3. 2017 ACC/AHA Guidelines
Normal BP
<120 systolic and <80 diastolic
Elevated BP
120-129 systolic and <80 diastolic
Stage I Hypertension
130-139 systolic and 80-89 diastolic
Stage II Hypertension
At least 140 systolic and 90 diastolic
4. New Guidelines Impact
For a 45 year old adult without HTN, the 40 year risk
for developing HTN is:
93% for African Americans
92% for Hispanics
86% for whites
84% for Chinese
5. SPRINT Trial
Hypothesis: treating SBP to <120 mmHg is superior to
less aggressive target of treating to <140 mmHg.
6. SPRINT Trial
9361 patients
Higher risk patients
50 years old or above (25% above age 75)
At least one cardiovascular risk factor
Clinical cardiovascular disease
Chronic kidney disease stage III or worse
Framingham risk score >15%
Age >75 yo
8. SPRINT Trial
Primary outcome: composite of CV death, stroke or
MI, hospital for heart failure or acute coronary
syndrome.
Secondary endpoints: individual components of
primary endpoint, all cause mortality, and composite
for primary endpoint and all cause mortality
9. SPRINT Trial
Intensive treatment group: on average, were on 3
antihypertensives
Comparison, less aggressive group: on average, were on
2 antihypertensives
12. SPRINT Trial
Trial ended early with median follow up 3.26 years
(planned 4-5 years)
Results
25% reduction in primary endpoint
27% risk of all cause mortality
13. Number of
Participants
Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89)
Standard
Intensive
(243 events)
During Trial (median follow-
up = 3.26 years)
Number Needed to
Treat (NNT)
to prevent a primary
outcome = 61
Outcome
Cumulative Hazard
(319 events)
14. SPRINT Adverse Events
Hypotension 2.4 vs 1.4 %
Syncope 2.3 vs 1.7%
Injurious fall 2.2 vs 2.3%
Bradycardia 1.9 vs 1.6%
Electrolyte abnormality 3.1 vs 2.3%
Acute renal failure 4.1 vs 2.5%
15. SPRINT Impact
A single RCT led to new guidelines that radically
increased definition of HTN, and increased number of
those who warrant therapy
16. HOPE 3
Polypill approach to reducing cardiac risk in
intermediate risk patients
Hypothesis: Using statins and lowering BP will reduce
cardiac risk in all intermediate risk patients
Rosuvastatin vs placebo
Candesartan/HCTZ vs placebo
Rosuvastatin +Candesartan/HCTZ vs placebo
17. HOPE 3
Men >55, Women>65
All have at least one risk factor
Obesity
Low HDL
Tobacco use
Dysglycemia
Family history of early CAD
Mild CKD
18. HOPE 3
Exclusion criteria
Known CVD
Indication for, or contraindication against one of the
trial meds
12,705 enrolled
Duration of follow up 5.6 years
19. HOPE 3 Results
Combined cardiac endpoint
Cholesterol lowering 4.4% vs 5.7% (p<0.001)
BP lowering 4.8% vs 5.2% (p=0.51)
Combined BP/Chol 4.6% vs 6.5% (p<0.001)
So rosuvastatin lowered risk, BP lowering did not
This has led to the argument that normotensive
patients (defined as <140/90) don’t benefit from
further BP lowering
20. HOPE 3 Results
However, these are all patients at intermediate risk,
not those with hypertension.
The subgroup of patients with SBP> 143.5mmHg did
have statistically significant difference in endpoint
(p=0.009).
21. Lessons from Hope
In intermediate risk patients, statins lower risk more
than BP meds unless BP starts out significantly high.
22. Lessons from SPRINT
In high risk patients, lower BP is likely better
How you take a blood pressure matters. 24 hour
average BP is what is most important. BP measured in
clinic does seem to be higher than BP measured at
home.
BP medications need to be aggressively titrated
Often, you should start with two medications from the
very beginning.
23. Treatment of Hypertension
Nonpharmacologic
Low salt diet
High potassium foods
Exercise
Limiting alcohol
Each lifestyle change can lower SBP by 4-5mmHg.
24. HTN treatment 2017 Guidelines
Low or intermediate risk patients with SBP 120-129 or
130-139 should start with nonpharmacologic changes
only
High risk patients can start one med if SBP>130, and
two meds if SBP>140 or DBP>90.
25. HTN Treatment
First line therapy:
Thiazide diuretics
Calcium channel blockers
ACE inhibitors or ARBs
Beta blockers are no longer first line
26. ALLHAT
41,000 hypertensive patients
Randomized to
Amlodipine
Lisinopril
Chlorthalidone
Doxasozin (ended early due to CHF risk)
27. ALLHAT
Lisinopril, chlorthalidone, and amlodipine were all
equivalent for primary outcome of fatal CAD or
nonfatal myocardial infarction
Chlorthalidone had greater BP reduction and lowest
rate of CHF.
28. HTN Treatment
African Americans (and likely Africans) have lower
rate of response to ACEi/ARB and greater response to
calcium channel blockers than whites
29. My usual 1st line treatment
Whites: start lisinopril and hydrochlorothiazide
Titrate these up to maximum tolerated dose
Then add amlodipine
Blacks: start amlodipine and hydrochlorothiazide
Titrate these up to maximum tolerated dose
Then add lisinopril
30. Add on Therapy
Forth agent should usually be spironolactone
This is due to hyperaldosteronism. Strongly suspect if
hypokalemic.
Bblockers Cavedilol, labatelol, nibivolol better than
metoprolol
Hydralazine
Minoxidil
Alpha blockers
31. Special Populations
Systolic CHF:
ACEi/ARB first-line for all
Bblockers (carvedilol, metop succinate, bisoprolol) for
all
Consider Hydralazine, isosorbide dinitrate for blacks
History of myocardial infarction or aortic disease
All need bblockers
Diabetics
ACEi/ARB are first line in all with microalbuminemia
32. Medication Issues
ACEi/ARB
Hyperkalemia and renal dysfunction
Need to check potassium and creatinine at one week
Angioedema
Spironolactone
Hyperkalemia in up to 20%
Most important med of all to check potassium
34. Resistant Hypertension
Defined as BP not controlled with 3 medications
What is the most common cause of resistant
hypertension?
35. What is the most common cause of resistant
hypertension?
Noncompliance with medication
In USA, 25% never fill the first prescription
At any one time, 50% are without their medicine
36. Tips to improve compliance
Explain to patients the reason for treatment (the Silent
Killer)
Start the meds at the dose you think will work best
Warn patients that titration is necessary
Schedule follow up to make titrations and to check on
side effects
Warn patients about the potential side effects
