Hypertension Update 2016AREEF ISHANI, MD MSCHIEF OF MEDICINEMINNEAPOLIS VA MEDICAL CENTERPROFESSOR OF MEDICINEUNIVERSITY OF MINNESOTA

Case 1

What should be your BP goal for an elderly (> 75 yrsof age) non-frail patient with HTN whose BP is measured with an oscillometric device using proper technique in the office ? 1.<125/90 mm Hg 2.<130/80 mm Hg 3.<130/90 mm Hg 4.<140/90 mm Hg 5.Unsure

Question 2

Question # 3 Choose the Best Answer: According to JNC 8, which of the following antihypertensive drug classes is not appropriate for initial use in an uncomplicated hypertensive patient? 1.Calcium Channel Blocker 2.Thiazide-type diuretic 3.Beta-blocker 4.ACE Inhibitor or ARB 5.None of the above

LEARNING OBJECTIVESAfter participating in this educational activity, clinicians should be better able to:

•Understand the epidemiology of hypertension and recent improvements in BP control rates

•Describe the proper role of taking BP in the office setting and the role of home monitoring

•Summarize current evidence for BP targets in the general population and the elderly

Mozzafarian D et al. Circulation 2015; 131: e29-322.

Minnesota Performance

How to measure BP

1. Preferably taken before the patient ever sees the clinician caring for the patient 2. - 5 minutes of rest - no conversation - seated comfortably with feet on the floor - arm at heart level - no tobacco or caffeine for 30 minutes before BP 3. Two to Three seated readings (averaged) using an automated oscillometric (AOBP) device

SPRINT Major Inclusion Criteria ≥50 years old Systolic blood pressure : 130 – 180 mm Hg Additional cardiovascular disease (CVD) risk

(one or more of the following) Presence of clinical or subclinical CVD (not stroke) Chronic kidney disease (CKD), defined as eGFR 20 –

59 mL/min/1.73m2

Framingham Risk Score for 10-year CVD risk ≥ 15%– Not needed if eligible based on preexisting CVD or

CKD Age ≥ 75 years

SPRINT Major Exclusion Criteria

StrokeDiabetes mellitus Polycystic kidney diseaseCongestive heart failure (symptoms or EF <

35%) Proteinuria >1g/dCKD with eGFR < 20 mL/min/1.73m2

(MDRD)Adherence flags

Baseline Characteristics of the Study Participants.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

Systolic Blood Pressure in the Two Treatment Groups over the Course of the Trial.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

Mean BP 134.6 vs 121.5BP Meds 1.8 vs 2.8

Wednesday, January 13, 20161:55 PM

Primary Outcome and Death from Any Cause.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

Forest Plot of Primary Outcome According to Subgroups.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

SPRINT Controversy – How was BP measured Protocol: “During the 5 minute rest period, participants should be resting and should not

be completing questionnaires or speaking with study staff. The staff member should leave the room during this 5 minute rest period. The following script can be used at this time.

“With their agreement, leave the room and return in 5 minutes. Push the button on the machine and wait for the output. Record the systolic and diastolic blood pressure and pulse readings obtained at each of the three readings.”

Actual Procedure: “In SPRINT, study staff were trained to program an Omron 907XL (Omron Healthcare Inc, Lake Forest, IL) to wait 5 minutes and then record 3 readings at 1-minute intervals. After the device was activated, research staff left the examining room, with the patient then being alone during the 5 minute rest period and while the 3 readings were recorded automatically (W.C. Cushman, personal communication, 2016).”

BP recorded in research studies using the standard BP measurement guidelines, which mandate a rest period before measurement (with or without automated office BP, is on average 10/7 mmHg lower than BP measured in routine clinical practice

Armstrong D, Matangi M, Brouillard D, Myers MG. Automated office blood pressure - being alone and not location is what matters most. Blood Press Monit . 2015;20:204–208

Candesartan 16 mg and HCTZ 12.5 mg qd vs PlaceboAlso Rosuvastatin 10 mg qd or Placebo

Conclusions• Lots of room for BP improvement – can focus on those with BP > 140 mmHg• Sprint Trial suggests moderate size benefit from lowering blood pressure to about 121

mmHg• Unclear if measurement of BP should alter targets in clinical practice• Potentially adding 10/7 to SPRINT target gets us to about 131 mmHg Systolic

• There is an associated increase in adverse events• Benefits of lower BP greater in elderly• HOPE 3 trial suggest caution in low risk patients• Meta Analysis of Trials (including Sprint) suggests linear relationship between change

in blood pressure and reduction in outcomes:• Every 10 mmHg decrease in systolic bp:

• 20% reduction in major cardiovascular events• 13% reduction in mortality

• Benefits across all subgroups (except renal failure)

• Beta blockers appear to be associated with harm compared to other bp medications