What Is the Optimal Systolic Blood Pressure Goal in Hypertension Therapy? William C. Cushman, MD Chief, Preventive Medicine Section, Memphis VA Medical Center Professor, Preventive Medicine, Medicine, and Physiology University of Tennessee Health Science Center JNC 7: BP Classification BP Level (mm Hg)* Category Systolic Diastolic < 120 and < 80 Normal 120-139 or 80-89
Pre-hypertension 140-159 or 90-99 Stage 1 Hypertension 160 or 100 Stage 2 Hypertension *Use higher value for classification. Chobanian AV et al. JAMA. 2003;289:2560-2572. Prevalence of Blood Pressure Categories in US Adults 20 Years of Age (NHANES 1999-2000) BP Category Prevalence Normal
39% Prehypertension 31% Hypertension 29% Greenlund, Croft, Mensah (CDC). Arch Intern Med. 2004;164:2113f Goal BP for Hypertensive Patients (mm Hg) JNC 7 VA-DoD Most patients <140/90 <140/90 Diabetes <130/80
<140/80 CKD <130/80 <140/90_ CVD (AHA): <130/80 ~75 million Americans have HTN 19881994 19992000 20012002 20032004 20052006 20072008 JAMA 2010;303:20432050 HTN Control Rates in VA < or 140/90 mm Hg* FY08 & 09 Target 75%
*<140/90 mm Hg in 2003-2007 5% drop (68% to 63%) in 2003 when < 140/90 calculated 6% drop (73% to 67%) in 2004 when < 140/90 calculated 1999-2009 data from: VA OQP High Blood Pressure and CHD Risk Lancet 2002; 360: 190313 High Blood Pressure and Stroke Risk Lancet 2002; 360: 190313 Why is it important not to intensify medications to reduce BP below the level proven in trials? Treating to lower BP levels may be harmful (J-curve?) Incidence of the primary outcome (first occurrence of death, nonfatal MI, or nonfatal stroke) by SBP and DBP strata in INVEST Trial
Messerli, F. H. et. al. Ann Intern Med 2006;144:884-893 Why is it important not to intensify medications to reduce BP below the level proven in trials? Treating to lower BP levels may be harmful (J-curve?) If neither beneficial nor harmful Adding unneeded drugs wastes patients and payers resources and time: More visits, drugs, monitoring, treating AEs More drugs may contribute to reduced adherence to other evidence-based drug treatments (e.g., statins and aspirin) Systolic BP in Trials Testing SBP Goals: SHEP, Syst-Eur, Syst-China, HYVET SHEP Syst-Eur Syst-China HYVET Entry SBP 160-219 160-219 160-219
144 Achieved: placebo 155 161 160 159 * Integrated SBP goal, personal communication, Barry Davis SBP = systolic blood pressure What should the SBP treatment goal be in patients with hypertension? Clinical trial evidence is very consistent for SBP goal <150 mm Hg. Indirect evidence, mostly from trials with DBP goals, suggest SBP goal <140 mm Hg may be reasonable. Public health: SBP goal <140 mm Hg has been recommended by many guidelines for several decades.
What should the Systolic BP treatment goal be in patients with diabetes mellitus? Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk Cardiovascular Mortality Rate per 10,000 Patient-Years Elevated SBP increases risk of CV death almost twofold in diabetic vs nondiabetic patients 250 Nondiabetic patients Diabetic patients 200 150 100 50 0 <120 120139 140159
160179 SBP (mm Hg) Stamler J et al. Diabetes Care. 1993;16:434-444. MRFIT 180199 200 ACCORD Double 2 x 2 Factorial Design Lipid Placebo BP (Systolic) Fibrate Intensive Standard <120 mm Hg <140 mm Hg Intensive
Glycemic Control 1383 1374 1178 1193 5128 Standard Glycemic Control 1370 1391 1184 1178 5123 2765
2362 2371 10,251 2753 5518 4733* ACCORD BP Trial Design Primary BP question: does a therapeutic strategy targeting systolic blood pressure (SBP) <120 mm Hg reduce CVD events compared to a strategy targeting SBP <140 mm Hg in patients with type 2 diabetes at high risk for CVD events? 4733 participants with type 2 diabetes were randomly assigned to intensive (SBP <120 mm Hg) or standard (SBP <140 mm Hg) therapy. Mean follow-up: 4.7 years. 94% power for 20% reduction in primary event rate, assuming standard group rate of 4%/yr and 5.6 yrs follow-up. Primary and Secondary Outcomes for ACCORD BP Trial Primary outcome -- composite of:
Nonfatal MI, nonfatal stroke, CVD death Secondary outcomes: 1.Expanded macrovascular outcome: 1 + any revascularization and hospitalization for HF 2.major CAD events 3.nonfatal MI 4.combined fatal and nonfatal stroke 5.nonfatal stroke 6.total mortality 7.CV mortality 8.HF ACCORD BP Trial Eligibility Stable Type 2 Diabetes >3 months HbA1c 7.5% to 11% (or <9% if on more meds) High CVD risk = clinical or subclinical disease or 2 risk factors Age (limited to <80 years after Vanguard) 40 yrs with history of clinical CVD (secondary prevention) 55 yrs otherwise Systolic blood pressure 130 to 160 mm Hg (if on 0-3 meds) 161 to 170 mm Hg (if on 0-2 meds) 171 to 180 mm Hg (if on 0-1 meds) Urine protein <1.0 gm/24 hours or equivalent Serum Creatinine 1.5 mg/dl
Many drugs/combinations provided to achieve goal BP according to randomized assignment Intensive Intervention: 2-drug therapy initiated: thiazide-type diuretic + ACEI, ARB, or blocker Drugs added and/or titrated at each visit to achieve SBP <120 mm Hg At periodic milepost visits: addition of another drug required if not at goal Standard Intervention: Intensify therapy if SBP 160 mm Hg @ 1 visit or 140 mm Hg @ 2 consecutive visits Down-titration if SBP <130 mm Hg @ 1 visit or <135 mm Hg @ 2 consecutive visits Characteristic Mean or % Characteristic Mean or %
Age (yrs) 62 Blood Pressure (mm Hg) 139/76 Women % 48 On Antihypertensive % 87 2 prevention % 34 Creatinine (mg/dL) 0.9 eGFR (mL/min/1.73m2)
Median value Mean # Meds Intensive: Standard: 3.2 1.9 3.4 2.1 3.5 2.2 3.4 2.3 Average after 1st year: 133.5 Standard vs. 119.3 Intensive, Delta = 14.2 Intensive N (%) 77 (3.3) Standard N (%) 30 (1.3) <0.0001
188 (40) 0.36 Serious AE P Symptom experienced over past 30 days from HRQL sample of N=969 participants assessed at 12, 36, and 48 months post-randomization Intensive Standard Events (%/ Events (%/ yr) yr) HR (95% CI) Primary Total Mortality Cardiovascular Deaths Nonfatal MI Nonfatal Stroke Total Stroke P
0.25 34 (0.30) 55 (0.47) 0.63 (0.41-0.96) 0.03 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01 Also examined Fatal/Nonfatal HF (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal MI and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome, revascularization and unstable angina (HR=0.95, p=0.40) Nonfatal Stroke Total Stroke 100
HR = 0.63 95% CI (0.41-0.96) P=0.03 80 Patients with Events (%) Patients with Events (%) 100 60 40 20 HR = 0.59 95% CI (0.39-0.89) P=0.01 80 60 40 20
No CVD reduc 11,140 140 none 135 14% mortality reduc 4,733 134 <120 119 NSD in CVD 41% stroke reduc ABCD ADVANCE ACCORD-BP Cushman, et al. Am J Cardiol 2007;99[suppl]:44i-55i; Patel, et al. Lancet 2007;370:829-840;
ACCORD Study Group. NEJM 2010;362;1575-85. The ACCORD BP trial evaluated the effect of targeting a SBP goal of 120 mm Hg, compared to a goal of 140 mm Hg, in patients with type 2 diabetes at increased cardiovascular risk. The results provide no conclusive evidence that the intensive BP control strategy reduces the rate of a composite of major CVD events in such patients.
Many patients with achy joints/hips/feet assume their symptoms are due to osteoporosis, which is not likely in the absence of a fracture, and pain without a fracture is more typical of osteomalacia. Vertebral fractures are by far most common, and...
Geography is the most popular defining characteristic: ... making the Caribbean one of the melting pots of the world. Impact of historical processes. MIGRATION. ... They added to the economy by planting rice, cocoa and ground provisions.
Energy may be converted from one form to another. ... 1 mole of any substance contains 6.02 1023 molecules (Avogadro's number) ... Ions are formed by transfer of valence shell electrons between atoms. Anions (- charge) have gained one or...
Aim: Define the contribution of PGE2 and its receptor EP4 to intestinal blood flow regulation in preterm neonates with NEC. Methods: Rat pup model of NEC. At 48hours of age, intestinal laser Doppler blood flow was assessed at baseline and...
jasÓn personajes hÉroe griego, educado por el centauro quirÓn , y futuro rey de yolcos pelÍas usurpador del trono de yolcos. es asesinado, de forma involuntaria, por sus hijas medea princesa de la cÓlquida, con poderes de hechicera argonautas orfeo,...
then find spanish (spain, traditional sort) select keyboard under spain, traditional sort and. click on spanish. at the bottom ribbon of your computer, you will see . en --- that is for english. if you click on es below it,...
Stratospheric Water Vapor James Jung Contributions From: Fanglin Yang, Shrinivas Moorthi, Yu-Tai Hou Paul Van Delst, David Groff, Andrew Collard, Daryl Kleist NCEP Global Branch Meeting 7 October 2010 Outline Background Estimates/Results from research projects HALOE SAGE II Estimates from...
Current Standard: V1.3 is the outgoing standard. All new fisheries assessment and re-certification to be assessed under V2.0 since May 1st 2018. This is first complete reissuance of the Alaska RFM Standard since the program's inception in 2010.
Ready to download the document? Go ahead and hit continue!