1.  Update on Hypertension Troy L. Randle, DO, FACC, FACOI

2. Financial Disclosures  I have no financial disclosures at this time.

3. Objectives  Update on JNC-8 and understand the differences in treatment of hypertension according to the newer guidelines.

4. Cardiovascular Statistics  Heart Disease  Leading causes of death in US  Accounts for more than 40% of all deaths  About 95,000 Americans die of heart disease or stroke each year  Amounts to one death every 33 seconds  Heart Disease is the leading cause of disability among working adults

5. CVD Risk Factors  Hypertension*  Cigarette smoking  Obesity* (BMI >30 kg/m 2 )  Physical inactivity  Dyslipidemia*  Diabetes mellitus*  Microalbuminuria or estimated GFR <60 ml/min  Age (older than 55 for men, 65 for women)  Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome.

6. Hypertension About 1 in 3 U.S. adults— as estimated 68 million— have high blood pressure, which increases the risk for heart disease and stroke, leading causes of death in the United States.

7. Causes of Hypertension

8.  Sleep apnea  Drug-induced or related causes  Chronic kidney disease  Primary aldosteronism  Renovascular disease  Chronic steroid therapy and Cushing ’ s syndrome  Pheochromocytoma  Coarctation of the aorta  Thyroid or parathyroid disease

10. Hypertension  Assessment  Start with the basics: Take your own blood pressures for patient with Hypertension!  Two measurements  Both arms  Patient seated for at least two minutes

11. Testing  Electrocardiogram  Urinalysis  Blood glucose, and hematocrit  Serum potassium, creatinine (or the corresponding estimated GFR), and calcium  Lipid profile, after 9 to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides  Echocardiogram  Ambulatory Blood Pressure Monitoring  Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

12. Hypertension  High Blood Pressure

13. Hypertension on Heart

14. Hypertension on the Body

15. Target End Organ Damage  Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure  Brain Stroke or transient ischemic attack  Chronic kidney disease  Peripheral arterial disease  Retinopathy

16. Causes of Resistant Hypertension  Compliance  Improper BP measurement  Excess sodium intake  Inadequate diuretic therapy  Medication Inadequate doses Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements  Excess alcohol intake  Identifiable causes of HTN

17. Hypertension – The Numbers

18. Blood pressure classification

19. Questions Leading to JNC-8  In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?  In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?  In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

20. Recommended Treatment Goals  In adults (general population) greater than 60 years of age:  SBP<150, DBP<90  In adults (general population) less than 60 years of age:  SBP<140, DBP<90  In adults with diabetes or chronic kidney disease:  SBP<140, DBP<90

21. JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

22. Recommend Treatment Meds  Nonblack population  Thiazide diuretic  Calcium-channel blocker  ACE-I/ARB  Black population  Thiazide diuretic  Calcium-channel blocker  CKD  ACE-I/ARB

23. JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

25. Additional Considerations in Antihypertensive Drug Choices  Potential unfavorable effects  Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia.  BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or third-degree heart block.  ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.  ACEIs should not be used in individuals with a history of angioedema.  Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.

26. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure50%

28. Recommended Treatment Goals  In adults (general population) greater than 60 years of age:  SBP<150, DBP<90  In adults (general population) less than 60 years of age:  SBP<140, DBP<90  In adults with diabetes or chronic kidney disease:  SBP<140, DBP<90

29. Recommend Treatment Meds  Nonblack population  Thiazide diuretic  Calcium-channel blocker  ACE-I/ARB  Black population  Thiazide diuretic  Calcium-channel blocker  CKD  ACE-I/ARB

30. Comparing BP Control – JNC 7 to JNC8  Atherosclerosis Risk in Communities Study  6088 participants  JNC 7 Prevalence: 82%  JNC 7 Controlled: 63%  JNC 8 Controlled: 79%  Despite criteria used, >20% still uncontrolled.  Therapeutic Inertia

31. Case #1  TR is a 50 yo Black male with history of DM, dyslipidemia.  BP is 180/110mmHg HR 84bpm  What do you do next?

32. Case #1  TR is a 50 yo Black male with history of DM, dyslipidemia.  BP is 180/110mmHg HR 84bpm  What do you do next?  Education  Studies  Medication Treatment

33. Case #1  TR is a 50 yo Black male with history of DM, dyslipidemia.  Calcium-channel blocker (Norvasc 5mg daily)  BP 160/90  What do you do next?

34. Case #2  TL is a 38 yo Non-black female with history of DM, dyslipidemia.  BP is 160/90mmHg HR 84bpm  What do you do next?  Education  Studies  Medication Treatment

35. Case #2  TL is a 38 yo Non-black female with history of DM, dyslipidemia.  BP is 160/90mmHg HR 84bpm  Medication Options  Thiazide diuretic  Calcium-channel blocker  ACE-I/ARB(???)

36. Case #3  LR is a 83 yo Non-black female with history of hypothyroidism and dyslipidemia.  BP is 148/90mmHg HR 84bpm  What would you do next?

37. Case #4  LR is a 83 yo Non-black female with history of hypothyroidism and dyslipidemia.  BP is 168/90mmHg HR 84bpm  What would you do next?  Medications?

38. References  James PA, Oparil S, Carter BL, et al. 2014 Evidence- Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.  Mozaffarian, D. et al. 2014. AHA Statistical Update Heart Disease and Stroke Statistics—2015 Update. Circulation. 2015; 131: e29-e322

39. Questions ???