Transcript Hypertension Evidence The Gold standard

Hypertension Evidence and
CHS Guidelines
2005
© Continuing Medical Implementation
…...bridging the care gap
Evidence Evolution
• Hard end-points
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Mortality
CVD events
Cerebrovascular events
PVD events
CHF
Progression to ESRD
• Surrogate end-points
– Rising CR
– Progression to proteinuria
– Progression/regression of micro-albuminuria
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© Continuing Medical Implementation
…...bridging the care gap
Evidence Evolution
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MRC-1985
HAPPHY-1987
EWPHE-1991
STOP-1991
SHEP-1991-4
STONE-1996
SYS-EUR-1997
SYS-CHINA-1996-98
HOT-1998
UKPDS -1998
CAPPP-1999
STOP 2 -1999
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HOPE -2000
MICRO-HOPE -2000
INSIGHT -2000
NORDIL -2000
CALM -2000
INDT -2001
IRMA -2001
RENAAL -2001
PROGRESS -2001
LIFE-2002
SCOPE 2002
ALLHAT 2002
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CHS Guideline Evolution 2002
• Impact of the ALLHAT - 2002
• Consideration of
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PROGRESS - 2001
IDNT - 2001
RENAAL - 2001
ANBP2 - 2003
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0 Treat Hypertension in the Context of Overall
Cardiovascular Risk
Grade 1
Grade 2
Grade 3
SBP 140-159 or
DBP 90-99
(mild hypertension)
SBP 160-179 or
DBP 100-109
(moderate hypertension)
SBP ? 180
or DBP ? 110
(severe hypertension)
Low risk
Medium risk
High risk
Medium risk
Medium risk
V high risk
III. 3 risk factors or
TOD or De novo
diabetes
High risk
High risk
V high risk
IV. ACC or Diabetes
V high risk
V high risk
V high risk
Other Risk Factors &
Disease History
I. No other risk
factors
II. 1-2 risk factors
Risk strata (typical % 10 year risk of stroke, myocardial infarction or death)
<15%
15-20%
20-30%
 30%
Adapted from WHO/ISH Recommendations on Hypertension. Chalmers J et al. J Hyper 1999;17:151-85.
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Canadian Hypertension Education Program Recommendations
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Guideline Evolution 2004
Hypertension
Post stroke
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• PROGRESS - 2001
ALLHAT - 2002
LIFE - 2002
ANBP2 - 2003
OPTIMAAL - 2002
EPHESUS - 2003
CHARM - 2003
• Psaty-Network meta-analysis
• Law Meta-analysis
• Staessen Meta-regression
analysis
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ASA and Statins
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HOT - 1998
ASCOT-LLA - 2003
PROSPER - 2002
HPS - 2002
ALLHAT-LLT - 2002
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CHS January 2004
Indications for drug therapy in adults with hypertension
without compelling indications for specific agents:
Strongly consider antihypertensive therapy if DBP ≥ 90
with TOD or CV risk factors
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Elevated SBP, smoking, dyslipidemia, strong FH CAD, truncal
obesity, sedentary lifestyle
Rx antihypertensive therapy for DBP ≥ 100 or SBP ≥
160 without TOD or CV risk factors
Rx statin therapy in HTN patients > 40 yr of age with 3
or more CV risk factors or established atherosclerotic
disease
Strongly consider low dose ASA in HTN patients > 50 yr
of age. (Caution if BP not controlled)
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Cardiovascular risk factors for consideration of statin
therapy in non-hyperlipidemic patients with hypertension
(derived from ASCOT-LLA)
• Male
• Age 55 years or older
• Left ventricular
hypertrophy
• Other electrocardiogram
abnormalities:
– left bundle branch block,
left ventricular strain
pattern, abnormal Q waves
– or ST-T changes compatible
with ischemic heart disease
• Peripheral arterial disease
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• Previous stroke or
transient ischemic attack
• Microalbuminuria or
proteinuria
• Diabetes mellitus
• Smoking
• Family history of
premature cardiovascular
disease
• TC/HDL ≥ 6
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CHS January 2004
Recommendations for individuals with diastolic hypertension
with or without systolic hypertension. Initial therapy:
• Grade A:
– thiazide diuretics
• Grade B:
–  -blockers (in those
younger than 60 years)
– ACE inhibitors (in
non-Blacks)
– long-acting
dihydropyridine CCBs
– angiotensin receptor
antagonists (ARBs)
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• If adverse effects substitute
another drug from this group
• Avoid hypokalemia: Use K
sparing diuretic with thiazides
• Use combination therapy if
partial response
• Add other classes if poor
control
– - blocker, centrally acting
agents or non-DHP CCB
• - blocker not recommended as
first line agents
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CHS January 2004
Recommendations for individuals with
Isolated Systolic Hypertension Initial therapy:
• Grade A:
– thiazide diuretics
– long-acting dihydropyridine
CCBs
• Grade B:
– angiotensin receptor
antagonists (ARBs)
• If adverse effects
substitute another drug
from this group
• Avoid hypokalemia: Use
K sparing diuretic with
thiazides
© Continuing Medical Implementation
• Use combination therapy
if partial response
• Add other classes if poor
control or adverse effects
– - blocker, ACE inhibitors,
centrally acting agents or
non-DHP CCB
• -blockers and -blockers
are not recommended as
first line agents
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CHS January 2004
Considerations for individualization of anti-hypertensive therapy
Indication
Initial Therapy
Second line Rx
Notes/Cautions
DM with nephropathy
ACE-i or ARB
addition thiazide, * blockers , LA-CCB,
ACE/ARB combo
DM without
nephropathy
ACE-i or ARB
or thiazide
Combo1st line Rx or *blockers, LA-CCB
*Cardioselective
 -blockers
If CR >150 mmol/l use
loop diuretic for volume
control
Angina
 -blockers + strongly
consider ACE-i
LA-CCB
Prior MI
 -blockers + ACE-i
Combine additional Rx
CHF
 -blockers + ACE-i +
spironolactone (ARB if
ACE-i intolerant )
Hydralazine /ISDN:
thiazide or loop diuretics
as additive therapy
Prior CVA or TIA
ACE-i/diuretic
combination
Renal Disease
ACE-i/diuretic as
additive Rx
LVH
ACE-I, ARBs, DHPCCB, thiazide,  blockers < 55 yr
Avoid short acting
nifedipine
Avoid non DHP-CCB
(diltiazem, verapamil)
BP reduction  recurrent
events
ARB if ACE-i intolerant
Combo other agents
Avoid ACE-i if bilateral
Renal artery stenosis
Avoid hydralazine and
minoxidil
Guideline Evolution 2005
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SHEAF Study
Ohasama Cohort
OvA Study
Staessen et al
Thijs et al
VALUE
ACTION
INVEST
VALIANT
BP Lowering Treatment Trialists Collaboration
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Guideline Evolution 2005
• Key Messages
– Expedited diagnosis of hypertension (HTN)
– Use any validated technology to diagnose HTN
• Office BP
• Ambulatory BP
• Self/Home BP
– Focus on BP control rather than preferred
“first line” agent
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Guideline Evolution 2005
• Integrate global CVD management into
HTN management plan
• Lifestyle modifications are key
• Combination therapies (lifestyle and Rx) to
achieve target
• Focus on adherence
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Choice of Pharmacological Treatment
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO
Treatment in the
absence of compelling
indication
YES
Individualized
Treatment
(with compelling indications)
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Choice of pharmacological treatment
for hypertensive patients without other
compelling indications:
 Treatment of Systolic Diastolic
hypertension
 Treatment of Isolated Systolic
hypertension
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Treatment of Adults with Systolic-Diastolic
Hypertension without Other Compelling
Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
ACE-I
ARB
Longacting
CCB
Betablocker*
* Not indicated as first line therapy over 60
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Combination Therapy for Systolic-Diastolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
1. Dual Combination Therapy
CONSIDER
2. Triple or Quadruple Therapy
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse
effects, other classes of antihypertensive drugs may be combined
(such as alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
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Summary: Treatment of Systolic-Diastolic Hypertension
without Other Compelling Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification
therapy
Thiazide
diuretic
ACE-I
ARB
Long-acting
CCB
Betablocker*
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Dual Combination
Triple or Quadruple
Therapy
* Not indicated as first line therapy over 60
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Choice of pharmacological treatment
for hypertensive patients with other
compelling indications
 Treatment of diastolic-systolic
hypertension
 Treatment of isolated systolic
hypertension
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Treatment Algorithm for Isolated Systolic Hypertension
without Other Compelling Indications
TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
diuretic
ARB
Long-acting
DHP CCB
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Summary: Treatment of Isolated Systolic Hypertension
without Other Compelling Indications
TARGET <140 mmHg Systolic BP
Lifestyle modification
therapy
Thiazide
diuretic
ARB
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Dual combination
Triple or Quadruple*
combination
Long-acting
DHP CCB
*If blood pressure is still not
controlled, or there are
adverse effects, other
classes of antihypertensive
drugs may be combined
(such as alpha blockers,
centrally acting agents, or
nondihydropyridine calcium
channel blocker).
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Anti-Hypertensive
Therapeutic Classification
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
ARB
*Caution combining non-DHP-CCB (especially verapamil) with a -blocker
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First Line Therapy
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
ARB
*Caution combining non-DHP-CCB (especially verapamil) with a -blocker
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Systolic/Diastolic HTN
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
ARB
*Caution combining non-DHP-CCB (especially verapamil) with a -blocker
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Post-CVA or TIA
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
ARB
*Caution combining non-DHP-CCB (especially verapamil) with a -blocker
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Isolated Systolic HTN-Elderly
(K sparing)
DIURETIC
-blocker
(Thiazide)
Long Acting
DHP-CCB
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ACE inhibitor
ARB
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Isolated Systolic HTN-Elderly
(K sparing)
DIURETIC
-blocker
(Thiazide)
Long Acting
DHP-CCB
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ACE inhibitor/
ARB
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CAD - Chronic Angina
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
ARB
Consider adding ACE-I for all patients with
documented CAD (Grade A) based on
HOPE and EUROPA
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*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
CAD-Recent MI or LV
Dysfunction
(K sparing)
DIURETIC
-blocker*
(Thiazide)
ACE inhibitor
Long Acting
CCB*
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
CHF + HTN
DIURETIC
-blocker
(loop/spironolactone)
Long Acting
DHP-CCB
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ACE inhibitor
ARB if ACE
intolerant
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DM without Nephropathy
BP Target < 130/80
(K sparing)
DIURETIC or
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
or ARB
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
DM with Nephropathy
First line therapy:
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
or ARB
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
or ARB
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC
Cardioselective
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
or ARB
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
or ARB
© Continuing Medical Implementation
…...bridging the care gap
*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC
-blocker*
(Thiazide)
Long Acting
CCB*
ACE inhibitor
and ARB
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*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
Non-diabetic Nephropathy
BP Target < 125/75
DIURETIC
(Thiazide or loop)
-blocker*
As additive
therapy
Long Acting
CCB*
ACE inhibitor
ARB if ACE
intolerant
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*Caution
combining non-DHP-CCB (especially verapamil)
with a -blocker
See www.hypertension.ca for
Complete Recommendations
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Global Vascular Protection for
Patients with Hypertension
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Diet (DASH)
Weight loss (waist < 102 cm M and 88 cm F)
Exercise- 30 to 60 min 4-7 days/week
Smoking Cessation
Moderate Alcohol intake
Low dose ASA if BP controlled
Statin
ACE inhibitors for established vascular disease
ACE inhibitors or ARBs for diabetics or patients with
kidney disease
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Important Messages for the
Management of Hypertension
 Expedite the diagnosis of hypertension
 Assess the risk
 Treat to target
 Lifestyle
 Combination therapy
 Promote adherence
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Summary
Hypertension is a major factor responsible
for progression of atherosclerotic disease.
Therefore, a comprehensive treatment of
hypertension should aim at CV risk reduction
strategies, including management of all
associated risk factors.
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