3. Hypertension
• Hypertension (HTN) is defined as a sustained diastolic blood pressure
greater than 90 mmHg usually accompanied by an elevated systolic
blood pressure greater than 140 mmHg.
• Several studies indicate that SBP is a better predictor of CV risk than
DBP and is often used as the primary clinical marker of disease control
in HTN.*
*Mourad J-J. The evolution of systolic blood pressure as a strong predictor of cardiovascular risk and the
effectiveness of fixed-dose ARB/CCB combinations in lowering levels of this preferential target. Vascular Health
and Risk Management. 2008;4(6):1315-1325.
http://stroke.ahajournals.org/content/early/2012/01/26/STROKEAHA.111.636688
4. Blood Pressure Staging
Blood Pressure
Category
Systolic mmHg Diastolic
mmHg
Normal <120 AND <80
Pre-hypertension 120-139 OR 80-89
Hypertension
Stage 1
140-159 OR 90-99
Hypertension
Stage 2
≥ 160 OR ≥ 100
2014. Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the
American Society of Hypertension and the International Society of Hypertension
5. JNC7 Guidelines
• Published in 2003
• Commissioned and reviewed by National Heart, Lung & Blood Institute
(NHLBI)
• Patients have 90% lifetime risk to develop HTN at age 55
• Goal: To prevent HTN and CVD before it happens
6. JNC8 Guidelines
• JNC8- results of 5 key trials: HDFP, Hypertension-Stroke Cooperative, MRC, ANBP,
and VA Cooperative.
• In the above trials, patients between 30-59 year old received medication to lower DBP
<90mmHg.
o Results showed a reduction in cerebrovascular events. heart failure and overall mortality in
patients treated to the DBP target level.
o JNC8 panel wanted to keep DBP < 90mmHg as the only goal among younger patients.
• Patients 60 and older SBP control remains the most important factor.
o More conservative panelists pushed to keep the target SBP goal as well as the DBP goal.
• Patients age 60 years and older, blood pressure goal is <150/90.
o In the general population aged 60 years and older, if pharmacologic treatment for high BP
results in lower SBP and treatment is not associated with ADRs or quality of life, treatment does
not need to be adjusted.
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)
9. JNC8 controversy
• National consensus on guideline.
• Conflicts between major organizations/guidelines.
• Insurance reimbursement for performance accountability
James P, et al. JAMA. 2013; 284427
Wright J, et al. Ann Intern Med. 2014; Special Article
10. American/International Society of Hypertension
(ISH) - BP Targets
• Most evidence linking the effects on cardiovascular or renal outcomes to treated blood pressures
have been based on clinical trials in middle-aged to elderly patients (typically between 55 and 80
years).
• Some recent trials suggest that in people 80 or older, achieving a systolic blood pressure of <150
mm Hg is associated with strong cardiovascular and stroke protection
o A target of <150/90 mm Hg is recommended for patients in this age group.
• Almost no clinical trial evidence regarding blood pressure targets in patients younger than 50
years exists.
o Diastolic blood pressure may be important in this age group, so achieving a value <90 mm Hg
should be a priority
o In addition, it is also a reasonable expectation that targets <140/90 mmHg
o In addition, it is also a reasonable expectation that targets <140/90 mm Hg (eg, < 130/80
mm Hg) could be appropriate in young adults and can be considered
• Some experts still recommend <130/80 mm Hg if albuminuria is present in patients with
chronic kidney disease.
2014. Clinical Practice Guidelines for the Management of Hypertension in the Community .A Statement by the
American Society of Hypertension and the International Society of Hypertension
12. American/International Society of Hypertension
(ISH) - Treatment for HTN and Comorbidities
Comorbidities HTN Standard treatment Add-on therapy
DM ACE-I or ARB
* For AA pts, CCB or Thiazide is ok to
start
Thiazide or CCB
* For AA pts, if CCB/Thiazide is started,
add ACE-I/ARB
CAD BB + ACE-I/ARB
*If hx of MI, a BB + ACE-I/ARB are
needed regardless of BP
Thiazide or CCB
Systolic HF ACE-I/ARB + BB + Diuretic +
Spironolactone
DHP CCB
Diastolic HF ACE-I/ARB + BB + Diuretic DHP CCB
Recurrent Stroke
Prevention
ACE-I or ARB Thiazide or CCB
CKD ACE-I or ARB Thiazide or CCB
14. Reimbursement Issues
• There are many guidelines available for healthcare professionals.
• Many major guidelines can cause confusions National consensus?
• Which one to use for patient’s better outcomes?
• How healthcare professional get reimbursed for performance
measurement?
James P, et al. JAMA. 2013; 284427
Wright J, et al. Ann Intern Med. 2014; Special Article
15. SPRINT clinical trial:
(Systolic Blood Pressure Intervention trial)
• Landmark clinical trial sponsored by the NHLBI and NIH.
• Evaluate the benefits of maintaining a new target for SBP (120 mmHg) among adults
age 50 or older .
• The study population included variety of women, racial/ethnic minorities, and the
elderly.
• These patients had risk factors for cardiovascular disease.
o Excluded patients with DM, prior stroke, or polycystic kidney disease.
• Manage intensive blood pressure may save lives, can be beneficial and yield better
health results overall
• Published Nov. 2015
https://www.sprinttrial.org
https://www.nhbli.nih.gov/news/spotlight/fact-sheet/systolic-blood-pressure-intervention-trial-sprint-
questions-and-answers
17. References:
• American heart association. Understanding blood pressure readings. The American Heart
Association.http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/All-
About-Heart-Rate-Pulse_UCM_438850_Article.jsp.Published August 4, 2014
• 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)
• 2014. AHA/ACC/CDC Science Advisory. An Effective Approach to High Blood Pressure
Control. A Science Advisory From the American Heart
• 2014. Clinical Practice Guidelines for the Management of Hypertension in the Community A
Statement by the American Society of Hypertension and the International Society of Hypertension
• Go A, et al. Journal of the American College of Cardiology, 2014
• https://www.sprinttrial.org
• https://www.nhbli.nih.gov/news/spotlight/fact-sheet/systolic-blood-pressure-intervention-trial-
sprint-questions-and-answers
• James P, et al. JAMA. 2013; 284427; Wright J, et al. Ann Intern Med. 2014; Special Article
• Weber M, et al. J of Clin HTN. , 2014
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