), e.g., in seniors, those with CHD, DM 2, hyperlipidemia, smokers and CKD
Use of BP-lowering meds is recommended for:
Secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 or a DBP ≥80, or
Primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 or DBP ≥80, or
Primary prevention of CVD in adults with no history of CVD and an estimated 10-year ASCVD risk <10% and a SBP ≥140 or a DBP ≥90
Prevalence of HTN is lower in women than men until about age 50, but is then higher
While no RCTs have been powered to assess outcomes specifically in women (other than special recs for mgmt during pregnancy), there is no evidence that the BP threshold for initiating treatment, the treatment target, the choice of medication or the combination of medications differs for women
For adults with confirmed HTN, a BP target of <130/80 is recommended

18. 2017 Guideline for High BP in Adults
Part 2 discusses Principles of Drug Therapy & Special Populations, eg…
Choice of Drugs
Preference for QD Drugs to increase compliance
Which drugs to avoid with secondary factors (eg, low GFR, blacks…)
Drugs not to use in combination (eg, ACEI + ARB, CCBs + HF…)
Preferred agents with comorbid:
DM 2
CKD
CVA / TIA
Metabolic Syndrome
Valvular Heart and Aortic Disease

19. 2017 Guideline for High BP in Adults
Age-related issues
Treatment of HTN is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65), with an average SBP ≥130 with SBP treatment goal of <130
For older adults (≥65) with HTN and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia

20. Clinical Update on Nursing Home Medicine: 2017 Updates from the AMDA meeting (Morley, et al) – Conclusions
SPRINT and PARTAGE suggest HTN treatment targets for those with minimal morbidities and for those with multiple morbidities
PARTAGE reinforces current geriatric practice, as well as current guidelines, discouraging intense blood pressure control with 2 or more antihypertensives in a population with multiple morbidities
SPRINT senior implies that robust elders benefit from and tolerate an intense target of 120 when measured as performed in the study, using the mean of serial measurements from a high quality automated cuff with the clinician outside the room. This target translates to a sBP closer to 130 when measured using a more typical technique
Elders with a wide range of cognitive skills &fitness, but without DM 2, CHF, CVA, or dementia, may benefit from an intensive target, but muist be willing and able to take about 3 antihypertenisves