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Description : Check out this medical presentation on Blood Pressure, which is titled "New Hypertension Guidelines and The Pivotal Role of Pharmacists in Improving BP Control and Reducing the Incidence of Cardiovascular Disease", to know about BP control and reducing the incidence of cardiovascular disease.

Tags : Blood Pressure, Hypertension, Guidelines, BP Control, Cardiovascular Disease

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Slide 1-

New Hypertension Guidelines and The Pivotal Role of Pharmacists in Improving BP Control and Reducing the Incidence of Cardiovascular Disease Adam Bress, Pharm.D., M.S. Assistant Professor Department of Population Health Sciences Division of Health System Innovation and Research University of Utah School of Medicine VA Salt Lake Health Care System April 21, 2018
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Heart disease remains the leading cause of death in the United states
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HYPERTENSION: LEADING modifiable RISK factor FOR GLOBAL MORTALITY Prevalence in 2016: 29% of adult Americans  41% by 2030 40% of adult black Americans – highest in world 63% of Americans age  60y 90% of Americans age  85y  80 million Americans with hypertension! 60% of strokes 50% of heart failure, chronic kidney disease 30% of end-stage renal disease 25% of MI, premature death Lancet 2015; 386:399 NCHS Data Brief 2017; No.289
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U.S. hypertension: PREVALENCE AND CONTROL, 2016 NCHS Data Brief No. 289, 2017 Hypertension 2017;70:736
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Evolution of bp thresholds for initiation and titration of antihypertensive medication Pfeffer M. N Engl J Med. 2016 DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH UKPDS 38 N=143 N=380 N=10,940 N=3,427 N=17,345 N=4,736 N=1,627 N=4,695 N=33,357 N=3,845 N=9,361 N=12,705 N=12,705 ACCOMPLISH N=11,506 N=18,790 SPS3 N=1,148 Drug vs. Placebo Comparing different drugs Comparing different BP targets
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ACC/AHA 2017 BP GUIDELINE: WHAT’S NEW? New BP classification scheme Out-of-office BP necessary to Dx HTN New target BP levels HTN Rx according to: BP level 10y cardiovascular risk Initial low-dose, 2-drug Rx for most patients Favor indapamide/chlorthalidone over HCTZ Adjust Rx using home BP monitoring Recommends team-based care to manage hypertension
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changes in the 2017 ACC/AHA Blood Pressure guidelines? Selected highlights: New BP classification system Use of BP levels and CVD risk to guide antihypertensive medication initiation Lower targets for BP during treatment of hypertension
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BP Clinical Practice Guidelines (CPGs) Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High BP, 1977 Consensus report, with six recommendations Stepped-care treatment for adults with DBP ≥105 mm Hg No recommendations for lifestyle change or drug treatment based on SBP Seventh Report of JNC on Prevention, Detection, Evaluation, and Treatment of High BP, 2003 Structured, comprehensive guideline; recommendations supported by more/better evidence Detailed BP classification system; focus on SBP but included DBP recommendations Lifestyle modification recommended as initial treatment for high BP Antihypertensive drug therapy when SBP/DBP exceeded 140/90 mm Hg (130/80 for DM or CKD) Several subsequent US BP clinical practice guidelines Most focused on aspects of antihypertensive drug treatment In 2013, NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA
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2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Initiative led and managed by: American College of Cardiology American Heart Association Major professional organizations invited to partner Nine accepted invitation American Academy of Physician Assistants American College of Preventive Medicine American Geriatrics Society American Pharmacists Association American Society of Hypertension American Society of Preventive Cardiology Association of Black Cardiologists National Medical Association Preventive Cardiovascular Nurses Association
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2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults In 2014, a 21 member multidisciplinary Writing Committee appointed to develop the guideline: Cardiologists, epidemiologists, internists, endocrinologist, geriatrician, nephrologist, neurologist, nurse, pharmacist, physician assistant, 2 lay/patient representatives Representation for each of the 11 participating professional organizations No Writing Committee member had a relevant relationship with industry Writing Committee
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2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults Formal voting by all members of Writing Committee Assigned: Class of Recommendation (COR), indicating the strength of the recommendation Level of Evidence (LOE), indicating the quality of the supporting evidence Accompanied by most important references (except recommendations based on expert opinion) 448 Evidence Tables (provide details of studies used to support recommendations) Guideline Recommendations
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Highlight #1: Changes in BP Categories from JNC7 to the New 2017 acc/aha BP Guideline The categorization of BP should be based on the average of ≥ 2 readings on ≥ 2 occasions following a standardized protocol.
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Rationale: Association of systolic blood pressure and cardiovascular mortality be decade of age Data from 61 prospective observational studies of blood pressure and mortality n= 958,074 Systolic Blood Pressure (mm Hg) 120 140 160 180 256 128 64 32 16 8 4 2 1 40-49 y Age at risk: 70-79 y 60-69 y 50-59 y 80-89 y Lewington. Lancet. 2002 CVD Mortality
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Impact: Prevalence of Hypertension – 2017 ACC/AHA and JNC7 Guidelines Number of US adults with hypertension, millions Prevalence of hypertension JNC7 2017 ACC/AHA Muntner P. JACC. 2018.
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Highlight #2: Treatment initiation is based BP levels and CVD risk SBP <130 and <80 mm Hg Don’t treat SBP ≥130-140 or DBP ≥80-90 mm Hg Treat if any of the following: History of CVD, DM, or CKD 10 yr risk of CVD ≥ 10% using the Pooled Cohort equations Age ≥65 years and SBP ≥130 SBP ≥140 or DBP ≥ 90, mm Hg Treat all Whelton PK. JACC. 2018.
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Impact: new recommendations only treat 6% more; but 37% more people not at goal Hypertension Recommended Rx Treatment BP Above Goal Among those treated 103.3 31.1 72.2 77.7 4.2 JNC7 and 2017 ACC/AHA 29.2 7.9 21.3 Muntner P. JACC. 2018. 81.9 2017 ACC/AHA only
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Rationale: because rrr is similar, Treating High Risk Adults results in Larger Absolute CVD Risk Reduction Sundstrom, Lancet, 2014 -1 NNT 71 NNT 51 NNT 41 NNT 26
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Not Taking Antihypertensive Medication All-Cause Mortality SBP and DBP Levels, mm Hg Taking Antihypertensive Medication ≥140 or ≥90 Recommended Antihypertensive Medication Initiation <130 and <80 ≥140 or ≥90 Not Recommended Antihypertensive Medication Intensification Recommended Antihypertensive Medication Intensification <130 and <80 22.7 Not Recommended Antihypertensive Medication Initiation 3.4 20.5 10.2 33.6 3.8 22.4 21.9 32.9 4.8 29.6 17.5 42.5 5.6 29.9 30.6 From REGArDS: Adults with grey zone BP recommended treatment by the new guidelines have a six-fold higher risk of CVD than those not recommended treatment Rate/1,000 py Cumulative Incidence 130 to <140 or 80 to <90 Cardiovascular Disease Events Rate/1,000 py Cumulative Incidence 130 to <140 or 80 to <90 6-fold 6-fold Colantonio LD. Under Review.
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Recommendation for Choice of Initial Medication
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Highlight #3: Bp target goal now <130/80 mm Hg for almost everyone
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Results of Recent Trials Testing the Impact of an Intensive BP Goal on Hypertension Morbidity/Mortality SBP< 120 mmHg SBP< 130 mmHg SBP< 120 mmHg Stopped early after a median follow-up of 3.26 years with significantly lower rate of the primary outcome and all-cause mortality Did not achieve it’s primary end point but found significant reduction in CVA Did not achieve reduction total recurrent stroke, but fewer hemorrhagic stroke
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Highlight #3: Bp target goal now <130/80 for almost everyone Rationale: Lowering BP to incrementally lower levels prevents CVD and death Regardless of baseline BP, achieved BP, or diabetes status Results similar with and without SPRINT Network Meta-analysis: 42 RCTs; 144,220 pts Bundy J. JAMA Cardiology. 2017. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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VARIABLE HYPERTENSION GUIDELINES 2017! SPRINT criteria Stroke/TIA CVD eGFR < 45 DM Metabolic Synd. JACC 2017;on-line 11/13 Can J Card 2017;33:557 Ann Int Med 2017;166:430
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The new BP Guidelines recommend team-based care with a clinical pharmacist to manage hypertension Structured, Team-Based Care Interventions for Hypertension Control
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Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP
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RCT data show that Team-based care models with a clinical pharmacist: Reduce clinical inertia Improve BP control Reduce cardiovascular disease events
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Team-based care reduces clinical inertia Therapeutic inertia = (number of visits BP not at goal – number of visits with a medication change)/ total number of visits. Therapeutic inertia 28% vs. 44%
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Team-based care with an interventional pharmacist improves bp control
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Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis. Mills KT, Obst KM, Shen W, Molina S, Zhang H, He H, Ann Intern Med. 2018;168:110–120.
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How does team based-case work? 1 Care Clinician ID Uncontrolled HTN: • Paper/EMR registries • Pt. call-back Improve Clinical BP Measurement: • Accurate electronic > Manual • AOBP on pts in isolation  Therapeutic Inertia: • Initial low-dose, 2-drug Rx • Adjust Rx q 2-4 wk by optimal 3-4 drug algorithm • HBPM program • RN/Pharmacist administer algorithm • Performance feedback  Rx Adherence • Phone FU • Walk-in BP ’s • Education: - HTN outcomes - BP goals - HBPM - Side effects   J Clin Hypertens 2016;18:260 Am J Prev Med 2014;47:86 Curr Opin Card 2014;29:344 Kaiser Perm HTN control rate: - 650,000 HTN pts - 44%, 2001  90%, 2013
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Team-based care models with a clinical pharmacist reduces CVD events
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MEDICATION ADHERENCE IS CRITICAL AT SUCCESSFUL IMPLEMENTATION OF INTENSIVE TREATMENT “Drugs don’t work in patients who don’t take them.” ~ Former US Surgeon General: C. Everett Koop DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Adherence is major factor in optimal antihypertensive treatment outcomes What are the recent trends in antihypertensive medication discontinuation and adherence after starting treatment? What are the sociodemographic, clinical, and medication characteristics associated with discontinuation and adherence? Tajeu GS. Hypertension. 2016. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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ANTIHYPERTENSIVE Medication DISCONTINUTATION RATES AT ONE-YEAR among Medicare beneficiaries initiating treatment P-trend=0.451 Adjusted for calendar year, age, race/ethnicity, sex, antihypertensive drug class initiated, Medicaid buy-in, dementia, diabetes, coronary heart disease, stroke, chronic kidney disease, heart failure, history of depression, falls, polypharmacy, Medicare Part D coverage gap from the year prior to antihypertensive medication initiation and variables from the six months after antihypertensive medication initiation. Tajeu GS. Hypertension. 2016. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH Discontinuation - having no days of medication available to take during the final 90 days of the 365 day follow up period after initiation.
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Trends in low adherence to antihypertensive medication Tajeu GS. Hypertension. 2016. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH Low adherence - interval-based proportion of days covered (PDC) < 80% during the follow up period among beneficiaries who did not discontinue.
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Risk ratios for discontinuation and non-adherence by antihypertensive medication Tajeu GS. Hypertension. 2016. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Implementation of 2017 acc/aha guideline goals means more medication initiations and titrations # of BP medications in SPRINT: 56% vs 24% required  3 BP meds Wright JT Jr. N Engl J Med. 2015 DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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risk of injurious falls after initiation or titration of antihypertensive medication N=90,127 Medicare beneficiaries with hypertension who had serious fall injury between 7/1/2007 and 12/31/2012 based on emergency department and inpatient claims. Case cross over design. Shimbo D. Circ Cardiovasc Qual Outcomes. 2016 DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Hazard ratios for a serious falls associated with demographic characteristics and medication use Bress AP, In preparation Hazard ratios adjusted for demographics, region, Charlson comorbidity index score, medication variables, cardiovascular comorbidities and factors common among older adults. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Hazard ratios for a serious falls associated with demographic characteristics and medication use Bress AP, In preparation Hazard ratios adjusted for demographics, region, Charlson comorbidity index score, medication variables, cardiovascular comorbidities and factors common among older adults. DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Conducting fall risk factor assessment in older adults initiating antihypertensive medication may be a strategy to improve the recognition of those at risk for serious fall injuries. Injurious falls summary Summary Selected characteristics identify patients at high risk for serious fall injuries following antihypertensive medication initiation. Demographics Older age, Female sex, White race Medication Use Factors Common among Older Adults Syncope, Osteoporosis, Depression, Dementia, Serious fall injury Use of >10 medications Cardiovascular Comorbidities Stroke DIVISION OF HEALTH SYSTEM INNOVATION AND RESEARCH
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Summary and concussions New BP classification system, hypertension is now defined as SBP/DBP >130/80 Use of BP levels and CVD risk to guide antihypertensive medication initiation Lower targets for BP during treatment of hypertension; 130/80 for almost all Team-based care with pharmacists is critical to improving BP control rates