Hypertension management 2018

This lecture presents the 1-Updated recommendations regarding definition and proper diagnosis of HTN. 2-Updated guidelines for threshold of BP to start treatment and targets of treatment. 3- Updated recommendations on CV risk assessment and management. 4-Hypertension and comorbidities: updated guidelines

1. Hypertension Management -2018 ( Major Novelties in Definition, Measurement and Therapy) Dr Monkez M Yousif Professor of Internal Medicine Member of AGA, EASL and ISC-Hepatitis WG Zagazig University August 27, 2018

2. Objectives Updated recommendations regarding definition and proper diagnosis of HTN. Updated guidelines for threshold of BP to start treatment and targets of treatment Updated recommendations on CV risk assessment and management Hypertension and comorbidities: updated guidelines

3. References

4. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)

5. Epidemiology of Hypertension

6. One of the key risk factors for cardiovascular disease is hypertension or raised blood pressure. Hypertension already affects 1.1 billion people worldwide (WHO 2015), leading to heart attacks and strokes. By 2025, it is estimated over 1.5 billion people will have hypertension. Researchers have estimated that raised blood pressure currently kills nine million people every year.

7. Epidemiology of Hypertension in Egypt

8. Prevalence of HTN among adults 15-59 years: EDHS 2008 vs 2015 53.5 % 45.6% 17% 12.8%

9. Awareness of condition and treatment status among hypertensive women and men age 15-59 EHIS 2015

10. Figure 2 The Lancet  2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8) Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade

11. Figure 4 The Lancet  2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8 ) IHD mortality rate in each decade of age versus usual blood pressure at the start of that decade

12. CV benefits of treating HTN Hebert et al, Archives Int Med 1993

13. BP and CVD Risk

14. CVD Risk Factors Common in Patients With Hypertension *Factors that can be changed and, if changed, may reduce CVD risk. †Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress). CKD indicates chronic kidney disease; and CVD, cardiovascular disease. Modifiable Risk Factors* Relatively Fixed Risk Factors † Current cigarette smoking, secondhand smoking Diabetes mellitus Dyslipidemia/hypercholesterolemia Overweight/obesity Physical inactivity/low fitness Unhealthy diet CKD Family history Increased age Low socioeconomic/educational status Male sex Obstructive sleep apnea Psychosocial stress

15. Classification of BP

16. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413–46. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . JAMA 2003;289:2560–71.

17. ESC/ESH 2013/2018 Definitions and classification of office blood pressure levels Category SBP DBP Optimal < 120 and < 80 Normal 120-129 and / or 80-84 High normal 130-139 and/or 85-89 Hypertension stage I 140-159 and/or 90-99 Hypertension stage II 160-179 and/or 100-109 Hypertension stage III ≥ 180 and/or ≥ 110 Isolated SBP ≥ 140 and < 80

18. Categories of BP in Adults * ACC/AHA 2017 *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure. BP Category SBP   DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg

19. Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†   SBP/DBP ≥130/80 mm Hg or Self-Reported Antihypertensive Medication† SBP/DBP ≥140/90 mm Hg or Self-Reported Antihypertensive Medication‡ Overall, crude 46% 32%   Men (n=4717) Women (n=4906) Men (n=4717) Women (n=4906) Overall, age-sex adjusted 48% 43% 31% 32% Age group, y 20–44 30% 19% 11% 10% 45–54 50% 44% 33% 27% 55–64 70% 63% 53% 52% 65–74 77% 75% 64% 63% 75+ 79% 85% 71% 78% Race-ethnicity§ Non-Hispanic White 47% 41% 31% 30% Non-Hispanic Black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32% The prevalence estimates have been rounded to the nearest full percentage. *130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014. †BP cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition of hypertension in JNC 7. §Adjusted to the 2010 age-sex distribution of the U.S. adult population. BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure .

20. Measurement of BP

21. Accurate Measurement of BP in the Office COR LOE Recommendation for Accurate Measurement of BP in the Office I C-EO For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP.

22. Selection Criteria for BP Cuff Size for Measurement of BP in Adults Arm Circumference Usual Cuff Size 22–26 cm Small adult 27 –34 cm Adult 35 –44 cm Large adult 45 –52 cm Adult thigh

23. Out-of-Office and Self-Monitoring of BP COR LOE Recommendation for Out-of-Office and Self-Monitoring of BP I A SR Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. SR indicates systematic review .

24. Clinical indications for HBPM & ABPM Conditions in which white-coat hypertension is more common, e.g.: Grade I hypertension on office BP measurement Marked office BP elevation without HMOD Conditions in which masked hypertension is more common, e.g.: High–normal office BP Normal office BP in individuals with HMOD or at high total CV risk When there is considerable variability in the office BP Evaluation of resistant hypertension

25. Corresponding Values of SBP/DBP for Clinic, HBPM, Daytime, Nighttime, and 24-Hour ABPM Measurements ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; DBP diastolic blood pressure; HBPM, home blood pressure monitoring; and SBP, systolic blood pressure. Clinic HBPM Daytime ABPM Nighttime ABPM 24-Hour ABPM 120/80 120/80 120/80 100/65 115/75 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90

26. BP Patterns Based on Office and Out-of-Office Measurements ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.   Office/Clinic/Healthcare Setting Home/Nonhealthcare/ABPM Setting Normotensive No hypertension No hypertension Sustained hypertension Hypertension Hypertension Masked hypertension No hypertension Hypertension White coat hypertension Hypertension No hypertension

27. Screening and Diagnosis of Hypertension Optimal BP <120/80 Normal BP <120-129/80-84 High normal BP 130-139/85-89 Hypertension ≥140/90 Repeat BP at least every 5 y Repeat BP at least every 3 y Repeat BP at least annually Repeated visits for office BP measurement Out of office BP measurement (ABPM-HBPM) Out of office BP measurement (ABPM-HBPM) Consider Masked HTN Use either to confirm diagnosis

28. Patient Evaluation

29. Basic and Optional Laboratory Tests for Primary Hypertension Basic testing Fasting blood glucose* Complete blood count Lipid profile Serum creatinine with eGFR* Serum sodium, potassium, calcium* Thyroid-stimulating hormone Urinalysis Electrocardiogram Optional testing Echocardiogram Uric acid Urinary albumin to creatinine ratio *May be included in a comprehensive metabolic panel. eGFR indicates estimated glomerular filtration rate.

30. Hypertension and CV Risk Assessment

31. 10-y CV Risk Categories Subjects with any of the following: CVD Type 2 diabetes, or type 1 diabetes & target organ damage Patients with moderate to severe CKD (GFR <60mL/min/1.73m2) SCORE ≥10% Very high risk Subjects with: Markedly elevated single risk factors such as: Familial dyslipidaemias Severe hypertension. SCORE ≥ 5% and <10% High risk SCORE is ≥1 and <5% at 10 years, further modulated by: family history of premature CAD abdominal obesity physical activity pattern HDL-C TG hsCRP social class Moderate risk SCORE less than 1% and free of qualifiers Low risk

32. Hypertension and Total CV Risk Assessment There is also emerging evidence that increased serum uric acid to levels lower than those typically associated with gout (6.5-7 mg/dl) is independently associated with increased CV risk in both the general population and hypertensive patients.

33. Classification of hypertensive stages according to BP levels, presence of cv risk factors, HMOD, or comorbidities BP grading Other risk factors, HMOD, or disease Hypertension disease staging Grade III ≥180/110 Grade II 160-179/ 100-109 Grade I 140-159/ 90-99 High normal 130-139/ 85-89 High risk Moderate risk Low risk Low risk No other risk factors Stage I (Uncomplicated) High risk Moderate high risk Moderate risk Low risk 1 or 2 risk factors High risk High risk Moderate high risk Low moderate ≥ 3 risk factors High-very high risk High risk High risk Moderate high risk HMOD, CKD grade 3, or DM without organ damage Stage II (Asymptomatic disease) Very High risk Very High risk Very High risk Very High risk Symptomatic CVD, CKD ≥ grade 4 or DM with organ damage Stage III ( Established disease)

34. Initiation of BP Lowering Treatment

35. Initiation of BP Lowering Treatment (Life style changes and medications) at different initial office BP levels High-normal BP 130-139/85-89 Grade I 140-159/90-99 Grade II 160-179/100-109 Grade III ≥180/110 Consider drug treatment in very high risk patients with CVD especially CAD Immediate drug treatment in high or very high risk patients with CVD, HMOD or renal disease Immediate drug treatment in all patients Immediate drug treatment in all patients Life style advice Life style advice Life style advice Life style advice Drug treatment in low moderate risk patients without CVD, renal disease, or HMOD after 3-6 months of life style intervention if BP not controlled Aim for BP control in 3 months

36. Summary of office BP thresholds for treatment Office SBP treatment threshold (mmHg) Age Group DBP treatment threshold + Stroke/ TIA +CVD +CKD + DM HTN ≥ 90 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 18-65 years ≥ 90 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 65-79 years ≥ 90 ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 80 years ≥ 90 ≥ 90 ≥ 90 ≥ 90 ≥ 90 DBP treatment threshold

37. Office BP treatment targets in hypertensive patients- General recommendations Class/Level Recommendation I A The first objective of treatment should be to lower BP to < 140/90 mmHg in all patients I A Provided that treatment is well tolerated treatment BP should be targeted to 130/80 mmHg or lower in most patients II aB A DBP target of < 80 mmHg should be considered for all hypertensive patients, independent of the level and risk of comorbidities.

38. Office BP treatment target ranges Office SBP treatment target ranges (mmHg) Age Group DBP treatment target range + Stroke/ TIA +CVD +CKD + DM HTN < 80 - 70 Target to 130 or lower if tolerated Not < 120 Target to 130 or lower if tolerated Not < 120 Target to <130 – 140 if tolerated Target to 130 or lower if tolerated Not < 120 Target to 130 or lower if tolerated Not < 120 18-65 years < 80 - 70 Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated 65-79 years < 80 - 70 Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated Target to <130 – 140 if tolerated ≥ 80 years < 80 - 70 < 80 - 70 < 80 - 70 < 80 - 70 < 80 - 70 DBP treatment target range

39. Nonpharmacological Interventions 2017 Hypertension Guideline

40. Nonpharmacological Interventions COR LOE Recommendations for Nonpharmacological Interventions I A Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese. I A A heart-healthy diet , such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension. I A Sodium reduction is recommended for adults with elevated BP or hypertension. I A Potassium supplementation , preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.

41. Nonpharmacological Interventions (cont.) COR LOE Recommendations for Nonpharmacological Interventions I A Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension. I A Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively. * In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

42. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*   Nonpharmacologi-cal Intervention Dose Approximate Impact on SBP Hypertension Normotension Weight loss Weight/body fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. -5 mm Hg -2/3 mm Hg Healthy diet DASH dietary pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. -11 mm Hg -3 mm Hg Reduced intake of dietary sodium Dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. -5/6 mm Hg -2/3 mm Hg Enhanced intake of dietary potassium Dietary potassium Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. -4/5 mm Hg -2 mm Hg *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH? Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to . Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

43. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)   Nonpharmacological Intervention Dose Approximate Impact on SBP Hypertension Normotension Physical activity     Aerobic ● 90–150 min/ wk ● 65%–75% heart rate reserve -5/8 mm Hg -2/4 mm Hg Dynamic resistance ● 90–150 min/ wk ● 50%–80% 1 rep maximum ● 6 exercises, 3 sets/exercise, 10 repetitions/set -4 mm Hg -2 mm Hg Isometric resistance ● 4 × 2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/ wk ● 8–10 wk -5 mm Hg -4 mm Hg Moderation in alcohol intake Alcohol consumption In individuals who drink alcohol, reduce alcohol† to: ● Men: ≤2 drinks daily ● Women: ≤1 drink daily -4 mm Hg -3 mm *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. †In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

44. Drug Therapy for Hypertension

45. Drugs for the treatment of Hypertension In previous guidelines 5 major drug classes (ACEIs, ARBs, BBs, CCBs, Ds) were recommended based on Proven ability to reduce BP CV event reduction in placebo-controlled studies Broad equivalence in overall CV morbidity/mortality Conclusion that benefit predominantly derives from BP lowering These conclusions have since been confirmed by recent meta-analyses These guidelines thus recommend that the same 5 major classes of drugs should form the basis of antihypertensive therapy

46. Major Novelties on antihypertensive treatment Increasing dose of initial monotherapy. Monotherapy substitution. “Stepped - care” approach (monotherapy with subsequent addition of other drugs). Initial two drug combination treatment. Use of single pill combinations.

47. Rationale for initial two drug-combination therapy in most patients Greater BP reduction even vs maximum dose monotherapy. Reduced heterogeneity of the BP response to initial therapy. Steeper dose-response relationship with treatment up-titration. No/small increase in risk of hypotensive episodes (even in grade I hypertension). More frequent BP control after 1 year Better adherence to treatment Reduced therapeutic inertia Reduce CV events (grade I hypertension, HOPE-3)

48. Single-pill combination Already favored by 2013 ESC/ESH Guidelines (improved adherence to treatment) Further supported by recent studies using various methods to assess adherence (direct/indirect) Facilitated by availability of several SPCs with a range of doses

49. What is the best effective evidence-based treatment strategy to improve BP control Use combination treatment in most patients, especially in the context of lower BP targets Use single-pill-combination therapy in most patients to improve adherence to treatment Above treatment algorithm, that is simple, applies extensively and is pragmatic. Exceptions: BP in the high normal range and in frail older patients

50. Core drug treatment strategy for uncomplicated hypertension The core algorithm is also appropriate for most patients with HMOD, CVA, DM, or PAD

51. Drug treatment strategy for hypertension + DM

52. Drug treatment strategy for hypertension CAD

53. Drug treatment strategy for hypertension and hear failure with reduced ejection fraction

54. Drug treatment strategy for hypertension and CKD

55. Drug treatment strategy for hypertension and AF

56. Clinician’s Sequential Flow Chart for the Management of Hypertension Clinician’s Sequential Flow Chart for the Management of Hypertension Measure office BP accurately Detect white coat hypertension or masked hypertension by using ABPM and HBPM Evaluate for secondary hypertension Identify target organ damage Introduce lifestyle interventions Identify and discuss treatment goals Use ASCVD risk estimation to guide BP threshold for drug therapy Align treatment options with comorbidities Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Insure appropriate follow-up Use team-based care Connect patient to clinician via telehealth Detect and reverse nonadherence Detect white coat effect or masked uncontrolled hypertension Use health information technology for remote monitoring and self-monitoring of BP ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

57. Conclusions BP measurement: Wider use of out of office BP measurement with ABPM and/or HBPM especially HBOM, is an option to confirm the diagnosis of hypertension, detect white coat and masked hypertension and monitor BP control. Less conservative treatment of BP in older and very old patients: Lower BP thresholds and treatment targets for older patients- with emphasis on consideration of biological rather than chronological age( i.e the importance of frailty, independence and the tolerability of treatment). Recommendations that treatment should never be denied or withdrawn on basis of age, provided that treatment is tolerated.

58. A SPC strategy to improve BP control: Preferred use of two-drug combination for the initial treatment of most patients with hypertension. A single pill treatment strategy for hypertension with the preferred use of SPC therapy for most patients. Simplified drug treatment algorithms with the preferred use of ACEI or ARB combined with a CCB or/ and a thiazide / thiazide -like diuretic as the core treatment strategy for most patients, with BB used for specific indications. New target ranges for BP in treated patients Target BP ranges for treated patients to better identify the recommended BP target and lower safety boundaries for treated patients according to a patient’s age and comorbidities.

59. Detection of poor adherence to drug therapy A strong emphasis on the importance of evaluating treatment adherence as a major cause of poor BP control. A key role for nurses, pharmacists in the longer-term management of hypertension The important role of nurses and pharmacists in the education, support, and follow up of treated hypertensive patients is emphasized as part of the overall strategy to improve BP control.