Should The New Hypertension Guidelines Affect Your Practice - Peterson

JNC-8 New GuidelinesFinally
Let the controversies begin

Eric D Peterson, MD, MPH
Director of DCRI

Feb, 2014
http://www.dcri.duke.edu/research/coi.jsp
All Rights Reserved, Duke Medicine 2007 sb/Strategy & Innovation Group | 2
Affects 1 billion people worldwide
US about 1 in 3 adults
73 million have hypertension (SBP >140/90)
A 55yo normotensive person has up to a 90% lifetime
risk of developing hypertension (Vasan 2001)
Number one reason listed for office visits
Causes/contributes to 457,000 admissions per year
A leading cause/contributor to death (MI, stroke,
vascular disease)
The greatest danger to a man with high blood pressure
lies in its discovery, because then some fool is certain to
try and reduce it.- J.H. Hay, 1931.

Hypertension may be an important compensatory
mechanism which should not be tampered with, even
were it certain that we could control it. Paul Dudley
White, 1937.

How Aggressive to Treat Hypertension
Some Early Views on the Controversy
Stroke and IHD Mortality vs Systolic BP by Age
M
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y

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F
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a
b
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r
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k

a
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9
5
%

C
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)

Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Stroke
Age at risk
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Ischemic Heart Disease
Usual Systolic BP (mm Hg)
50-59 years
60-69 years
70-79 years
80-89 years
Age at risk:
40-49 years
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Lancet. 2002;360:1903-1913
BP Reductions as Small as 2 mmHg Reduce
the Risk of CV Events by Up to 10%

Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
2 mmHg
increase in
mean SBP
10% increase in
risk of stroke
mortality
7% increase in
risk of ischemic
heart disease
mortality
Benefits of Treating Hypertension: RCT
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
Heart failure Stroke Cardiovascular
death
R
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s
k

r
e
d
u
c
t
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o
n

(
%
)
50%
40%
20%
Hebert, Archives Int Med 1993; Moser, Am Coll Cardiol 1996
Lifestyle Modifications
Goal blood pressure <140/90 mm Hg
<130/80 mm Hg with diabetes or chronic kidney disease*
Initial drug choices
Without Compelling indications
Stage 1 Hypertension
(SBP 140-159 DBP 90-99 )
Diuretics for most; may
consider ACE inhibitor,
ARB, beta blocker, CCB or
combination
Stage 2 hypertension
(SBP 160 or DBP 100)
2-drug combination for
most (Diuretic +ACE, ARB,
beta blocker, or CCB)
With compelling indications
Drug(s) for compelling
indications
Diuretics, ACE inhibitor,
ARB, beta blocker, CCB as
needed
* Released in 2003
NHLBI Drops Out of
Guidelines Business
JNC-8 Significantly
Delayed

James et al JAMA December 13 2014


JNC-8 Hypertension Treatment Choices


The Evidence for Targets: JATOS Study
2200 pts per arm
Baseline BP 170/90
Target
<150 mild vs. <140 strict
Drugs:
Ca++blocker 50-60%
Ace 30-40%
Alpha blocker 15%
Diuretic 15%
Follow-up 2 yrs
Hypertens Res. 2008;31(12):2115-2127
JATOS Results
Hypertens Res. 2008;31(12):2115-2127
The Evidence for Targets: VALISH Trial
Hypertension. 2010;56(2):196-202
1630 pts per arm
Baseline BP 170/80
Target
Mild <150, strict <140
Drugs:
Valsartan 100%
Ca++ blacker 30%
Diuretic 10-15%
Median Follow-up 3 yrs
Hypertension. 2010;56(2):196-202
VALISH Trial
RCTs Evaluating SBP Targets
in those Aged < 60
Does the absence of evidence lead to
the conclusion of evidence of absence?
JNC-8 authors concluded:
- Yes for those >60
- No for those <60

Guidelines, Performance Measures and Policy
Guideline:
In past: practical advice on a course of action
Have become: RCT-based, rigorous

Performance Measures:
Distillation of guidelines:
Use strict criteria to define what should and must
be done to avoid a quality concern
Often applied to public reporting or financial
incentives

BP Treatment Targets Have Risks Both Ways
If one votes to keep all at 140/90
PMs and incentives may encourage over-treatment
Worse symptoms, falls, costs in elderly

If one votes to move to 150/90 in elderly
Risk of under-treatment
Despite existing guideline goals/PMs, <50%
of public reaches goal!
JNC-8 Implications for US
All US Adults Ages 18-59 Ages 60+
JNC 7: HTN 66.6 32.8 33.8
Controlled 26.6 (39.9%) 13.3 (40.5%) 13.3 (39.3%)
JNC 8: HTN 60.8 30.8 30.0
Controlled 34.3 (56.4%) 14.6 (47.4%%) 19.7 (65.7%)
Major Findings
Currently: 66.7 million in US have hypertension,
of which 39.9% met guideline targets.
Using JNC 8: 60.8 million in US have hypertension,
of which 56.4% have controlled blood pressure.
In 60+, switching to JNC-8
improves BP control rates from 34.3% to 60.8%
reclassifying 13.6 million with previously
uncontrolled BP now seen as under control

Conclusions
Hypertension: common, costly and modifiable

Interpretation of existing evidence is challenging
Determining the optimal threshold will require
more RCTs.

In interim: My view:
Aim for 140/90 but allow for individualization
Whats your take?

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JNC-8 New GuidelinesFinally

Let the controversies begin

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