Vous êtes sur la page 1sur 3

977

GUIDELINES MANAGEMENT OF HYPERTENSION 44

Systemic Hypertension: Management


Treatment of Hypertension Lifestyle Modification
All patients with hypertension or prehypertension (BP of 120 to
Ronald G. Victor and Peter Libby 139/80 to 89 mm Hg) should receive counseling on lifestyle modifica-
tion according to the 2013 ACCF/AHA guidelines on lifestyle manage-
ment to reduce cardiovascular (CV) risk.13
New hypertension practice guidelines from at least 10 expert com-
mittees in the United States, Canada, and Europe have been pub-
lished since the last edition of this textbook.1-10 The recommendations Drug Therapy
have become progressively more evidence based. The 2014 report of Table 44-G2 summarizes the major differences between the
the Eighth Joint National Committee (referred to as JNC 8 for conve- 2003 JNC 7 recommendations14 and common features shared by
nience) members is the most strictly evidence-based set of hyperten- the new recommendations of JNC 8,1 the 2013 European Society
sion guidelines produced to date.11 Treatment recommendations are of Hypertension/European Society of Cardiology (ESH/ESC) guide-
based on strict interpretation of data only from randomized con- lines,4 the 2011 U.K. National Center for Clinical Excellence (NICE;
trolled trials (RCTs) of hypertension; major RCTs of antihypertensive now called National Center for Care Excellence) guidelines,8 and the
agents were excluded from consideration if the study population 2011 ACCF/AHA guidelines on treatment of hypertension in the
included patients with high risk for atherosclerotic cardiovascular elderly.9 JNC 7 recommended 140/90 mm Hg or higher as the office
disease (ASCVD), with or without hypertension. Unlike past JNC BP threshold for initiation of antihypertensive drug therapy in most
reports, JNC 8 is not a comprehensive set of practice guidelines. patients, regardless of age, and a lower than usual threshold of
Before JNC 8 was finalized in 2013, the National Heart, Lung and 130/80 mm Hg or higher for patients with diabetes mellitus or chronic
Blood Institute (NHLBI) decided that it would no longer sanction kidney disease (CKD). The new guidelines have relaxed the BP
professional practice guidelines. Although the final report underwent threshold for initiation of drug therapy to 150/90 mm Hg or higher for
extensive peer review before being published by the Journal of the elderly patients and have eliminated the 130/80 mm Hg or higher
American Medical Association,12 JNC 8 differs from preceding JNC threshold for patients with diabetes or CKD—who now have the same
reports in that it was neither endorsed by NHLBI nor reviewed or 140/90 mm Hg or higher treatment threshold recommended for most
endorsed by any professional medical society and thus does not other hypertensive patients.
constitute the official U.S. hypertension guidelines. As a result, other JNC 7 recommended a thiazide diuretic as the best choice to initi-
practice guidelines appeared in 2014 from the American Society of ate drug therapy for most cases of hypertension. In contrast, the new
Hypertension (ASH)/International Society of Hypertension (ISH)2 guidelines recommend initiating therapy with one or more of
and from the American College of Cardiology Foundation/American three first-line drug classes: a calcium channel blocker (CCB), an
Heart Association/Centers for Disease Control and Prevention (ACCF/ angiotensin-converting enzyme inhibitor (ACEI) or angiotensin
AHA/CDC).3 receptor blocker (ARB), and/or a thiazide. Chlorthalidone has
replaced hydrochlorothiazide (HCTZ) as the preferred thiazide
because of its greater potency, longer duration of action, and much
DIAGNOSIS OF HYPERTENSION larger evidence base.15 Although JNC 7 reserved combination drug
therapy for mainly stage 2 hypertension (BP ≥ 160/110 mm Hg), the
An initially elevated office blood pressure (BP)—higher than new guidelines recognize that low-dose combination therapy is an
140 mm Hg systolic or 90 mm Hg diastolic—must always be con- excellent way to initiate drug therapy even for those with mild hyper-
firmed either by home or ambulatory BP monitoring, as emphasized tension. An ACEI (or ARB) plus CCB combination is at least as
by both the new European guidelines 4 and updated U.K. guidelines,8 effective—and possibly more effective—than an ACEI (or ARB) plus
or must be remeasured at least three times over a period of at least thiazide combination. A CCB plus thiazide is also an effective
4 weeks to ensure that hypertension is present (Table 44-G1). Only
if the office BP level is very high (≥180/110 mm Hg) or if symptomatic
target-organ damage is present should therapy begin before the diag- TABLE 44-G2 Comparison of 2003 JNC 7 Guidelines with
nosis is carefully established. New Recommendations Common to the Guidelines by the
2014 JNC 8 Committee, 2013 ESH/ESC, 2011 UK-NICE, and
2011 ACCF/AHA
2003 JNC 7
TABLE 44-G1 Definition of Hypertension by Office REPORT 2011-2014 GUIDELINES
and Out-of-Office Blood Pressure Levels
Blood pressure ≥140/90 mm Hg ≥150/90 mm Hg for elderly
SYSTOLIC BLOOD DIASTOLIC threshold for for most patients patients*
PRESSURE BLOOD PRESSURE initiation of ≥130/80 mm Hg ≥140/90 mm Hg for
CATEGORY (mm Hg) (mm Hg) drug therapy for patients with nonelderly patients and
diabetes or CKD patients with diabetes or
Office BP ≥140 and/or ≥90 CKD
Home BP ≥135 and/or ≥85 First-line Thiazide diuretic Three first-line drug classes:
Ambulatory BP therapy for most patients CCB, ACEI or ARB, thiazide

Daytime ≥135 and/or ≥85 Preferred HCTZ Chlorthalidone


(or awake) thiazide

Nighttime ≥120 and/or ≥70 Combination Mainly for stage 2 A good option for stage 1
(or sleep) drug therapy hypertension hypertension
ACEI + thiazide ACEI + CCB ≥ ACEI + thiazide
24 hour ≥130 and/or ≥80
*Only JNC 8 defines “elderly” as 60 years or older; the other guidelines define “elderly”
Modified from Mancia G, Fagard R, Narkiewicz K, et al: 2013 ESH/ESC guidelines as 80 years or older or based more on frailty than on a specific chronologic age.
for the management of arterial hypertension: The Task Force for the Management Modified from James PA, Oparil S, Carter BL, et al: 2014 Evidence-based guideline
of Arterial Hypertension of the European Society of Hypertension (ESH) and of the for the management of high BP in adults: Report from the panel members appointed
European Society of Cardiology (ESC). J Hypertens 31:1281, 2013. to the Eighth Joint National Committee (JNC 8). JAMA 311:507, 2014.
978
combination, but ACEI plus ARB combinations and ACEI (or ARB) • Increasing the BP treatment threshold to 150 mm Hg systolic and
VI plus aliskiren combinations should be avoided
1
because they promote the treatment target to 140 to 149 mm Hg (rather than 10 mm Hg
hypotension and worsen renal function. lower) will probably reduce the intensity of antihypertensive
PREVENTIVE CARDIOLOGY

Table 44-G3 compares the 10 sets of hypertension guidelines pub- therapy in the large population at highest risk for hypertensive
lished between 2010 and 2014. With gaps in the evidence base, expert complications—including black adults (as incorporated into the
panels and individual panelists disagree on some aspects but 2013 ACC/AHA pooled cohort ASCVD risk calculator).17
agree on others about when to start (or intensify) therapy and about • Evidence supporting the new higher (SBP of 150 mm Hg) thresh-
which drugs are best for which patients. Several points should be old was based on insufficient evidence.
emphasized. • The higher SBP goal in patients 60 years or older runs the con-
siderable risk of increasing the population-level BP and reversing
When to Start or Intensify Therapy? the progressive decline in CV disease, especially stroke.
• Most of the new guidelines have raised the seated office BP thresh- • Most guidelines have raised the office BP treatment threshold in
old for initiation/intensification of drug therapy in hypertensive patients with diabetes mellitus to 140/90 mm Hg or higher—except
elderly patients to 150/90 mm Hg or higher, except for an even more for the 2013 American Diabetes Association (ADA) guidelines,6
conservative recommendation of 160/90 mm Hg or higher by the which recommend 140/80 mm Hg or higher, and the 2013 Canadian
2013 ESH/ESC guidelines.4 guidelines,5 which still recommend 130/80 mm Hg or higher.
• Only JNC 8 defines “elderly” as 60 years or older. The other guide- • Most guidelines have raised the treatment threshold in CKD
lines define elderly as 80 years or older. Several JNC 8 panel to 140/90 mm Hg or higher, except for the 2012 Kidney Disease
members did not support this definition and wrote a minority view Improving Global Outcomes (KDIGO) guidelines,7 which recom-
position paper16 citing the following evidence supporting a BP mend 130/80 mm Hg or higher for proteinuric CKD.
treatment threshold of 140 mm Hg systolic for patients 60 to 79 • All but the three most recent sets of guidelines from the United
years of age: States use global ASCVD risk in deciding when to initiate therapy.

TABLE 44-G3 Comparison of Recent Guidelines for Adults with Hypertension


THRESHOLD OFFICE
BLOOD PRESSURE LEVEL
(mm Hg) FOR INITIATION OR
GUIDELINE POPULATION INTENSIFICATION OF THERAPY INITIAL DRUG THERAPY OPTIONS
2014 JNC 8 Committee1 General ≥ 60 yr ≥150/90 Nonblack: thiazide,* ACEI or ARB, CCB
General < 60 yr ≥140/90 Black: thiazide, CCB
Diabetes ≥140/90 Thiazide, ACEI or ARB, CCB
CKD ≥140/90 ACEI or ARB
2014 ASH/ISH2 General ≥ 80 yr ≥150/90 Nonblack/stage 1: thiazide, ACEI or ARB, CCB
General < 80 yr ≥140/90 Black/stage 1: thiazide, CCB
Stage 2: CCB or thiazide + ACEI or ARB
Diabetes ≥140/90 ACEI or ARB
CKD ≥140/90 ACEI or ARB
2013 AHA/ACC/CDC3 General ≥140/90 Stage 1: thiazide for most or ACEI or ARB, CCB
Stage 2: thiazide + ACEI or ARB or thiazide +
CCB or ACEI or ARB + CCB
2013 ESH/ESC4 General ≥ 80 yr ≥160/90 Beta blocker, thiazide, CCB, ACEI or ARB
General 60-79 yr ≥150/90 or ≥140/90
General ≤ 60 yr ≥140/90
Diabetes ≥140/85 ACEI or ARB
CKD, no proteinuria ≥140/90 ACEI or ARB
CKD + proteinuria ≥130/90 ACEI or ARB
2013 CHEP5 General ≥ 80 yr ≥150/90 Thiazide, beta blocker (<60 yr), ACEI or ARB
General < 80 yr ≥140/90 (nonblack)
Diabetes ≥130/80 ACEI or ARB (+ additional CVD risk); ACEI or
ARB, thiazide, CCB (− additional CVD risk)
CKD ≥140/90 ACEI or ARB
2013 ADA6 Diabetes ≥140/80 ACEI or ARB
2012 KDIGO 7
CKD, no proteinuria ≥140/90 ACEI or ARB
CKD + proteinuria ≥130/80
2011 UK NICE8 General ≥ 80 yr ≥150/90 ≥55 yr or black: CCB, thiazide
General < 80 yr ≥140/90 <55 yr: ACEI or ARB
2011 ACCF/AHA: elderly General ≥ 80 yr ≥150/90 ACEI or ARB, CCB, thiazide
hypertensive patients9 General < 80 yr ≥140/90
2010 ISHIB10 Black ≥135/85 Thiazide, CCB
Black + target-organ ≥130/80
disease or CVD risk

*Evidence from randomized controlled trials supports the use of chlorthalidone, a thiazide-like diuretic, rather than hydrochlorothiazide.
ACC = American College of Cardiology; ADA = American Diabetes Association; AHA = American Heart Association; ASH = American Society of Hypertension; CDC =
Centers for Disease Control and Prevention; CHEP = Canadian Hypertension Education Program; CVD = cardiovascular disease; ISH = International Society of Hypertension;
KDIGO = Kidney Disease: Improving Global Outcome; UK NICE = U.K. National Institute for Health and Clinical Excellence.
Modified from James PA, Oparil S, Carter BL, et al: 2014 Evidence-based guideline for the management of high BP in adults: Report from the panel members appointed
to the Eighth Joint National Committee (JNC 8). JAMA 311:507, 2014.
979
The European guidelines continue to be the most conservative and 2. Weber MA, Schiffrin EL, White WB, et al: Clinical practice guidelines for the man-
agement of hypertension in the community: A statement by the American Society of
reserve drug therapy for stage 1 hypertension only for those with Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich) 44
clinical CV disease, target-organ damage, diabetes, CKD, or an 16:14, 2014.

Systemic Hypertension: Management


3. Go AS, Bauman M, King SM, et al: An effective approach to high blood pressure control: A
estimated 10-year CV disease risk of 20% or higher.4 science advisory from the American Heart Association, the American College of Cardiology,
• The 2010 International Society on Hypertension in Blacks (ISHIB) and the Centers for Disease Control and Prevention. Hypertension Epub 2013 Nov 15.
guidelines10 may be the least evidence based,18 but they also are 4. Mancia G, Fagard R, Narkiewicz K, et al: 2013 ESH/ESC guidelines for the management of
arterial hypertension: The Task Force for the Management of Arterial Hypertension of the
the most risk based and recommend initiation of drug therapy with European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
an office BP of 135/85 mm Hg or higher in black patients with J Hypertens 31:1281, 2013.
5. Canadian Hypertension Education Program (CHEP): 2013 Recommendations. 2013. (http://
uncomplicated hypertension (who are at higher risk than other www.hypertension.ca/chep).
groups for the development of complications) and for a BP of 6. American Diabetes Association: Standards of medical care in diabetes 2013. Diabetes Care
36(Suppl 1):S11, 2013.
130/80 mm Hg or higher in the presence of target-organ disease, 7. Kidney Disease Improving Global Outcomes (KDIGO) Blood Pressure Work Group: KDIGO
comorbidity, or an estimated 10-year risk for CV disease of 10% or clinical practice guideline for the management of blood pressure in chronic kidney disease.
higher. Kidney Int Suppl 2:337, 2012.
8. Krause T, Lovibond K, Caulfield M, et al: Management of hypertension: Summary of NICE
With all these guidelines, the goal of therapy is to achieve average guidance. BMJ 343:d4891, 2011.
systolic and diastolic BP levels just below the thresholds for initiating 9. Aronow WS, Fleg JL, Pepine CJ, et al: ACCF/AHA 2011 expert consensus document on hyper-
tension in the elderly: A report of the American College of Cardiology Foundation Task Force
or intensifying therapy. on Clinical Expert Consensus Documents developed in collaboration with the American
Academy of Neurology, American Geriatrics Society, American Society for Preventive Car-
diology, American Society of Hypertension, American Society of Nephrology, Association
Which Drugs for Which Patients? of Black Cardiologists, and European Society of Hypertension. J Am Soc Hypertens 5:259,
• There is general consensus that at the end of the day, the vast major- 2011.
ity of hypertensive patients—regardless of age, race/ethnicity, 10. Flack JM, Sica DA, Bakris G, et al: Management of high blood pressure in blacks: An update
of the International Society on Hypertension in Blacks consensus statement. Hypertension
and absence or presence of target-organ damage or comorbid 56:780, 2010.
conditions—will require triple combination drug therapy with a 11. Bauchner H, Fontanarosa PB, Golub RM: Updated guidelines for management of high blood
pressure: Recommendations, review, and responsibility. JAMA 311:477, 2014.
CCB, an ACEI or ARB, and a diuretic. The only issue is which drug 12. Peterson ED, Gaziano JM, Greenland P: Recommendations for treating hypertension: What
or drugs to prescribe first. are the right goals and purposes? JAMA 311:474, 2014.
13. Eckel RH, Jakicic JM, Ard JD, et al: 2013 AHA/ACC guideline on lifestyle management to
• Most guidelines, including those of the ISHIB, prefer both a thiazide reduce cardiovascular risk: A report of the American College of Cardiology/American Heart
and a CCB over an ACEI or ARB to initiate therapy in black patients. Association Task Force on Practice Guidelines. J Am Coll Cardiol Epub 2013 Nov 15.
• There is overwhelming consensus that an ACEI or ARB is first-line 14. Chobanian AV, Bakris GL, Black HR, et al: Seventh report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension
antihypertensive therapy for patients with diabetes. 42:1206, 2003.
• There is overwhelming consensus that an ACEI or ARB is first-line 15. Roush GC, Holford TR, Guddati AK: Chlorthalidone compared with hydrochlorothiazide in
reducing cardiovascular events: Systematic review and network meta-analyses. Hyperten-
antihypertensive therapy for patients with CKD. sion 59:1110, 2012.
16. Wright JT Jr, Fine LJ, Lackland DT, et al: Evidence supporting a systolic blood pressure goal
of less than 150 mmHg in patients aged 60 years or older: The minority view. Ann Intern Med
160:499, 2014.
Percutaneous Intervention 17. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al: 2013 ACC/AHA guideline on the assessment
The 2013 ESC guidelines on catheter-based renal denervation19 will of cardiovascular risk: A report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation Epub 2013 Nov 15.
need to be reevaluated in light of a 2014 press release stating that the 18. Wright JT Jr, Agodoa LY, Appel L, et al: New recommendations for treating hypertension in
Symplicity HTN-3 trial failed to meet its primary efficacy endpoint.20 black patients: Evidence and/or consensus? Hypertension 56:801, 2010.
19. Mahfoud F, Luscher TF, Andersson B, et al: Expert consensus document from the
European Society of Cardiology on catheter-based renal denervation. Eur Heart J 34:2149,
2013.
References 20. Medtronic: Press release: Medtronic announces U.S. renal denervation pivotal trial fails
1. James PA, Oparil S, Carter BL, et al: 2014 Evidence-based guideline for the management of to meet primary efficacy endpoint while meeting primary safety endpoint. 2014. (http://
high blood pressure in adults: Report from the panel members appointed to the Eighth Joint newsroom.medtronic.com/phoenix.zhtml?c=251324&p=irol-(newsArticle_Print&ID=188933
National Committee (JNC 8). JAMA 311:507, 2013. 5&highlight).