KEY POINTS - Southern Medical Association
Take Home Messages from ONTARGET • In patients with vascular disease or high-risk diabetes, ARB and ACEI were equally effective in reducing CV events • Combining ACEI + ARB does not lead to advantageous therapeutic outcomes in high-risk patients (68% of whom have HTN) and increases the risk of adverse events – Possible exceptions: • Persistent albuminuria? • HF with decreased systolic function? • Little outcomes data on the combination of direct renin inhibitor (DRI) with either ACEI or ARB What may we (or should we) expect from JNC 8? Risk Stratification Evidence-Based Recommendations Role of B-Blocker Rx Resistant Hypertension Practice Strategies Lesson #4 • We are doing better in the treatment and control of BP. JNC 8 should include -a global risk chart to allow us to understand that BP elevation is only 1 factor that contributes to hypertensive morbidity and mortality - an Evidenced-based approach to goal BP targets - The importance of out-of-office BP measurement - Class effect vs within class differences - The importance of getting to goal sooner rather than later http://cardiophile.org/tag/jnc-8-hypertension-guidelines. Greater Emphasis on Global Risk Assessment to Determine BP Goals • Demographics and BP – Age/Gender – BP/Pulse pressure/Central Pressure • Other CV risk factors – DM/Impaired fasting glucose – Dyslipidemia – Obesity/Sedentary lifestyle – Tobacco abuse – Family history • End-organ damage – Left ventricular hypertrophy – Retinopathy – Microalbuminuria/eGFR < 60 mL/min/1.73 m 2 • Established CV or renal disease – Atherosclerosis in any vascular bed – Stroke/TIA – HF – Renal insufficiency Initiation of Antihypertensive Treatment Other risk factors, OD, or disease No other risk factors Normal SBP 120–129 or DBP 80–84 No BP intervention High normal SBP 130–139 or DBP 85–89 No BP intervention 1–2 risk factors Lifestyle changes Lifestyle changes 3 risk factors, MS, OD, or diabetes Diabetes Established CV or renal disease Lifestyle changes Lifestyle changes Lifestyle changes + immediate drug treatment Grade 1 HTN SBP 140–159 or DBP 90–99 Lifestyle changes for several months then drug treatment if BP uncontrolled Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes and consider drug treatment Lifestyle changes + drug treatment Lifestyle changes + drug treatment Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment Grade 2 HTN SBP 160–179 or DBP 100–109 Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes + drug treatment Lifestyle changes + immediate drug treatment Grade 3 HTN SBP ≥180 or DBP ≥110 Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment EGFR = estimated glomerular filtration rate; TIA = transient ischemic attack; CHF = chronic heart failure Adapted from: Tate C. In: Ferri F, ed. Ferri: Practical Guide to the Care of the Medical Patient. 6th ed. Mosby, Inc; 2004:115-236. • Chobanian AV, et al. JAMA. 2003;289(19):2560-2572. Mancia G et al. J Hypertens. 2007;25:1105-1187 HTN = hypertension; MS = metabolic syndrome; OD = organ damage.
0% 10% 20% 30% Positive Benefits of Prompt BP Lowering* Syst-Eur: Risk Reduction Reduction in relative risk Prompt* vs delayed BP lowering prevented 17 strokes or 25 major CV events per 1000 patients followed for 6 years 13% reduction in all-cause mortality (P=0.09) 15% reduction in CV events (P=0.03) 28% reduction in stroke (P=0.01) VALUE: Analysis of Results Based on Immediate Response* Fatal/Nonfatal cardiac events Fatal/Nonfatal stroke All-cause death Myocardial infarction Heart failure hospitalizations Pooled Treatment Groups 0.4 0.6 0.8 1.0 1.2 1.4 Immediate responders* (n = 9336) † ** ** Odds Ratio 95% CI 0.88 (0.79–0.97) 0.83 (0.71–0.98) 0.90 (0.81–0.99) 0.89 (0.76–1.04) 0.87 (0.75–1.01) Non-immediate responders (n = 5663) BP=blood pressure; CV=cardiovascular. *In this study, prompt was defined as any treatment utilized in the first 2.0 years. Staessen JA et al. J Hypertens. 2004;22:847-857. *Those not on previous tx: SBP ≥10 mm Hg at one month; those on previous tx: SBP ≤ baseline at one month. **P