Balanced information for better care

Don’t let the pressure get to you:An update on the changing recommendations for treating hypertension

2 Changing recommendations for treating hypertension

Educate staff on techniques for obtaining accurate BP readings. • See AlosaHealth.org/Hypertension for office cards regarding accurate

BP assessment.

Use home BP measurement to diagnose ‘white coat hypertension’ and monitor response to treatment.

• Recommend patients record 3 or 4 BP measurements each day.

Continuous automated ambulatory BP monitoring is the most accurate predictor of CV events,2 but it can be difficult and costly to arrange.

New trial data and guidelines have made hypertension care more complex; the following is an evidence-based synthesis of the new data.

Ensure accurate BP measurement: Check pressure twice during the same visit

FIGURE 1. An evaluation of nearly 40,000 patients found that measuring BP a second time in the same visit resulted in lower readings. Nearly 50% of patients who had a systolic blood pressure (SBP) of 140-159 mm Hg at the beginning of the visit had an SBP <140 mm Hg in the same visit.1

Median drop in blood pressure was 8 mm Hg, equivalent to the impact of starting one hypertensive medication.

140-159 160-180 >180 All0

-5

-10

-15

-20Med

ian

ch

ang

e in

SB

P, m

m H

g

<140

Initial SBP, mm Hg

Alosa Health | Balanced information for better care 3

The rate of injurious falls was no higher in patients with an SBP <130 vs. those with a higher SBP.

The benefit is even greater in older patients.3

Lowering BP reduces CV events across a wide range of pressures

FIGURE 2. A meta-analysis of 42 randomized trials involving 144,220 patients shows that CV benefits occur with any BP reduction, and are greater with lower achieved BPs.4

The benefit of achieving lower BP outweighs the risk of harm.

FIGURE 3. In a population of patients treated to an SBP goal of <130, far more will benefit from prevented CV events or death than will have side effects.5

Number of patients treated for one patient to be harmed

acute kidney injury

hypotension

syncope

electrolyte abnormality

0 400 800 1200

468

603

1171

1189

Higher number is better

Number needed to treat for one patient to benefit

major CV event

all cause mortality

Lower number is better

0

129

70

400 800 1200

vs. Mean achieved SBP

Reduction to 120-124

Reduction to 130-134

Reduction to 140-144

125-129 130-134135-139140-144145-149150-154155-159≥160

135-139140-144145-149150-154155-159≥160

145-149150-154155-159≥160

0.82 (0.67-0.97)0.71 (0.60-0.83)0.68 (0.55-0.85)0.58 (0.48-0.72)0.55 (0.42-0.72)0.46 (0.34-0.63)0.41 (0.32-0.54)0.36 (0.26-0.51)

0.96 (0.83-1.14)0.83 (0.74-0.94)0.78 (0.63-0.98)0.65 (0.51-0.85)0.58 (0.48-0.72)0.51 (0.39-0.69)

0.94 (0.74-1.20)0.79 (0.63-0.99)0.70 (0.60-0.84)0.62 (0.48-0.80)

Hazard Ratio (95% CI) for major CV event or death

0.1 1.0 2Hazard ratio

Favors lower blood pressure

4 Changing recommendations for treating hypertension

Evolving information on the management of high blood pressure: putting it all together FIGURE 4. The 2017 American College of Cardiology and American Heart Association (ACC/AHA) guideline BP categories, a practical guide for when to start treatment, and treatment goals6

• For patients whose management requires assessment of 10-year

CVD risk, continue to reassess at follow-up visits.

• All patients requiring management should achieve an SBP <130, and a DBP goal <80 in adults less than 60 years of age.

Calculate cardiovascular disease risk using the ASCVD risk calculator: www.cvriskcalculator.com OR tools.acc.org/ASCVD-Risk-Estimator-Plus

*ASCVD (atherosclerotic cardiovascular disease) includes acute coronary syndrome, myocardial infarction, angina, revascularization, stroke, TIA, or peripheral arterial disease.

Normal BP SBP <120 and

DBP <80

Elevated BP SBP 120-129 and

DBP <80

Hypertension stage 1 SBP 130-139 or

DBP 80-89

Hypertension stage 2 SBP ≥140 or

DBP ≥90

Promote good lifestyle habits.

AND

No drug needed. Follow up periodically and reassess management as needed.

N Y

Has ASCVD* or 10-year CVD risk ≥10%

Start BP lowering drug and proceed to drug treatment

algorithm (See Figure 5).

Non-drug therapy Non-drug therapy Non-drug therapy

Alosa Health | Balanced information for better care 5

Lifestyle interventions are the foundation of any BP lowering regimenNon-drug approaches such as a low sodium, heart healthy, or DASH diet; aerobic exercise as tolerated; and weight loss are key components of any treatment plan.

All four major anti-hypertensive drug classes are equally good choices for patients requiring drug therapy: thiazide diuretics, angiotensin converting enzyme inhibitors (ACEIs) / angiotensin receptor blockers (ARBs), or calcium channel blockers (CCBs).7

While beta-blockers are indicated to prevent CV outcomes in patients with ASCVD, they are no longer first-line drugs for the management of hypertension because they are less effective than other drug classes in preventing stroke.7

FIGURE 5. Algorithm for initiating and intensifying drug treatment in eligible patients

YN

Initiate a single agent,* either a: thiazide, long acting ACEI / ARB,† or CCB.

Two agents will likely be necessary†† (e.g., ACEI + CCB).

Monitor response to treatment, assess adherence, and screen for side effects.

If not at BP goal, up-titrate a single medication or add another agent.

* For African Americans, initiate a thiazide or CCB. † Combining an ACEI and an ARB confers no additional benefit and may increase adverse events. † † For older patients, start one medication and intensify therapy at the first follow-up visit.

Is the SBP >20 mm Hg above goal?

Achieving the BP goal is more important than the path there.

6 Changing recommendations for treating hypertension

CostsFIGURE 6. Price of a 30-day supply of drugs commonly used to treat hypertension

Prices from goodrx.com, April 2018. Listed doses are based on Defined Daily Doses by the World Health Organization, and should not be used for dosing in all patients. All prices shown are for generic products unless otherwise noted. These prices are a guide; patient costs may be subject to copays, rebates, and other incentives.

$4$16

$19$21

$14$11$10

$10benazapril 7.5 mgenalapril 10 mgfosinopril 15 mglisinopril 10 mg

moexipril 15 mgperindopril 4 mgquinapril 15 mgramipril 2.5 mg

trandolopril 2 mg

ACEIs

$6$15$16

amlodipine 5 mgfelodipine ER 5 mg

nifedipine ER 30 mg

CCBs

$16

$4

clorthalidone 25 mghydrochlorothiazide (HCTZ) 25 mg

indapamide 2.5 mg

Diuretics

$187aliskiren (Tekturna) 150 mgDirect renin inhibitor

$10

$184$34

$45

$7$13

$21$12

azilsartan (Edarbi) 40 mgcandesartan 8 mg

eprosartan 600 mgirbesartan 150 mg

losartan 50 mgolmesartan 20 mgtelmisartan 40 mg

valsartan 80 mg

ARBs

$12

$275ACEIs + CCBs $16benazepril 10 mg/amlodipine 5 mg

benazepril 10 mg/amlodipine 5 mg (Lotrel)

ACEIs + diuretics $23benazepril 10 mg/HCTZ 12.5 mg$10enalapril 10 mg/HCTZ 25 mg

$24fosinopril 10 mg/HCTZ 12.5 mg$4lisinopril 10 mg/HCTZ 12.5 mg

$19moexipril 15 mg/HCTZ 25 mg$17quinapril 20 mg/HCTZ 25 mg

$188azilsartan 40 mg/chlorthalidone 25 mg (Edarbyclor)$48candesartan 16 mg/HCTZ 12.5 mg

$14irbesartan 150 mg/HCTZ 12.5 mg$8losartan 50 mg/HCTZ 12.5 mg

$131losartan 50 mg/HCTZ 12.5 mg (Hyzaar)$14olmesartan 20 mg/HCTZ 12.5 mg

$216olmesartan 20 mg/HCTZ 12.5 mg (Benicar HCT)$49telmisartan 40 mg/HCTZ 12.5 mg

$207telmisartan 40 mg/HCTZ 12.5 mg (Micardis HCT)$11valsartan 80 mg/HCTZ 12.5 mg

$279valsartan 80 mg/HCTZ 12.5 mg (Diovan HCT)

$0 $100 $200 $400

$57$268

$41$367

olmesartan 20 mg/amlodipine 5 mg/HCTZ 12.5 mgolmesartan 20 mg/amlodipine 5 mg/HCTZ 12.5 mg (Tribenzor)

valsartan 160 mg/amlodipine 5 mg/HCTZ 25 mgvalsartan 160 mg/amlodipine 5 mg/HCTZ 25 mg (Exforge HCT)

ARB / CCB / diuretic

$300

$10

$222

$258

$30

$57

$23

olmesartan 20 mg/amlodipine 5 mgolmesartan 20 mg/amlodipine 5 mg (Azor)

telmisartan 40 mg/amlodipine 5 mg telmisartan 40 mg/amlodipine 5 mg (Twynsta)

valsartan 160 mg/amlodipine 5 mgvalsartan 160 mg/amlodipine 5 mg (Exforge)

$268ARBs + CCBs

ARBs + diuretics

Alosa Health | Balanced information for better care 7

Key messages

• Make sure the BP measurement is taken accurately, and more than once during a visit.

• Behavioral interventions, especially reducing sodium intake, form the foundation of BP management.

• Set 130/80 mm Hg as the BP goal for most patients, based on a synthesis of recent data and guidelines.

• Achieving the BP goal is more important than the choice of drug within the recommended classes.

• Reinforce a reduced salt diet and lifestyle modifications throughout treatment.

• Regularly assess response to treatment: screen for side effects, ask about adherence, and intensify treatment as needed to achieve a patient’s BP goal.

References:(1) Einstadter D, Bolen SD, Misak JE, Bar-Shain DS, Cebul RD. Association of Repeated Measurements With Blood Pressure Control in Primary Care. JAMA Intern Med. 2018.

(2) Banegas JR, Ruilope LM, de la Sierra A, et al. Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality. N Engl J Med. 2018;378(16):1509-1520.

(3) Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA. 2016;315(24):2673-2682.

(4) Bundy JD, Li C, Stuchlik P, et al. Systolic Blood Pressure Reduction and Risk of Cardiovascular Disease and Mortality: A Systematic Review and Network Meta-analysis. JAMA Cardiol. 2017;2(7):775-781.

(5) Bundy JD, Mills KT, Chen J, Li C, Greenland P, He J. Estimating the Association of the 2017 and 2014 Hypertension Guidelines With Cardiovascular Events and Deaths in US Adults: An Analysis of National Data. JAMA Cardiol. 2018.

(6) Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-e248.

(7) 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.

Visit AlosaHealth.org/Hypertensionfor more information and resources about BP and its

management for clinicians and patients.

Copyright 2018 by Alosa Health. All rights reserved.

These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient’s clinical condition. More detailed information on this topic is provided in a longer evidence document at AlosaHealth.org.

About this publication

The Independent Drug Information Service (IDIS) is supported by the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania.

This material is provided by Alosa Health, a nonprofit organization which is not affiliated with any pharmaceutical company. IDIS is a program of Alosa Health.

This material was produced by Jing Luo, M.D., M.P.H., Instructor in Medicine; Michael A. Fischer, M.D., M.S., Associate Professor of Medicine (principal editor); Niteesh K. Choudhry, M.D., Ph.D., Professor of Medicine; Jerry Avorn, M.D., Professor of Medicine; Dae Kim, M.D., M.P.H., Sc.D., Assistant Professor of Medicine; Gregory Curfman, M.D., Assistant Professor of Medicine; all at Harvard Medical School, and Ellen Dancel, PharmD, M.P.H., Director of Clinical Materials Development at Alosa Health. Drs. Avorn, Choudhry, Fischer, and Luo are physicians at the Brigham and Women’s Hospital, and Dr. Kim practices at the Beth Israel Deaconess Medical Center, both in Boston. None of the authors accepts any personal compensation from any drug company.

Medical writer: Jenny Cai