Making Sense of the New

Guidelines: Hypertension
The More We Learn, the Less We Know

Zeb K. Henson, M.D.

Assistant Professor, Department of Medicine & Department of Pediatrics
University of Mississippi Medical Center
 Financial Disclosures

• Nothing to disclose
 Objectives
• Briefly review 2014 JAMA
HTN Guidelines

“Don’t run back inside, • Use clinical scenarios to

Darling, you know just what discuss and provide
I’m here for…” justification for some of
these recommendations

• Discuss clinical barriers to

implementation of these
guidelines
 JNC 7 Review
Issues addressed in JNC-7 JNC-7 Classifications of HTN:
Prevalence and Burden

Measurement

Definition

Lifestyle and Pharmacologic

Treatment

Secondary Hypertension

Resistant Hypertension
 Lifestyle Modifications
Not at goal BP <140/90,
or <130/80 for diabetes, CKD or
CAD, or <120/80 for LV dysfunction

Initial Drug Choices

No Compelling Indications Compelling Indications

Stage 1 HTN Stage 2 HTN Drugs for compelling

1. Thiazides for most Two-drug combo indications; others as
2. Consider ACEI, for most; usually
ARB, BB, CCB or needed
thiazide and ACEI,
combo ARB, BB, or CCB
“Compelling Indications”
 Growing Up
ACCOMPLISH
ALTITUDE
ONTARGET ACCF/AHA

CAMELOT ESH/ESC HYVET ACCORD-BP ESH/ESC

REIN-2 AHA NICE ASH/ISH

2003 2005 2007 2009 2011 2014

JNC-7 JNC-8
The story of the committee…
End Result
 It’s not JNC 7;
nor was it ever meant to be.

It’s “the facts” of what we have

learned from RCTs.
 2014 JAMA HTN Guidelines
Clinical Questions
1. “In adults with hypertension, does initiating
antihypertensive pharmacologic therapy at specific BP
thresholds improve health outcomes?”

2. “In adults with hypertension, does treatment with

antihypertensive pharmacologic therapy to a specified BP
goal lead to improvements in health outcomes?”

3. “In adults with hypertension, do various antihypertensive

drugs or drug classes differ in comparative benefits and
harms on specific health outcomes?”
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP A
goal of 150/90 mmHg.
2. General population < 60 y/o, initiate medications and treat to A/E
DBP goal of 90 mmHg.
3. General population < 60 y/o, initiate medications and treat to E
SBP goal of 140 mmHg.
4. In population > 18 y/o with CKD, initiate medications and treat to E
BP goal of 140/90 mmHg.
5. In population > 18 y/o with DM, initiate medication and treat to E
BP goal of 140/90 mmHg.
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive B
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
7. In general black population (including DM), initial anti-hypertensive C
therapy should include thiazide diuretic or CCB.
8. In population with CKD, initial (or add-on) anti-hypertensive B
therapy should include ACE-I or ARB.
9. Main objective of therapy is to attain and maintain a BP goal and E
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

Figure Legend:
Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension

Copyright © 2014 American Medical

Date of download: 6/17/2014
Association. All rights reserved.
A 67 year old male presents to your primary care clinic having recently moved
to town. He has no complaints. His PMHx includes high cholesterol (with an
unknown LDL) for which he takes Simvastatin 10mg. He had one prior
hospitalization for chest pain, but was told “nothing was wrong” with his
heart after a 1 night hospital stay. He has a 15 pck-yr history of tobacco use
and quit 17 years ago. He swims regularly and abides by a strict
Mediterranean diet.
On exam, his BP = 146/86 (repeated to verify) and other vital signs are
normal. His cardiovascular and eye exam are unremarkable.
Lab studies reveal a normal CBC, normal serum creatinine, and no
proteinuria. His EKG exhibits voltage criteria for LVH.
How would you manage his BP (assume his reading is verified by home
monitoring)?

A. Encourage more exercise and a better diet

B. Order 24 hr ambulatory monitoring and decide therapy based on those
results
C. Begin therapy with a thiazide-type diuretic
D. Inform him that based on new guidelines, no anti-hypertension therapy
is needed
E. Let him decide if he wants to take medicines
 Closer Look
Recommendation Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP A
goal of 150/90 mmHg.

What do we do with HTN in the elderly?

(Better yet, who is elderly?)
 HTN in the Elderly
• Comparison:
– 2014 JAMA: > 60 y/o = < 150/90

– ESH/ESC: >80 y/o or elderly < 80 y/o = < 150/90

– CHEP: >80 y/o = < 150/90

– NICE: > 80 y/o = < 150/90

– ASH/ISH: > 80 y/o = < 150/90

 Closer Look
Corollary Recommendation Level of Evidence
1. General population > 60 y/o, if treatment results in BP < 140/90 E
mmHg and is well-tolerated, treatment does not need to be adjusted

**No convincing evidence that 140/90 is too low**

 HTN in the Elderly
Advantages Disadvantages
• Decreased medication • Individual consequences
burden

• Evidence-”proven” • Population consequences

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment in the elderly

Clinical scenario Recommendations

Elderly patients with SBP ≥160 mmHg • Reduce SBP to 140-150 mmHg

Fit elderly patients aged <80 years with initial • Consider antihypertensive treatment
SBP ≥140 mmHg • Target SBP: <140 mmHg

Elderly >80 years with initial SBP ≥160 mmHg • Reduce SBP to 140-150 mmHg
providing in good physical and mental condition

Frail elderly • Hypertension treatment decision at discretion of

treating clinician, based on monitoring of
treatment clinical effects

Continuation of well- tolerated hypertension • Consider when patients become octogenarians

treatment

All hypertension treatment agents are • Diuretics, CCBs, preferred for isolated systolic
recommended and may be used in elderly hypertension

SBP, systolic blood pressure; CCB, calcium channel blockers.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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 What would I do?
A. Encourage more exercise and a better diet
B. Order 24 hr ambulatory monitoring and decide therapy based on those
results
C. Begin therapy with a thiazide-type diuretic
D. Inform him that based on new guidelines, no anti-hypertension therapy
is needed
E. Let him decide if he wants to take medicines
A 43 y/o woman with HTN returns for a follow up visit of her BP.
She is without complaints but admits that she has gained about
15 pounds over the last year due to stress, poor diet, and
inactivity. At her last visit 6 months ago, her BP was 132/78
mmHg on Lisinopril HCTZ 20/12.5mg.
On exam today, her BP is 138/88 (and verified on repeat). Her
exam is unchanged. Her serum creatinine is 1.3 mg/dL, and her
RUA reveals > 500 mg/dL of proteinuria.
What would be your next step in managing her blood pressure
and proteinuria?

A. Encourage improved lifestyle adherence and weight

reduction but make no medication changes
B. Increase her thiazide diuretic
C. Increase her ACE-inhibitor
D. Increase both her ACE-I and her TZD
 Closer Look
Recommendation Level of Evidence
4. In population > 18 y/o with CKD, initiate medications and treat to E
BP goal of 140/90 mmHg.

Comparison:
– ESH/ESC: no proteinuria = < 140/90
with proteinuria = < 130/90
-- CHEP: < 140/90 for all
-- KDIGO: no proteinuria = < 140/90
with proteinuria = < 130/80
 Why the confusion?
RCTs Meta-analyses
• Modification of Diet in • Annals of Internal
Renal Disease (MDRD) Medicine (2011)

• African-American Study • Canadian Medical

of Kidney Disease and VS. Association Journal
Hypertension (AASK)
(2013)
• Ramipril Efficacy in
Nephropathy (REIN-2)
 What would I do?

A. Encourage improved lifestyle adherence and weight reduction but make

no medication changes
B. Increase her thiazide diuretic
C. Increase her ACE-inhibitor
D. Increase both her ACE-I and her TZD

Nothing beyond “expert opinion” to govern specific

medication titration.
A 43 y/o AAM w/ Type 2 DM and HTN, presents for follow up.
His is asymptomatic and adherent to his medication regimen:
Metformin 500mg BID, Lis/HCT 20/25mg daily, Amlodipine 5mg,
and ASA 81mg.
On exam, his BP = 138/88 mmHg. His cardiovascular exam is
normal. He has decreased pinprick sensation in his bilateral
great toes. Peripheral pulses are normal.
On lab review, his CBC, BMP, and RUA are normal. His A1c=8.3%.
In addition to adjusting his Type 2 DM medication regimen, what
additional changes would you make?

A. None
B. Increase Amlodipine to 10mg
C. Increase Lisinopril to 40mg
D. Add an additional BP agent, such as a beta-blocker
 Closer Look
Recommendation Level of Evidence
5. In population > 18 y/o with DM, initiate medication and treat to E
BP goal of 140/90 mmHg.

Comparison:
– ESH/ESC: < 140/85
– ASH/ISH: < 140/90
– CHEP: < 130/80
– ADA: < 140/80
 Why the confusion?
• Not enough patients

• Not enough uniformity in evidence

• Therefore, did not make recommendation

different than “usual” BP control
 What would I do?

A. None
B. Increase Amlodipine to 10mg
C. Increase Lisinopril to 40mg
D. Add an additional BP agent, such as a beta-blocker

Nothing beyond “expert opinion” to govern specific

medication titration.
The “other” recommendations…
 Closer Look
Recommendation Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive B
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
7. In general black population (including DM), initial anti-hypertensive C
therapy should include thiazide diuretic or CCB.
8. In population with CKD, initial (or add-on) anti-hypertensive B
therapy should include ACE-I or ARB.

Too many comparisons to list

 What’s the controversy?
• “Demotion” of beta-blockers
– Admittedly doesn’t include newer agents

• “Demotion” of ACE-I and ARBs in African-

Americans
– Unless CKD

• Absence of a specific recommendation for ACE-I

and ARBs in Diabetics
– In absence of albuminuria
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP A
goal of 150/90 mmHg.
2. General population < 60 y/o, initiate medications and treat to A/E
DBP goal of 90 mmHg.
3. General population < 60 y/o, initiate medications and treat to E
SBP goal of 140 mmHg.
4. In population > 18 y/o with CKD, initiate medications and treat to E
BP goal of 140/90 mmHg.
5. In population > 18 y/o with DM, initiate medication and treat to E
BP goal of 140/90 mmHg.
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive B
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
7. In general black population (including DM), initial anti-hypertensive C
therapy should include thiazide diuretic or CCB.
8. In population with CKD, initial (or add-on) anti-hypertensive B
therapy should include ACE-I or ARB.
9. Main objective of therapy is to attain and maintain a BP goal and E
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
 Concluding Remarks
• Five of 10 • No recommendation to
recommendations are decrease medicines in
“E” well-controlled elderly

• Only deals with one risk • More recommendations

factor—BP to come
– AHA/ACC Guidelines
– SPRINT
 Their own conclusions
• “The relationship between naturally occurring BP
and risk is linear down to very low BP, but the
benefit of treating to these lower levels with
antihypertensive drugs is not established.”

• “These lifestyle treatments have the potential to

improve BP control and even reduce medication
needs…we support the recommendations of the
2013 Lifestyle Work Group.”
 Their own conclusions
• “The recommendations from this evidence-based
guideline from panel members appointed to the
Eighth Joint National Committee (JNC 8) offer
clinicians an analysis of what is known and not
known about BP treatment thresholds, goals, and
drug treatment strategies to achieve those goals
based on evidence from RCTs. However, these
recommendations are not a substitute for clinical
judgment, and decisions about care must
carefully consider and incorporate the clinical
characteristics and circumstances of each
individual patient.”