This document discusses guidelines for diagnosing and treating hypertension. It summarizes findings from the SPRINT and HOPE-3 trials regarding blood pressure targets. The SPRINT trial found that treating systolic blood pressure to under 120 mmHg reduced cardiovascular risks more than treating to under 140 mmHg. However, the HOPE-3 trial found statin therapy reduced risk more than blood pressure medication alone in intermediate-risk patients. The document provides recommendations on lifestyle changes, medication options, special patient populations, and evaluating treatment resistance and secondary causes of hypertension.

1. Stephen Gimple, MD, FACC
Meritas Health Cardiology
June 2022

2. Hypertension
 Normal blood pressure
 120/80 mmHg
 High blood pressure
 >130/80

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

7. SPRINT trial
 Exclusions
 Diabetes
 Prior stroke
 Polycystic kidney disease or ESRD
 CHF

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

10. SPRINT intensive treatment

11. SPRINT SBP during follow up

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

33. Medication Issues
 Thiazide Diuretics
 Hypokalemia and hyponatremia (check labs one week)
 gout
 Calcium channel blockers
 Increased edema
 Beta blockers
 Fatigue and bradycardia
 Hydralazine
 edema

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

37. Secondary Hypertension
 Rare
 Renal Disease
 Renal Artery stenosis
 Obstructive sleep apnea
 Other medications
 Hyperaldosteronism
 Pheochromocytoma