Management of Hypertension: SPRINT to Change the Guidelines?

Educational Objectives

The goal of this program is to improve the management of hypertension. After hearing and assimilating this program, the clinician will be better able to:

1. Adopt the Eighth Joint National Committee guidelines for control of blood pressure (BP).

2. Recommend lifestyle management strategies and appropriate drugs for the treatment of hypertension.

3. Ensure careful measurement of BP and utilize ambulatory BP monitoring when indicated.

Summary

Introduction: relationship between blood pressure (BP) and cardiovascular disease (CVD) — curvilinear and starts at relatively low BP level (115-118 mm Hg; not level to start treatment or goal of treatment); risk for CVD doubles with every 10 to 20 mm Hg increase; no change in new guidelines for high-normal categories typically called “prehypertension” (most clinicians recommend lifestyle modifications, not medication)

Prevalence of hypertension (HTN): in United States, affects slightly less than one-third of population (higher in blacks); ≈75% of patients labeled hypertensive being treated, and 50% controlled (by strict definition of <140/90 mm Hg on last 2 visits); risk factors — BP more poorly controlled among Latinos, blacks, young, and old; poverty, socioeconomic inequality, and less education lead to poorer control; control better among individuals with health insurance and those who see primary care provider; risk for stroke in blacks twice that of other racial and ethnic groups; more assertive management reasonable in blacks with borderline BP

Measurement of BP: typical office measurement — produces an artificially high BP measurement in almost all circumstances; standard method — patient seated in chair for 5 min with legs supported and arms bared and supported, not smoking, drinking coffee, or talking; ensure that cuff fits correctly; first sound systolic BP (SBP), while last sound diastolic BP (DBP); ≥2 readings in ≈2 min required (average BPs); in Systolic Blood Pressure Intervention Trial (SPRINT, 2015), automated machine used to obtain 3 BP measures, with no clinician in room; sphygmomanometer and automated machines (if well maintained) equivalent in efficacy; studies suggest that if home measurements used, there is less intensive drug therapy but also less BP control; because of diurnal variation, measure every 30 min to 1 hr for 24 hr; ambulatory BP monitoring (ABPM) — tracks for 18 hr while awake or for 24 hr; now recommended by United States Preventive Services Task Force (USPSTF) and standard of practice in Great Britain

Lifestyle management of HTN: can lower BP significantly; usually not sustained, but can delay use of medications and limit number of medications in highly compliant patients; weight loss uniformly effective in obese patients; alcohol restriction can lower BP in some who overuse; decreased sodium intake (≈2 g/day) effective in ≈33% of patients; Dietary Approaches to Stop Hypertension (DASH) diet lowers BP and is additive to sodium-restricted diet (even without weight loss); physical activity (6-7 days/wk) can also lower BP; caffeine consumption not associated with HTN

Eighth Joint National Committee (JNC 8) guidelines (2014): dealt with only 3 questions (when to start treatment, goal BP, and which medications to use); looked only at data from randomized controlled trials (RCTs)

Individuals >60 yr of age: 150 mm Hg new threshold for SBP; DBP threshold of 90 mm Hg unchanged; goal SBP <150 mm Hg (controversial); evidence for recommendation based on 6 RCTs (before SPRINT) that showed no additional benefit to treating to 140 mm Hg; regardless of age, treatment for HTN beneficial (except at end of life); Hypertension in the Very Elderly Trial — looked at patients >80 yr of age with BP >160 mm Hg (goal BP <150 mm Hg); treated with thiazide and angiotensin-converting enzyme (ACE) inhibitor if needed; found decrease of 36% in stroke, 45% in heart failure, 27% in CV death, and 28% in all-cause mortality; emphasized benefit of treating at any age and that treatment goal of <150 or <140 mm Hg acceptable; benefits seen early, and number needed to treat (NNT) low; for those >60 yr of age and asymptomatic, acceptable to treat to 140 mm Hg

Individuals <60 yr of age: unchanged; continued to recommend 90 mm Hg as appropriate DBP threshold and 140 mm Hg as appropriate SBP threshold

Individuals with chronic kidney disease (CKD) or diabetes: 140/90 mm Hg appropriate threshold; not necessary to treat to lower BP than general population

Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: looked at BP, lipid, and blood glucose control; compared BP of 140 mm Hg to 120 mm Hg in diabetics and found no difference in combined outcomes or mortality; slight reduction in stroke at 120 mm Hg, but with high NNT; as result, threshold BP of 140/90 mm Hg in diabetic patients unchanged (SPRINT study did not include patients with diabetes)

Drugs: for nonblack patients, no strong preferences; no clear advantages for drug of first, second, or third choice between thiazides, calcium-channel blockers (CCBs), ACE inhibitors, or angiotensin receptor blockers (ARBs); only modifier that ACE inhibitors and ARBs considered one category and should not be used together; β-blockers — not included in first 3 choices because as single agent, not as effective for prevention of stroke; good choice if required for comorbid condition; excellent fourth drug, if additional control needed; for black patients — evidence not as good that ACE inhibitors and ARBs as effective as thiazides and CCBs; recommendation to start with thiazides and CCBs, even if patient has diabetes; for those with CKD (based on creatinine and proteinuria), good evidence that ACE inhibitors and ARBs improve kidney outcomes, so drugs of first choice

Spironolactone: inexpensive; well tolerated at low doses; highly effective for persistent HTN (also true for β-blockers); if patient on 4 antihypertensives, determine cause of resistant HTN (poor adherence most common reason)

Recommendations from USPSTF: screening (but not necessarily treating) for BP starting at age 18 yr; emphasized careful measurement; obtain measurements outside clinical setting before starting treatment (favors ABPM, although careful home measurements option); ABPM indicated if undecided because of borderline readings, patient age or preference, or side effects; prevents overtreatment of white-coat HTN

SPRINT study: looked at 10,000 men and women ≥50 yr of age; ≈30% >75 yr of age; enrolled patients with SBP >130 mm Hg at very high CV risk, with average 10-yr Framingham risk score of 20%; patients with diabetes excluded; compared target BPs of <140 mm Hg and <120 mm Hg; required average of one extra medication to achieve target BP <120 mm Hg; <120 mm Hg group showed 25% reduction in composite CV outcome and 27% reduction in all-cause mortality; study stopped early; adverse events and side effects — increased risks for hypotension, syncope, electrolyte abnormalities, and acute kidney injury seen in tighter-control group (ie, although no difference in minor events or side effects, increased risk for adverse events requiring visit to emergency department [ED]); NNT — 100 patients for 3 yr to 120 mm Hg (rather than to 140 mm Hg) to prevent one death; number needed to harm (NNH) about same; tighter control involves additional cost (eg, extra medication, extra office visits, ED visits); SPRINT shows that target BP of 120 mm Hg has better CV and mortality benefits vs 140 mm Hg, with reasonable NNT, but notable adverse effects present; patients in study at very high risk and representative of small percentage of patients with HTN

Applying SPRINT to clinical practice: most reasonable to apply tighter control to patients at highest risk; ensure careful measurement of BP before applying approach

Readings

Armstrong C: Joint National Committee. JNC 8 guidelines for the management of hypertension in adults. Am Fam Physician, 2014 Oct 1;90(7):503-4; Bress AP et al: Generalizability of SPRINT Results to the U.S. Adult Population. J Am Coll Cardiol, 2016 Feb 9;67(5):463-72; Ismail-Beigi F et al: ACCORD Study Group. Combined intensive blood pressure and glycemic control does not produce an additive benefit on microvascular outcomes in type 2 diabetic patients. Kidney Int, 2012 Mar;81(6):586-94; James PA 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 Feb 5;311(5):507-20. Erratum in: JAMA. 2014 May 7;311(17):1809; Page MR: The JNC 8 hypertension guidelines: an in-depth guide. Am J Manag Care, 2014 Jan;20(1 Spec No.):E8; Reynolds K et al: The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults. Curr Hypertens Rep, 2015 Nov;17(11):86; Siu AL: U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 2015 Nov 17;163(10):778-86; SPRINT Research Group et al: A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med, 2015 Nov 26;373(22):2103-16; Still CH et al: SPRINT Study Research Group. Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial. J Am Soc Hypertens, 2015 Sep;9(9):670-9; Thomas G et al: New hypertension guidelines: one size fits most? Cleve Clin J Med, 2014 Mar;81(3):178-88.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Baron was recorded at the 44th Annual Advances in Internal Medicine, held May 23-27, 2016, in San Francisco, CA, and presented by the Department of Medicine, University of California, San Francisco, School of Medicine. For information about upcoming CME activities from University of California, San Francisco, School of Medicine, visit their website at www.cme.ucsf.edu. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

IM633302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.