Learning Objectives CV Updates: Pharmacists Technicians Hypertension and 1.Outline the 2017 ACC-AHA hypertension guideline 1. List BP goals for patients with Hypercholesterolemia recommendations for BP goal values and drug hypertension therapy for the management hypertension 2. Identify antihypertensive 2.Examine the evidence supporting lower BP goals for medications that are the treatment of patients with hypertension recommended as first-line 3.Compare and contrast the 2013 ACC-AHA guidelines agents for the treatment of hypercholesterolemia with the 3. Identify moderate-intensity ACC Expert Consensus Decision Pathway on the and high-intensity statin doses Joseph Saseen, PharmD, BCPS, BCACP Role of Non-Statin Therapies 4. Name the two patient Professor and Vice Chair 4.Interpret results from large outcome studies populations that the PCSK9 evaluating nonstatin therapies inhibitors are indicated for University of Colorado 5.Create treatment plans for patients presenting with hypertension and hypercholesterolemia Pre/Post Question #1 Pre/Post Question #2 Which of the following BP goals is recommended by the 2017 The SPRINT trial evaluated intense blood pressure lowering versus American College of Cardiology-American Heart Association standard blood pressure lowering. Which of the following clinical hypertension guidelines for a 55-year-old patient with diabetes and events were lower with intensive blood pressure lowering versus cardiovascular disease? standard blood pressure lowering? A. <120/80 mm Hg. A. The first occurrence of electrolyte abnormalities. B. <130/80 mm Hg. B. Adverse events that were fatal or life-threatening. C. <140/90 mm Hg. C. Acute kidney injury and/or acute renal failure. D. <150/90 mm Hg. D. The first the occurrence of a cardiovascular event. Pre/Post Question #3 Pre/Post Question #4 Which of the following medication regimens does the American What are the long-term effects of adding evolocumab therapy for College of Cardiology/American Heart Association (ACC/AHA) patients with stable ASCVD who are already treated with maximally recommend in their 2013 guidelines as initial therapy for patients tolerated statin therapy? with a baseline low-density lipoprotein cholesterol (LDL- C) of ≥190 mg/dL? A. Decreased CV events and an increased risk of cataracts. B. No change in CV events, but greater than a 50% decrease in A. Atorvastatin 20 mg daily. LDL-C. B. Evolocumab 140 mg every 2 weeks. C. Decreased CV events and an increased risk of injection site C. Rosuvastatin 20 mg daily. reactions. D. Simvastatin 40 mg daily with ezetimibe. D. No change in CV events, but a trend toward decreased risk of major CV events after 2.2 years. 1
Hypertension in the U.S. 2014 Goal BP Recommendations 60 ASH/ISH Guidelines JNC 8 Report 53.9 53.1 55 51.8 48.4 48.3 50 Age < 60 years: Age < 80 years: Percentage 43.3 45 • <140/90 mm Hg • <140/90 mm Hg 39.7 Control 40 (BP<140/90 mm Hg) 34.7 Prevalence Age ≥ 80 years: Age ≥ 60 years: 35 31.6 • <150/90 mm Hg • <150/90 mm Hg 30 29.9 29.6 • <140/90 mm Hg if diabetes or CKD 29.1 29.3 29 • <140/90 mm Hg if diabetes or CKD 28.4 28.6 28.7 27.9 25 20 ASH/ISH = American Society of Hypertension/International Society of Hypertension; JNC = Joint National Committee; CKD = chronic kidney 99-00 00-02 03-04 05-06 07-08 09-10 11-12 13-14 15-16 disease Years Weber MA et al. J Hypertens . 2014;32(1):14-26. James PA et al. JAMA . 2014; 311(5):507-20. Fryar CD, et al. NCHS Data Brief 2017;289 Hot off the press… 2017 ACC-AHA Hypertension Guideline Class of Recommendation (COR) - Strength Level of Evidence (LOE) - Quality Class I (Strong) Benefit >>> Risk Level A • Is recommended, is indicated, should be p erformed • High-quality evidence from > one randomized clinical trial (RCT) • Meta-analyses of high-quality RCTs Class IIa (Moderate) Benefit >> Risk Level B-R (Randomized) • Is reasonable, can be useful • Moderate-quality evidence from > one RCT • Meta-analyses of moderate-quality RCTs Class IIb (Weak) Benefit ≥ Risk Level B-NR (Nonrandomized) • May/might be reasonable/considered, effectiveness unknown • Moderate-quality from nonrandomized studies, observational, registry Class III: No Benefit (Moderate) Benefit = Risk Level C-D (Limited Data) • Is not recommended, is not useful Class III: Harm (Strong) Benefit < Risk Level C-EO (Expert Opinion) • Potentially harmful, causes harm Whelton PK, et al. Hypertension. 2017 [Epub ahead of print]. https://www.acc.org/guidelines/hubs/high-blood-pressure Recall the last time your BP was 2017 ACC-AHA: BP Categories measured… SBP DBP BP Category (mm Hg) (mm Hg) Normal <120 and <80 Was it measured properly? 120 – 129 Elevated and <80 130 – 139 80 – 89 Hypertension Stage 1 or ≥ 140 ≥ 90 Hypertension Stage 2 or If SBP and DBP in 2 different categories, apply the higher category; Based on an average of ≥2 properly measured values obtained on ≥2 occasions DBP, diastolic blood pressure; and SBP systolic blood pressure. Whelton PK, et al. Hypertension. 2017 [Epub ahead of print]. 2
Proper BP Measurements 2017 ACC-AHA: BP Measurements Step 1: Properly prepare the patient COR LOE Accurate Measurement of BP Step 2: Use proper technique for BP measurements For diagnosis and management, proper methods Step 3: Take the proper measurements needed for diagnosis I C-EO are recommended for accurate measurement and and treatment documentation of BP Step 4: Properly document accurate BP readings Step 5: Average the readings Step 6: Provide BP readings to patient Whelton PK, et al. Hypertension. 2017 [Epub ahead of print]. Whelton PK, et al. Hypertension. 2017 [Epub ahead of print]. Systolic Blood Pressure Intervention Trial 2017 ACC-AHA Hypertension Guideline (SPRINT) • Multicenter, randomized, controlled trial • 9,361 patients with hypertension randomized open-label to: Goal BP of <130/80 mm Hg for most - Intensive treatment: SBP <120 mm Hg - Standard treatment: SBP <140 mm Hg • Primary outcome: first the occurrence of a MI, acute coronary syndrome, stroke, heart failure, or CV disease death • Different evidence-based rankings based on ASCVD risk and/or presence of other comorbidities • Applies to healthier older patients ≥ 65 yr Ambrosius WT, et al. Clin Trials. 2014;11(5):532 – 546. Whelton PK, et al. Hypertension. 2017 [Epub ahead of print]. SPRINT: Protocol Procedures SPRINT: Study Criteria Inclusion Exclusion • Medication choice: • Secondary hypertension • ≥ 50 years old - ACEi, ARB, CCB, thiazide first-line; beta-blocker in coronary disease • Diabetes, previous stroke, or CV event • SBP 130 – 180 mm - Chlorthalidone encouraged as the primary thiazide within 3 months Hg • Symptomatic heart failure within 6 months - Amlodipine as the preferred CCB • Increased risk for or EF < 35% • Titration of medications was based on: • Proteinuria (> 1 g/day), polycystic kidney ASCVD based on - Mean of three office BP measurements, seated with automated device disease, glomerulonephritis, eGFR< 20 • Frequent routine measurement of BP and screening for additional criteria mL/min/1.73m2 or end-stage renal hypotension disease Ambrosius WT, et al. Clin Trials . 2014;11(5):532 – 546. Ambrosius WT, et al. Clin Trials. 2014;11(5):532 – 546. 3
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