jnc8handout cp

Hypertension Today: JNC-8 Evidence-Based Guidelines Event Type Live Online Expiration Date 7/16/2016 Credits 1 Contact Hour Target Audience Nurses, Pharmacists, Pharmacy Technicians

Program Overview

Hypertension (HTN) is a prevalent disease state throughout the United States and is one of the

risk factors for developing cardiovascular disease. Cardiovascular disease is the leading cause

of death in the United States. The optimal way to treat hypertension has been the focus of

many studies and has led to many conflicting opinions and guidelines over the past

decade. Most recently, in December 2013, the Eighth Joint National Committee (JNC8)

released their newest guidelines to address when to initiate therapy, what the optimal BP goal

is for patients, and what drug therapies we should be using to control hypertension.

Nurse/Pharmacist Educational Objectives

Review the historical goals and treatment of patients with hypertension

Determine optimal threshold for initiating treatment in patients with hypertension

Establish evidence based treatment goals for patients with hypertension

Select optimal treatment for patients with hypertension focusing on key evidence regarding

diuretics, combination therapy, and beta blockers

Pharmacy Technician Educational Objectives

List signs and symptoms of hypertension

List medications used to treat hypertension

Activity Type

Knowledge

Accreditation

Nurse Pharmacist Pharmacy Technician

N-875 0798-0000-14-275-L01-P 0798-0000-13-275-L01-T

PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

PharmCon, Inc. has been approved as a provider of continuing education for nurses by the Maryland Nurses Association which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation.

Faculty

Kate Moore, PharmD Associate Professor, Presbyterian College School of Pharmacy

Financial Support Received From

Pharmaceutical Education Consultants, Inc.

Disclaimer

PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the

value of the material is decreased. The content of the activity was planned to be balanced and

objective. Occasionally, authors may express opinions that represent their own viewpoint.

Participants have an implied responsibility to use the newly acquired information to enhance

patient outcomes and their own professional development. The information presented in this

activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions

drawn by participants should be derived from objective analysis of scientific data presented

from this activity and other unrelated sources.

Hypertension Today: JNC-8 Evidence-Based Guidelines

2014 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.

Reproduction in whole or in part without permission is prohibited.

Page 1


AccreditationPharmacists: 0798-0000-14-275-L01-PPharmacy Technicians: 0798-0000-14-275-L01-TNurses: N-875

Faculty

Kate Moore, PharmDPresbyterian School of Pharmacy

CE Credit(s)1.0 contact hour(s)

Faculty DisclosureDr. Moore has no actual or potential conflicts of interest in relation to this program.

Learning Objectives Review the historical goals and treatment of patients with hypertension Determine optimal threshold for initiating treatment in patients with hypertension Establish evidence based treatment goals for patients with hypertension Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination

therapy, and beta blockers

Legal DisclaimerThe material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

Objectives

Review the historical goals and treatment of patients with hypertension

Determine optimal threshold for initiating treatment in patients with hypertension

Establish evidence based treatment goals for patients with hypertension

Select optimal treatment for patients with hypertension focusing on key evidence regarding diuretics, combination therapy, and beta blockers

Disclosures

I have no financial disclosures




Page 2

Defining the Burden:Cardiovascular Disease

Leading cause of death in US

Responsible for 17% of national health expenditures

2 million heart attacks annually

Projected: By 2030, 40.5% of US will have CVD

Will account for $1 trillion/year

Risk Factors for Cardiovascular Disease Cigarette smoking

Hypertension

Elevated LDL Cholesterol

Family history of premature CHD (55 women

Diabetes

Obesity

Physical inactivity

Excessive alcohol use

MMWR 2011;60(36):124851

Defining the Burden: Risk Factor-Hypertension (2011)

http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm, accessed 1/30/2013

Hypertension and Cardiovascular Disease

Risk factor for heart disease and stroke BP >140/90 mmHg

DBP more potent predictor 50 yrs old

Two-fold increase in risk of CVD with BP 130-139/85-89 vs




Page 3

Historical Review: BP Goals

Discrepancy across guidelines JNC-7 vs AHA

Lower not always better Mortality may increase with lower DBP

Co-morbid Condition JNC-7 AHA

None




Page 4

Patient Case-Harry T. Nabb

Pt is 49 years old Caucasian male with no significant past medical history. He presents today for his routine yearly physical.

Vitals BP 136/88 (first reading), 134/84 (second reading)

Height 510

Weight 198 lbs (BMI 28.4)

When should we initiate treatment?

Treat Pre-hypertension? The TROPHY Study

Objective: to determine whether patients with pre-hypertension treated

for two years with candesartan reduces the incidence of hypertension for up to two years after the discontinuation of active treatment.

Comparison Candesartan vs placebo

Patients age 30-65 BP 130-139/89 mmHg or 140 or DBP >90)

NEJM 2006;354:1685-97

Treat Pre-hypertension? The TROPHY Study

Adverse effects Similar between groups

Conclusion Treating pre-hypertension can decrease the development of

hypertension

No information on cost effectiveness

No information on outcome impact (death, hospitalizations, stroke, MI)

Outcome CandesartanN=391

PlaceboN=381

P-value Relative Risk (95% CI)

Developed Hypertension 208 240

Hypertension at 2 years, % 13.6 40.4




Page 5

Cochrane Review of Mild Hypertension

Effect of treatment vs no treatment in patients with no history of CV events and BP 140-159/90-99mmHg on CV events, stroke, mortality

Withdrawals due to adverse effects of therapy

Trials included VA-NHLBI 1997 (chlorthalidone vs placebo)

ANBP 1984 (chlorthiazide vs placebo)

MRC 1981 (Bendrofluazide, propranolol vs placebo)

SHEP 2000 (chlorthalidone vs placebo)

Cochrane Database of Systematic Reviews 2012, Issue 8.

Cochrane Review of Mild Hypertension

OutcomeNo. of Trials

included

Number of

Subjects

Relative Risk (95% CI)

Mortality 4 8912 0.85 (0.65-1.15)

Stroke 3 7080 0.51 (0.24-1.08)

Coronary Heart Disease 3 7080 1.12 (0.8-1.57)

Total CV Events 3 7080 0.97 (0.72-1.32)

Withdrawal due to Adverse Events 1 17354 4.80 (4.14-5.57)

Cochrane Database of Systematic Reviews 2012, Issue 8.

Cochrane Review of Mild Hypertension Conclusion

Treatment of mild hypertension for 5 years does not reduce mortality, stroke, CHD, or CV events

Thoughts to ponder Therapies included do not match current practice

Many other trials show outcomes benefit with similar baseline BP ALLHAT-baseline BP 146/86

ACCOMPLISH-baseline BP 145/80

Negative impact of hypertension may take >5 years to develop

Does not apply to those with history of CV disease! Cochrane Database of Systematic Reviews 2012, Issue 8.

JNC-8: When should we initiate treatment?

Age 60 years SBP 150mmHg

DBP 90 mmHg

Age < 60 years SBP 140mmHg

DBP 90 mmHg

Strong recommendations to reduce risk of stroke, heart failure, coronary heart disease

JAMA 2013. doi:10.1001/jama.2013.284427




Page 6

What is our optimal blood pressure goal?

Patient Case-Harry T. Nabb

1 year has passed and Mr. Nabb returns for another physical. He did not make any lifestyle changes as recommended before and is currently not taking any medications

Vitals BP 144/88 (first reading), 142/84 (second reading)

Height 510

Weight 215 lbs (BMI 30.8)

Labs A1c 7.8, fasting BG 142

TC 201, LDL 140, HDL 32, TG 142

Hypertension Optimal Treatment (HOT) Trial

Comparison Target DBP




Page 7

HOT TrialResults-Overall Population




Page 8

ACCORD-BPResults-Primary Outcome

HR= 0.88 (0.73-1.06)

NEJM 2010;362:1575-85

Mean SBP Achieved:Intensive group-119mmHgControl group-133mmHg

ACCORD-BPResults-Primary & Secondary Outcomes

OutcomeIntensiveTherapy

# events (%/yr)

Standard Therapy

# events (%/yr)

Hazard Ratio(95% CI)

p-value

Primary Outcome 208 (1.87) 237 (2.09) 0.88 (0.73-1.06) 0.2

Nonfatal MI 126 (1.13) 146 (1.28) 0.87 (0.68-1.10) 0.25

Stroke 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01

Death-all cause 150 (1.28) 144 (1.19) 1.07 (0.85-1.35) 0.55

Death-CV cause 60 (0.52) 58 (0.49) 1.06 (0.74-1.52) 0.74

NEJM 2010;362:1575-85

ACCORD-BPResults-Adverse Events

EventIntensiveTherapy

# events (%)

Standard Therapy

# events (%)p-value

Event attributed to BP medication 77 (3.3) 30 (1.27)




Page 9

JNC-8: What is our Optimal BP Goal?

Age 60 years Goal




Page 10

Chlorthalidone (CTD)Trial Comparator Result

HDFP PCP choice CTD care better

MRFIT-10yr f/u

Usual care CTD better

SHEP Placebo CTD better

TOMHS acebutololdoxazosinamlodipineenalapril

No difference

ALLHAT amlodipinelisinopril

CTD better

Hydrochlorothiazide (HCTZ)Trial Comparator Result

VA II placebo HCTZ better

EWPHBPE Placebo No difference

HAPPHY Beta-blockers No difference

MAPPHY metoprolol Metoprololbetter

MRC-E PlaceboAtenolol

Atenololbetter

MIDAS CCB No difference

INSIGHT Nifedipine No difference

PATS Placebo HCTZ better

ANBP Enalapril Enalaprilbetter

Thiazide-type DiureticsClinical Trial Overview Chlorthalidone vs Hydrochlorothiazide

Mean Change from Week 0 to Week 8 in Mean Hourly Ambulatory SBP

Hypertension 2006;47:352-358.

Thiazide-type Diuretics Clinical Pearls

Chlorthalidone has a longer half-life & duration of action and is ~2x as potent

Doses >25mg of chlorthalidone & HCTZ do not offer significant benefit

No difference in hypokalemia Dose related side effect

Are not beneficial in renal dysfunction

Beta Blockers and Hypertension

2004 Meta-analysis Atenolol vs placebo

Decreased BP

No difference in all-cause or CV mortality, MI

Non-significant decrease in stroke

Atenolol vs other antihypertensives No difference in BP lowering

Higher mortality with atenolol

Lancet 2004;364:1684-89




Page 11

Beta Blockers and HypertensionOutcome Comparator # of studies (pts) Risk Ratio (95% CI)

Total mortality PlaceboDiureticCCBRAS agent

4 (23613)5 (18241)4 (44825)3 (10828)

0.99 (0.88-1.11)1.04 (0.82-1.54)1.07 (1.00-1.14)1.10 (0.98-1.24)

Stroke PlaceboDiureticCCBRAS agent

4 (23613)4 (18135)3 (44167)2 (9951)

0.8 (0.66-0.96)1.17 (0.65-2.09)1.24 (1.11-1.40)1.30 (1.11-1.53)

Coronary Heart Disease PlaceboDiureticCCBRAS agent

4 (23613)4 (18135)3 (44167)2 (9951)

0.93 (0.81-1.07)1.12 (0.82-1.54)1.05 (0.96-1.15)0.90 (0.76-1.06)

Withdrawal due to AE PlaceboDiureticCCBRAS agent

2 (16372)3 (11566)2 (21591)2 (9951)

6.35 (3.94-10.22)1.69 (0.95-3.00)1.20 (0.71-2.04)1.41 (1.29-1.54)

Cochrane Database of Systematic Reviews 2012, Issue 11

Decline of Beta Blockers

Limited role for first line therapy unless compelling indication HF (with ACE)

Post MI Duration recently questioned

Less tolerated than other agents Fatigue, exercise intolerance

Bradycardia

Sexual dysfunction

Bronchospasm

Beta Blocker Clinical Pearls

Not created equal Selectivity

Route of elimination

Indications

Monitor HR carefully

Caution initiation/titration in symptomatic heart failure

Selectivity lost at higher doses

Taper off slowly Risk of rebound hypertension, angina, sudden cardiac death

1-2 weeks minimum

ACE Inhibitors JNC-8: ACE reduce incidence of heart failure, but

similar effect on other cardiovascular, cerebrovascular, kidney outcomes and mortality compared to CCB ACE lead to higher incidence of stroke in general black

population compared to CCB

ACE improves kidney outcomes compared to CCB or BB, however does not improve cardiovascular outcomes

JAMA 2013. doi:10.1001/jama.2013.284427




Page 12

Angiotensin Receptor Blockers

JNC-8: No trials of sufficient quality to determine whether initial therapy with ARB improves outcomes compared to other therapies in general population ARB improves kidney outcomes in those with

proteinuria and hypertension compared to CCB, however does not improve cardiovascular outcomes

JAMA 2013. doi:10.1001/jama.2013.284427

Renin-Angiotensin Agent Clinical Pearls

Combination therapy (ACE + ARB/DRI) Increased hyperkalemia

No difference in clinical outcomes for hypertension

Avoid ACE or ARB + DRI in patients with DM & renal insufficiency

Angioedema ACE > ARB, DRI

Can happen with all 3 classes

Discontinue if increase in SCr >30%

Avoid in pregnancy or childbearing years

JNC-8: What Initial Agent should be Started?

General Non-black population (including diabetes) Thiazide-type diuretic, CCB, ACE or ARB

General black population (including diabetes) Thiazide-type diuretic or CCB

Age 18 years with CKD ACE or ARB

Main objective is to reach and maintain goal BP

JAMA 2013. doi:10.1001/jama.2013.284427

What Combination Therapy is Best?The ACCOMPLISH Trial

High risk patients: SBP 160 or on therapy, >60 with 1 risk factor,

or 55-59 with 2 risk factors

Benazepril 20mg + HCTZ 12.5mg

Benazepril 20mg+ Amlodipine 5mg

Benazepril 40mg + HCTZ 12.5mg



Benazepril 40mg + HCTZ 25mg

Add on from any other class

Add on from any other class

Primary endpoint: CV event or death from CV cause NEJM2008;359:2417-28.




Page 13

What Combination Therapy is Best to Initiate?

NEJM2008;359:2417-28.

P




Page 14

NOTES:

JAMA 2013. doi:10.1001/jama.2013.284427

NOTES:

JAMA 2013. doi:10.1001/jama.2013.284427

jnc8handout cp

Documents

treatment of patients

pharmacy management

optimal treatment

treatment goals

key evidence

l01t pharmcon

newest guidelines

initiating treatment