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KEY POINTS - Southern Medical Association

KEY POINTS - Southern Medical Association

Trends in the Management

Trends in the Management of Hypertension: JNC 7 JNC 7: Classification and Management of BP for Adults • Lifestyle modifications are recommended for all patients • Thiazide-type diuretics are recommended as the basis of therapy for most patients • Other therapeutic options – Angiotensin-converting enzyme inhibitors (ACEIs) – Angiotensin receptor blockers (ARBs) – β-blockers – Calcium channel blockers (CCBs) – Direct renin inhibitors (DRIs) • Patients with certain high-risk, compelling indications (e.g., heart failure, post-MI, high CAD risk, diabetes, CKD, and recurrent stroke prevention) are candidates for specific antihypertensive drug classes • Anyone over 20/10 mmHg is a candidate for dual drug initial therapy MI = myocardial infarction; CAD = coronary artery disease; CKD = chronic kidney disease; BP Classificati on SBP * (mm Hg) Normal < 120 Pre-HTN Stage 1 HTN Stage 2 HTN 120- 139 140- 159 DBP * (mm Hg) and < 80 or 80- 89 or 90- 99 160 or 100 Lifestyle Modificati on Encourag e Yes Yes Yes Without Compelling Indications No antihypertensive drug indicated One-Drug Therapy Indicated Initial Drug Therapy With Compelling Indications Drug(s) for the compelling indications † Drug(s) for the compelling indications Other antihypertensive drugs as needed to control BP Drugs for the compelling Two-drug indications combination indicated for most Other antihypertensive drugs as needed to control BP ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; BB = beta blocker; CCB = calcium channel blocker * Treatment determined by the highest BP category † Treat patients with chronic kidney disease (CKD) or DM to BP goal of < 130/80 mm Hg ‡ Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension Chobanian AV, et al. Hypertension. 2003;42:1206-1252 . Chobanian AV, et al. JAMA. 2003;289(19):2560-2572. What Have We Learned Since JNC 7*? Lesson #1 •The amount of BP reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension, not the choice of antihypertensive drug. *Published in 2003 Relative Risk of Outcome Event Associations of BP Differences Between Randomized Groups With Risks of Major Vascular Outcomes and Death 1.50 1.25 1.00 0.75 0.50 0.25 1.50 1.25 1.00 0.75 0.50 0.25 Stroke -10 -8 -6 -4 -2 0 2 4 CHD -10 -8 -6 -4 -2 0 2 4 1.50 1.25 1.00 0.75 0.50 0.25 Major CVD -10 -8 -6 -4 -2 0 2 4 1.50 1.25 1.00 0.75 0.50 0.25 CVD Death -10 -8 -6 -4 -2 0 2 4 SBP Difference Between Randomized Groups (mm Hg) CVD = cardiovascular disease. Turnbull F, Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2003;362:1527-1535. 1.50 1.25 1.00 0.75 0.50 0.25 1.50 1.25 1.00 0.75 0.50 0.25 Total Mortality -10 -8 -6 -4 -2 0 2 4 Heart Failure -10 -8 -6 -4 -2 0 2 4 BP-Lowering Treatment Trialists Comparisons of different active treatments Major CV Events ACE vs. D/BB CA vs. D/BB ACE vs. CA CV Mortality ACE vs. D/BB CA vs. D/BB ACE vs. CA Total Mortality ACE vs. D/BB CA vs. D/BB ACE vs. CA Lancet 2003; 360:1903 BP Difference (mm Hg) 2/0 1/0 1/1 2/0 1/0 1/1 2/0 1/0 1/1 Relative Risk 0.5 Favors 1.0 Favors 2.0 First Listed Second Listed RR (95% CI) 1.02 (0.98, 1.07) 1.04 (0.99, 1.08) 0.97 (0.95, 1.03) 1.03 (0.95, 1.11) 1.05 (0.97, 1.13) 1.03 (0.94, 1.13) 1.00 (0.95, 1.05) 0.99 (0.95, 1.04) 1.04 (0.98, 1.10)

Stroke BP-Lowering Treatment Trialists Comparisons of different active treatments BP Difference (mm Hg) ACE vs. D/BB 2/0 CA vs. D/BB 1/0 ACE vs. CA 1/1 Coronary Heart Disease ACE vs. D/BB 2/0 CA vs. D/BB 1/0 ACE vs. CA 1/1 Heart Failure ACE vs. D/BB 2/0 Relative Risk RR (95% CI) 1.09 (1.00, 1.18) 0.93 (0.86, 1.01) 1.12 (1.01, 1.25) 0.98 (0.91, 1.05) 1.01 (0.94, 1.08) 0.96 (0.88, 1.05) 1.07 (0.96, 1.19) CA vs. D/BB 1/0 1.33 (1.21, 1.47) ACE vs. CA 1/1 0.82 (0.73, 0.92) JNC 7: Compelling Indications for Individual Drug Classes Diuretic - blocker ACEI ARB CCB Aldo Antag. HF • • • • • Post-MI • • • • High CAD Risk • • • • • Diabetes • • • • • CKD • • Clinical Trial Basis ACC/AHA HF guideline; MERIT-HF; COPERNICUS, CIBIS, SOLVD; AIRE, TRACE, Val-HeFT; RALES ACC/AHA post-MI guideline; BHAT; SAVE, CAPRICORN, EPHESUS/VALIANT ALLHAT; HOPE, ANBP2; LIFE; CONVINCE, ONTARGET NKF-ADA guideline; UKPDS; ALLHAT NKF guideline; CAPPP; RENAAL; IDNT, REIN, AASK Stroke • • • PROGRESS, LIFE Lancet 2003; 360:1903 0.5 1.0 2.0 Favors Favors First Listed Second Listed • Published after JNC 7 Chobanian AV et al. JAMA. 2003;289:2560-2572. Guidelines Have Set Clear Treatment Goals JNC7/ADA/NKF/ISHIB Guidelines for Hypertension and Patients at High Risk AHA Scientific Statement: Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease Condition mm Hg Essential hypertension

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