Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice
Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice
Putting The 2014 Evidence-Based Guidelines For The Management of High Blood Pressure in Adults Into Practice
Panelists
Louis Kuritzky, MD
Clinical Assistant Professor
University of Florida
Gainesville, Florida
Raymond R. Townsend, MD
Professor of Medicine
Perelman School of Medicine
Philadelphia, Pennsylvania
ACCORD
Mean Number of Medications Prescribed
Time, y
3.2
3.4
3.4
3.5
3.5
3.5
3.4
3.4
1.9
2.1
2.1
2.2
2.2
2.3
2.3
2.3
Standard Therapy, %
208 (1.87)
237 (2.09)
Thiazide-type diuretic
Calcium channel blocker (CCB)
Angiotensin-concerting enzyme (ACE) inhibitor
Angiotensin receptor blocker (ARB)
Moderate Recommendation: Grade B
ALLHAT
Outcomes in Hypertensive Black Patients Treated
With Chlorthalidone, Amlodipine, and Lisinopril
6-Year Rate per 100 Persons
Chlorthalidone
Rate (SE)
Amlodipine
No.
Rate (SE)
Lisinopril
Outcome
No.
Total randomized
5369
CHD
(nonfatal MI + fatal CHD)
400
9.6 (0.5)
243
9.5 (0.6)
260
10.3 (0.7)
All-cause mortality
821
17.9 (0.6)
481
17.0 (0.8)
520
18.0 (0.8)
Cardiovascular mortality
362
8.1 (0.5)
215
8.4 (0.6)
224
8.4 (0.6)
Combined CHD
655
15.2 (0.6)
407
15.8 (0.8)
444
17.3 (0.8)
Combined CVD
1211
26.8 (0.7)
767
28.4 (1.0)
836
31.1 (1.0)
Stroke
257
6.0 (0.4)
145
5.7 (0.5)
212
8.0 (0.6)
93
2.3 (0.3)
65
2.7 (0.4)
71
3.1 (0.4)
Cancer
417
9.4 (0.5)
245
9.8 (0.7)
254
9.9 (0.7)
Hospitalized for
gastrointestinal bleeding
282
8.9 (0.5)
169
8.6 (0.7)
209
11.1 (0.8)
3213
No.
Rate (SE)
3210
Nonblack
Initiate thiazide-type diuretic or
ACEI or ARB or CCB, alone or
in combination
BP goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Black
All races
BP goal
SBP < 140 mm Hg
DBP < 90 mm Hg
At goal BP?
No
At goal BP?
At goal BP?
No
At goal BP?
Yes
ASCOT
Summary of All End Points
Primary
Secondary
0.87 (0.76-1.00)
0.87 (0.79-0.96)
0.84 (0.78-0.90)
0.89 (0.81-0.99)
0.76 (0.65-0.90)
0.77 (0.66-0.89)
0.84 (0.66-1.05)
Tertiary
Silent MI
Unstable angina
Chronic stable angina
Peripheral arterial disease
Life-threatening arrhythmias
New-onset diabetes mellitus
New-onset renal impairment
1.27 (0.80-2.00)
0.68 (0.51-0.92)
0.98 (0.81-1.19)
0.65 (0.52-0.81)
1.07 (0.62-1.85)
070 (0.63-0.78)
0.85 (0.75-0.97)
Post hoc
Primary end point + coronary
revascularization procedures
CV death + MI + stroke
0.86 (0.77-0.96)
0.84 (0.76-0.92)
0.50
0.70
1.00
1.45
2.00
Abbreviations
ACCORD = Action to Control Cardiovascular Risk in Diabetes
ACE = angiotensin-converting enzyme
ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial
ARB = angiotensin receptor blockers
ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial
BP = blood pressure
CCB = calcium channel blocker
CHADS = congestive heart failure, hypertension, age, diabetes mellitus, and
stroke
CHD = coronary heart disease
CI = confidence interval
CKD = chronic kidney disease
DBP = diastolic blood pressure
HYVET = Hypertension in the Very Elderly Trial
JNC 8 = Eighth Joint National Committee
MI = myocardial infarction
SBP = systolic blood pressure
References
1. James PA, Oparil S, Carter BL, et al. 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;311:507-520.
2. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure; National High Blood Pressure Education Program Coordinating
Committee. The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA.
2003;289:2560-2572.
3. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of
hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
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 European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.
5. Tight blood pressure control and risk of macrovascular and microvascular
complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.
BMJ. 1998;317:703-713.
References (cont)
6. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, et al. Effects of
intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med.
2010;362:1575-1585.
7. Hebert LA, Kusek JW, Greene T, et al. Effects of blood pressure control on
progressive renal disease in blacks and whites. Modification of Diet in Renal Disease
Study Group. Hypertension. 1997;30(3 Pt 1):428-435.
8. Wright JT Jr, Bakris G, Greene T, et al; African American Study of Kidney Disease and
Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug
class on progression of hypertensive kidney disease: results from the AASK trial. JAMA.
2002;288:2421-2431.
9. Ruggenenti P, Perna A, Loriga G, et al; REIN-2 Study Group. Blood-pressure control
for renoprotection in patients with non-diabetic chronic renal disease (REIN-2):
multicentre, randomised controlled trial. Lancet. 2005;365:939-946.
10. ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT).
NCT01206062. http://clinicaltrials.gov/ct2/show/NCT01206062?term=SPRINT&rank=3
Accessed March 14, 2014.
References (cont)
11. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in
hypertensive patients with and without the metabolic syndrome: Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med.
2008;168:207-217.
12. Wright Jr JT, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR.
Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in
Patients Aged 60 Years or Older: The Minority View. Ann Intern Med. 2014. [Epub
ahead of print]
13. Dahlf B, Devereux RB, Kjeldsen SE, et al; LIFE Study Group. Cardiovascular
morbidity and mortality in the Losartan Intervention For Endpoint reduction in
hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:9951003.
14. Poulter NR, Wedel H, Dahlf B, et al; ASCOT Investigators. Role of blood pressure
and other variables in the differential cardiovascular event rates noted in the AngloScandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).
Lancet. 2005;366:907-913.
References (cont)
15. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the
prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the
context of expectations from prospective epidemiological studies. BMJ.
2009;338:b1665.
16. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
Collaborative Research Group. Diuretic versus alpha-blocker as first-step
antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42:239-246.
17. Wright JT Jr, Dunn JK, Cutler JA, et al; ALLHAT Collaborative Research Group.
Outcomes in hypertensive black and nonblack patients treated with chlorthalidone,
amlodipine, and lisinopril. JAMA. 2005;293:1595-1608.
18. Dahlf B, Sever PS, Poulter NR, et al; ASCOT Investigators. Prevention of
cardiovascular events with an antihypertensive regimen of amlodipine adding
perindopril as required versus atenolol adding bendroflumethiazide as required, in the
Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOTBPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-906.