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Benefits of Hypertension Control:
What Levels ? Which Drugs ?
Dr. Akshay Mehta
Nanavati Superspeciality Hospital
Asian Hea...
Mr X is 64 yr old with BP of 148/84 since last 6
months despite all life style measures. He has no
other RF, CVD or TOD. H...
Hypertension Guidelines 2011- 2014
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood pressure
(in mm Hg)
NICE
2011
ESH/...
Published Online Journal of American Medical Association 18th Nov, 2013
• New relaxed drug Rx goals:
BP < 150/90 if age 60...
If you were to wake up in the
morning and had to have either a
stroke or a heart attack, which one
of the 2 would you like...
Adjusted risk of outcome events by achieved systolic blood pressure, divided
in to deciles (grey bars).
Sleight P Eur Hear...
Risk of
Hypertn
and
Absolute
Benefits of
Drug Therapy
Increase With
Age
Wang J et al. Hypertension. 2005;45:907-913
So for b/w age 60yrs & 80yrs, stopping at
SBP 150 goal is not a good idea
• If you want to prevent stroke
• If you want to...
Problems with JNC VIII panel report
• Not sanctioned by the NHLBI
• The panel’s report is now published in JAMA as a
stand...
A target of <150/90 mm Hg is recommended
for patients >80 if it can be done safely
JNC VIII panel - Corollary
Recommendation
• In the general population aged ≥60 years, if
pharmacologic treatment for high ...
JNC VIII Panel
Goals for CKD & Diabetes
• In the population aged ≥18 years with chronic kidney
disease (CKD), initiate pha...
Achieved systolic blood pressure (SBP) values and
reductions in cardiovascular (CV) events in trials of
antihypertensive t...
]able 1. Key studies on blood pressure targets in patients with chronic kidney disease
MDRD study REIN-2 AASK
Year of publ...
Satisfied with office BP ?
What about other BP goals ?
Superiority of ambulatory BP for predicting
CV death
Syst-Eur Study(Systolic hypertension in Europe Study)
Staessen JA et ...
Other Goals to look at :
More goals, better results !
• Out of office BP :
-Nocturnal BP & Dip
-BP variability –including ...
What are the lower limits ?
Is there a J curve ?
• No direct evidence
• Evidence from observational and post hoc analysis of trials
like INVEST, HYVET, ON TARGET etc :
• 1...
J curve in
ON TARGET
Copyright © The American College of Cardiology.
All rights reserved.
From: The J-Curve Between Blood Pressure and Coronary...
Copyright © The American College of Cardiology.
All rights reserved.
From: The J-Curve Between Blood Pressure and Coronary...
There could be a J shaped relationship between DBP and
cardiac events (MI) in elderly, having LVH and/or coronary
heart di...
Definitions of hypertension by office and
out-of-office BP levels
Ambulatory BP targets :
Heart Foundation
• • Daytime and night-time ABP “loads”* should be <20% above
normal values.
• Mea...
Which Drugs ?
All the following factors determine
choice of initial drugs in hypertension
except :
A. Age
B. Gender *
C. Race
D. Presenc...
Best drug(s) to initiate treatment with,
in the young (<55)
• ACEI/ARB
• BB
• CCB
• D
Young Elderly
RAAS
Na, Vol
WHY ?
ACEI/ARB
Or
BB
A or B
CCB or D
C or D
Gender
• No difference in drug Rx except :
• Pregnancy : M Dopa, α-BB, Hydralazine, BB,
CCB
• Women of repro age : BB, α-B...
Race :
• In blacks :
• Initial Rx should include CCB or D
• In kidney disease ACE/ARB foll by C or D
Hypertn & Co morbid conditions
Hypertension and HF ARB or ACE inhibitor + BB + diuretic + AA
√ ×
• Obese individual
• Physically,mentally active
• Resting tachycardia
• Resting bradycardia
• Postural hypotension
D, ...
√ ×
• Migraine
• Asthma
• Prostatism
• Gout
• Acute CVA
BB
CCB (NDHP) BB
αBB
ARB Diu
ACEI, BB, D Short
actg
DHPCCB
Drugs which activate the renin-angiotensin-aldosterone system
(green) make it more susceptible to the action of drugs whic...
The BHS recommendations for
combining BP lowering drugs
Which is a better combination with
ACE I/ ARB ?
• CCB
• Diu
ACCOMPLISH TRIAL
Cumulativeeventrate
HR (95% CI): 0.80 (0.72, 0.90)
20% Risk Reduction
Time to 1st CV morbidity/mortality ...
‘ACCOMPLISH’ SUBANALYSIS
Fat versus the thin !
• in patients treated with hydrochlorothiazide and benazepril,
there was a ...
NICE
GUIDANCE
Aug 2011
When to Initiate Rx with Beta blockers?
• women of child-bearing potential
• people with evidence of increased
sympathetic...
Best drug to reduce nocturnal BP
• ACEI/ARB
• BB
• CCB
• Diuretic √
Best drug to reduce BP variability
• ACEI/ARB
• BB
• CCB √
• D
Low-Dose Combination Rx
 Increased efficacy
 Fewer side-effects
WHEN indicated ?
Hypertension Guidelines 2011- 2014
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood pressure
(in mm Hg)
NICE 2011 ESH/...
All the following are sound
combination of drugs except ?
A. ACEI +CCB
B. CCB+BB
C. ARB + Diu
D. ACEI + ARB
Indian Hypertn Guidelines 2013
BP Goals :
• 140/90 mm Hg in the young and middle aged
• 140/80 mm Hg in diabetic patients
...
Indian Hypertn Guidelines 2013
• Which drugs :
• Beta-blockers not first line agents and now recommended as
agents for use...
Indian Hypertn Guidelines 2013
• Which Drugs
• When blood pressure is high by more than 20/10 mm of Hg
systolic and diasto...
Take home messages :
• BP Goal : Office BP < 140/90 in all except age 80 &
above
• Other Goals – more benefits : Out of of...
Benefits of hypertension control
Benefits of hypertension control
Benefits of hypertension control
Benefits of hypertension control
Benefits of hypertension control
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A presentation by Dr. Akshay Mehta on the benefits of hypertension control and which drugs to use for effective management of the condition.

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Benefits of hypertension control

  1. 1. Benefits of Hypertension Control: What Levels ? Which Drugs ? Dr. Akshay Mehta Nanavati Superspeciality Hospital Asian Heart Institute
  2. 2. Mr X is 64 yr old with BP of 148/84 since last 6 months despite all life style measures. He has no other RF, CVD or TOD. His brother had a stroke at age 73 yrs. Should one start drug Rx ? A. No, as per JNC VIII panel report B. Yes, as per other guidelines C. Leave it to the patient
  3. 3. Hypertension Guidelines 2011- 2014 Lindholm LH, Carlberg B. HT News 2014, Opus 35 Blood pressure (in mm Hg) NICE 2011 ESH/ ESC 2013 2014 Hypertension guidelines, US “JNC 8” ASH /ISH 2014 Indian Guidelines -2013 Definition of Hypertension ≥140/90 and daytime ABPM (or home BP) ≥135/85 ≥140/90 Not addressed ≥140/90 > 140/90 mm Hg Blood pressure targets < 140/90 <140/90 < 60 y. <140/90 <140/90 (young and middle aged) <140/90 ≥ 80 y. Elderly < 80 y. ≥ 80 y. Elderly 140 – 145/90 < 150/90 SBP 140-150 ≥ 60 y. <150/90 < 150/90 SBP <140 in fit patients Elderly ≥ 80 y. SBP 140-150 Blood Pressure target in patients with diabetes mellitus Not addresse d < 140/85 <140 /90 <140/90 <140/80
  4. 4. Published Online Journal of American Medical Association 18th Nov, 2013 • New relaxed drug Rx goals: BP < 150/90 if age 60+ years BP < 140/90 if age < 60 years The panel originally appointed by the NHLBI to review the evidence on treatment of hypertension
  5. 5. If you were to wake up in the morning and had to have either a stroke or a heart attack, which one of the 2 would you like to have?
  6. 6. Adjusted risk of outcome events by achieved systolic blood pressure, divided in to deciles (grey bars). Sleight P Eur Heart J Suppl 2009;11:F16-F18 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
  7. 7. Risk of Hypertn and Absolute Benefits of Drug Therapy Increase With Age Wang J et al. Hypertension. 2005;45:907-913
  8. 8. So for b/w age 60yrs & 80yrs, stopping at SBP 150 goal is not a good idea • If you want to prevent stroke • If you want to protect the >60 population, a large high risk group most likely to be protected with goal below 140 mm Hg SBP • Major trials show benefit with goal BP around 143 which is nearer 140 than 150 • Going to 140 mm Hg is safe
  9. 9. Problems with JNC VIII panel report • Not sanctioned by the NHLBI • The panel’s report is now published in JAMA as a stand-alone document • Prior guidelines based on the totality of evidence, including observational studies, RCTs, and meta- analyses, as well as expert opinion • JNC VIII panel depended only on specific RCTs which showed lack of definitive benefit for goal of 140 • But paradoxical that for young pts goal maintained at 140 despite NO evidence of benefit from RCT
  10. 10. A target of <150/90 mm Hg is recommended for patients >80 if it can be done safely
  11. 11. JNC VIII panel - Corollary Recommendation • In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.
  12. 12. JNC VIII Panel Goals for CKD & Diabetes • In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg • In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
  13. 13. Achieved systolic blood pressure (SBP) values and reductions in cardiovascular (CV) events in trials of antihypertensive treatment in diabetics. Zanchetti A Eur Heart J 2010;31:2837-2840 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org
  14. 14. ]able 1. Key studies on blood pressure targets in patients with chronic kidney disease MDRD study REIN-2 AASK Year of publication 1994 2005 2010 No. individuals included 840 338 1094 Cause of CKD Nondiabetic Nondiabetic 'Hypertensive' Baseline kidney 33 (low BP target) 36 (low BP target) 46 (low BP target) function (ml/min) 32 (usual BP target) 34 (usual BP target) 45 (usual BP target) Proteinuria at baseline 390 mg/day (low BP target) 2.8 g/day (low BP target) 80 mg/day (low BP target) 310 mg/day (usual BP target) 2.9 g/day (usual BP target) 80 mg/day (usual BP target) Target BP (mmHg) Low BP: MAP≤92 (≈125/75) Low BP:<130/80 Low BP: MAP≤92 (≈125/75) Usual BP: MAP≤107 (≈140/90) Usual BP: DBP<90 Usual BP: MAP≤102–107 (the latter ≈140/90) Primary endpoint Rate of change in GFR ESRD Combination of doubling of serum creatinine, ESRD, and death
  15. 15. Satisfied with office BP ? What about other BP goals ?
  16. 16. Superiority of ambulatory BP for predicting CV death Syst-Eur Study(Systolic hypertension in Europe Study) Staessen JA et al. JAMA 1999;282:539-46 0.00 0.04 0.08 0.12 0.16 0.20 90 110 130 150 170 190 210 230 Systolic blood pressure (mmHg) 2-yearsincidenceof cardiovascularendpoints Nighttime 24-h Daytime Conventional
  17. 17. Other Goals to look at : More goals, better results ! • Out of office BP : -Nocturnal BP & Dip -BP variability –including morning surge -Masked hypertn • Rate of BP control • Lower limits of BP goals- J curve ? • Central aortic BP • Pulse wave velocity
  18. 18. What are the lower limits ? Is there a J curve ?
  19. 19. • No direct evidence • Evidence from observational and post hoc analysis of trials like INVEST, HYVET, ON TARGET etc : • 1. No J shaped relationship between systolic BP and adverse events • 2. " " " b/w BP and other organs such as brain, kidney etc
  20. 20. J curve in ON TARGET
  21. 21. Copyright © The American College of Cardiology. All rights reserved. From: The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension: Exactly How Essential? J Am Coll Cardiol. 2009;54(20):1827-1834. doi:10.1016/j.jacc.2009.05.073 Incidence of MI and Stroke Stratified by Diastolic Blood Pressure in the INVEST Study
  22. 22. Copyright © The American College of Cardiology. All rights reserved. From: The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension: Exactly How Essential? J Am Coll Cardiol. 2009;54(20):1827-1834. doi:10.1016/j.jacc.2009.05.073 Interaction of the J-Curve With Coronary Revascularization Patients who were revascularized better tolerate a lower diastolic blood pressure (DBP) than those who were not.
  23. 23. There could be a J shaped relationship between DBP and cardiac events (MI) in elderly, having LVH and/or coronary heart disease (esp non revascularized), and wide pulse pressure. The critical DBP is 60 mm Hg.
  24. 24. Definitions of hypertension by office and out-of-office BP levels
  25. 25. Ambulatory BP targets : Heart Foundation • • Daytime and night-time ABP “loads”* should be <20% above normal values. • Mean day-time and night-time (sleep) ABP measurements should differ by >10%.
  26. 26. Which Drugs ?
  27. 27. All the following factors determine choice of initial drugs in hypertension except : A. Age B. Gender * C. Race D. Presence of comorbid conditions E. BMI (obesity)
  28. 28. Best drug(s) to initiate treatment with, in the young (<55) • ACEI/ARB • BB • CCB • D
  29. 29. Young Elderly RAAS Na, Vol WHY ? ACEI/ARB Or BB A or B CCB or D C or D
  30. 30. Gender • No difference in drug Rx except : • Pregnancy : M Dopa, α-BB, Hydralazine, BB, CCB • Women of repro age : BB, α-BB ACEI/ARB X X X
  31. 31. Race : • In blacks : • Initial Rx should include CCB or D • In kidney disease ACE/ARB foll by C or D
  32. 32. Hypertn & Co morbid conditions Hypertension and HF ARB or ACE inhibitor + BB + diuretic + AA
  33. 33. √ × • Obese individual • Physically,mentally active • Resting tachycardia • Resting bradycardia • Postural hypotension D, BB, A CCB ACEI, CCB BB, Centrl BB, Diltia αBl, Amlo Amlo, α Bl BB, Diltia ACEI/ARB Diu
  34. 34. √ × • Migraine • Asthma • Prostatism • Gout • Acute CVA BB CCB (NDHP) BB αBB ARB Diu ACEI, BB, D Short actg DHPCCB
  35. 35. Drugs which activate the renin-angiotensin-aldosterone system (green) make it more susceptible to the action of drugs which suppress the system (shown in red). How to combine drugs ?
  36. 36. The BHS recommendations for combining BP lowering drugs
  37. 37. Which is a better combination with ACE I/ ARB ? • CCB • Diu
  38. 38. ACCOMPLISH TRIAL Cumulativeeventrate HR (95% CI): 0.80 (0.72, 0.90) 20% Risk Reduction Time to 1st CV morbidity/mortality (days) p = 0 ACEI + HCTZ ACEI + CCB 650 526 .0002 INTERIM RESULTS Mar 08
  39. 39. ‘ACCOMPLISH’ SUBANALYSIS Fat versus the thin ! • in patients treated with hydrochlorothiazide and benazepril, there was a 69% higher risk in the lean patients as compared to obese • in people treated with amlodipine, this phenomenon not seen • in lean pts, amlodipine was better and reduced the risk of cardiovascular death 38%, total stroke by 40%, and MI by more than 50% • In obese patients diuretics - OK
  40. 40. NICE GUIDANCE Aug 2011
  41. 41. When to Initiate Rx with Beta blockers? • women of child-bearing potential • people with evidence of increased sympathetic drive. • Co morbid conditions requiring BB If BB alone not effective add CCB or D ?
  42. 42. Best drug to reduce nocturnal BP • ACEI/ARB • BB • CCB • Diuretic √
  43. 43. Best drug to reduce BP variability • ACEI/ARB • BB • CCB √ • D
  44. 44. Low-Dose Combination Rx  Increased efficacy  Fewer side-effects WHEN indicated ?
  45. 45. Hypertension Guidelines 2011- 2014 Lindholm LH, Carlberg B. HT News 2014, Opus 35 Blood pressure (in mm Hg) NICE 2011 ESH/ ESC 2013 2014 Hypertension guidelines, US “JNC 8” ASH /ISH 2014 Indian Guidelines -2013 Definition of Hypertension ≥140/90 and daytime ABPM (or home BP) ≥135/85 ≥140/90 Not addressed ≥140/90 > 140/90 mm Hg Blood pressure targets < 140/90 <140/90 < 60 y. <140/90 <140/90 (young and middle aged) <140/90 ≥ 80 y. Elderly < 80 y. ≥ 80 y. Elderly 140 – 145/90 < 150/90 SBP 140-150 ≥ 60 y. <150/90 < 150/90 SBP <140 in fit patients Elderly ≥ 80 y. SBP 140-150 Blood Pressure target in patients with diabetes mellitus Not addressed < 140/85 <140 /90 <140/90 <140/80 Initiate drug therapy with two drugs Not mentioned In patients with markedly elevated BP ≥160/100 ≥160/100 > 160/100
  46. 46. All the following are sound combination of drugs except ? A. ACEI +CCB B. CCB+BB C. ARB + Diu D. ACEI + ARB
  47. 47. Indian Hypertn Guidelines 2013 BP Goals : • 140/90 mm Hg in the young and middle aged • 140/80 mm Hg in diabetic patients • 130/85 mm Hg in pts who have survived stroke • 140-145/90 in elderly patients • Treatment of hypertension even in > 80 has been showed to be beneficial and has been recommended. • A J shaped curve does exist specially for non revascularised CAD patients and caution has been advocated in trying to lower blood pressure to low target levels specially in these patients.
  48. 48. Indian Hypertn Guidelines 2013 • Which drugs : • Beta-blockers not first line agents and now recommended as agents for use only in young or in hypertensives with specific indications. • Diuretics are now considered at par with of ACEI’s or ARB’s and CCB and not • as preferred agents as in previous guidelines. • Chlorthalidone is now available and shown to be better than Hydrochlorothiazide and its usage is to be preferred.
  49. 49. Indian Hypertn Guidelines 2013 • Which Drugs • When blood pressure is high by more than 20/10 mm of Hg systolic and diastolic it is now recommended to start with a combination of drugs. • Certain combinations have been shown to be better than others in recent trials. (Specially ACEI’s/ARB’s +CCB’s)
  50. 50. Take home messages : • BP Goal : Office BP < 140/90 in all except age 80 & above • Other Goals – more benefits : Out of office BP (esp noct BP, dip, variability, masked hypertn etc) • Initiate Rx accrdg to age and co morbid conditions • Use physiologically sound combinations • Avoid severe diastolic hypotension esp in non revascularized CAD pts
  • drssm

    Dec. 17, 2019
  • daniellephillips503645

    Jul. 6, 2018

A presentation by Dr. Akshay Mehta on the benefits of hypertension control and which drugs to use for effective management of the condition.

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