Hypertension and
Dyslipidemia Update
JNC-8 Predictions
ATP IV Predictions
Cynthia Less, MSN, APRN, FNP-C, NCSN
Hypertension
▪ 74.5 Million Hypertensive Americans
▪ HTN - Risk Factor for the following:
▪ Premature Cardiovascular Disease
▪ Heart Failure
▪ Stroke
▪ Chronic Kidney Disease and ESRD
▪ Cognitive Decline
▪ Premature Death
http://www.cdc.gov/nchs/data/databriefs/db107.htm
World Hypertension League
http://www.worldhypertensionleague.org/Pages/Home.aspx
World Health Organization
http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence/en/index.html
Blood Pressure Formula
• Blood Pressure = Stroke Volume x Heart Rate x
Peripheral Vascular Resistance
• A rise in any of the components will cause higher BP
• A drop in any of the components will cause lower BP
• Highest PVR found in elders, DM, African ancestry
Target Organ Damage
▪ Heart
▪ Left Ventricular Hypertrophy
▪ Angina / prior MI
▪ Prior coronary revascularization
▪ Heart failure
▪ Brain
▪ Stroke or transient ischemic attack
▪ Dementia
▪ Chronic Kidney Disease
▪ Peripheral Arterial Disease
▪ Retinopathy
CVD Risk Factors
▪
▪
▪
▪
▪
▪
▪
▪
▪
Age (Male 55, Female 65)
Hypertension
Diabetes mellitus
Elevated LDL or low HDL
Family history of premature CVD
Microalbuminuria or estimated GFR < 60 mL / min
Obesity
Physical inactivity
Tobacco use
Diagnosing Hypertension
▪ Clinic BP Measurement
▪ Home BP Monitors
▪ Ambulatory BP Monitors
Accurate Blood Pressure Measurement
▪ Must sit for 5 minutes
▪
▪
▪
▪
▪
▪
Back supported against chair, feet flat on floor
Cuff must encircle 80 % of arm circumference
Arm supported at level of the heart
Average of 2 readings at least 2 minutes apart
Repeat set if more than 5 mmHg apart
No caffeine, smoking, or exercise 30 minutes prior
The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute. December
2003.
Joint National Committee on Prevention Detection,
Evaluation and Treatment of High Blood Pressure
JNC-7
• 50 years and older = systolic pressure greater than 140 is
much more important risk factor for CVD than diastolic
• The risk of CVD beginning at 115/75 doubles with each
increment of 20/10
• Systolic of 120-139 or diastolic of 80-89 should be considered
pre-hypertensive
• Persons normotensive at age 55 have a 90% lifetime HTN
risk
JNC-7 Classifications
B/P CLASS
SBP
DBP
<120
And <80
Prehypertension
120-139
Or 80-89
Stage 1
140-159
Or 90-99
Stage 2
>160
Or >100
Normal
2007 European Societies of HTN and Cardiology:
Classification of HTN
BP Classification
SBP mmHg
DBP mmHg
Optimal BP
< 120
< 80
Normal
120 - 129
and /or 80 - 84
High Normal
130 - 139
and /or 85 - 89
Grade 1
140 - 159
and / or 90 - 99
Grade 2
160 - 179
and / or 100 - 109
Grade 3
> 180
and / or > 110
Isolated Systolic HTN
140
< 90
Mancia, G. et al. 2007 Guidelines for the Management of Arterial HTN: The Task Force for the Management of Arterial HTN of the Euro Soc of HTN (ESH) and of the Euro Soc of Card (ESC). J HTN 2007;
25: 1105.
Results of BP Screenings
▪
▪
▪
▪
▪
Recheck in 2 years if normal
Recheck in 1 year if prehypertension
Stage 1 - Confirm in 2 months
Stage 2 - Confirm in 1 month
If > 180 / 110, treat now
Classification of Prehypertension and
Hypertension in Children and Adolescents
Classification
Normal
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
Systolic or diastolic blood pressure*
< 90th percentile
90th to < 95th percentile or ≥
120/80 mm Hg†
95th to < 99th percentile plus 5 mm
Hg
> 99th percentile plus 5 mm Hg
*—Based on sex, age, and height; measured on at least three separate occasions.
†—Blood pressure of 120/80 mm Hg or greater is prehypertension regardless of
whether it is less than the 90th percentile. If 120/80 mm Hg is in the 95th percentile
or greater, then the patient has hypertension.
Am Family Physician. 2012 Apr 1;85(7):693-700
Children and Adolescents
• HTN defined as BP—95th percentile or greater,
adjusted for age, height, and gender
• Use lifestyle interventions first, then drug therapy for
higher levels of BP or if insufficient response to lifestyle
modifications
Children and Adolescents
• Drug choices similar in children and adults, but
effective doses are often smaller
• Uncomplicated primary HTN is not a reason to
restrict physical activity
Benefits of Lowering BP
• Stroke incidence =35–40% reduction
• Myocardial infarction=20–25% reduction
• Heart failure=50% reduction
Lifestyle Modification
Approximate SBP Reduction-Range with Modification
•
•
•
•
•
Weight reduction
DASH eating plan
Sodium reduction
Physical activity
Moderate alcohol consumption
5–20 mmHg/10 kg weight loss
8–14 mmHg
2–8 mmHg
4–9 mmHg
2–4 mmHg
Medications
• Lifestyle changes FIRST
• Medications have SIDE EFFECTS
• Prescription is based on underlying diagnosis
• Comorbidities
Medications
A
B
C
D
ACEIs/ARBs
Beta-Blockers
CCBs
Diuretics
DM, CHF, Post MI
Young
CHF, Post MI
Young
Black
Elderly
Black
Elderly
Angioedema
Cough 30% rate
Increased K+
Low Na+
Can increase lipids,
cholesterol
Increased depression
Increased asthma,
COPD symptoms
Dihydroperidines:
edema, constipation,
heart failure
Non-Dihydroperidines:
decreased heart rate
HCTZ: low K+, increased
Ca++, increased uric acid,
increased lipids,
increased glucose, low
Na+, increased Cr
Loop: low K+, low Ca++,
low Na+, increased Cr
The Renin Angiotensin
System
Gum hyperplasia
Fatigue
Non-adherence
▪
▪
▪
▪
▪
▪
Misunderstanding of condition
Denial of illness / Asymptomatic
Lack of patient involvement in care plan
Unexpected adverse effects of medicine
Too many follow-up visits, lab requests
Emphasis on PCMH Goals / Objectives
The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute. Dec 2003.
HTN Emergency
DBP=>120 mg Hg
“The presence of acute or ongoing end organ damage constitutes a hypertensive emergency,
whereas the absence of such complications is known as a hypertensive urgency.”
• Acute heart failure
• Acute coronary syndrome
• Stroke or encephalopathy
• Intracranial hemorrhage
• Acute target organ damage (TOD)
Bales, A, Hypertensive crisis: How to tell if it's an emergency or an urgency, Postgraduate Medicine, vol 105, no 5, 99, available at www.postgraduatemedicine.com
HTN Urgency
• Stage 2 HTN without treatment
• No evidence of acute onset TOD
• Alert
• No headache or chest pain
• Treatment Goal
• Prompt but gradual BP reduction
• 25% reduction of mean arterial
pressure or
• Diastolic pressure to 100 to 110
mm Hg over next several minutes
to several hours
Questions?
▪ What now?
▪ Do we continue current practices “as is”?
▪ Monitor how BPs are screened
▪ Question and change confirmation methods
▪ Adapt ambulatory BP monitor / HBPM
▪ Change preferences for 1st line agents
▪ Change preferences for 1st line combination medications
•
•
•
U.S. guidelines for the detection, evaluation, and treatment of
hyperlipidemia in adults
Developed by an expert panel for the National Heart, Lung, and Blood
Institute (NHLBI)
• Division of National Institutes of Health (NIH)
• Long history of developing clinical practice guidelines
• First JNC report published 1977
ATP release history:
• ATP I First released in 1988
• ATP II 1993
• ATP III 2001
National Cholesterol Education Program
(NCEP) Adult Treatment Panel (ATP)
Guidelines
Lipid Review
Cholesterol (Understanding Disease:
Cardiovascular Medicine)
http://www.youtube.com/watch?NR=1&v=mCYAOeEe6w&feature=endscreen
Biology of Progression of Atherosclerosis
http://www.youtube.com/watch?feature=player_detailpag
e&v=Yyr67JBiU0Q
Adult Treatment Panel III (ATP III)
• Provides clinical guidelines for treatment for
cholesterol testing and management
• Evidence-based and extensively referenced
• Provides scientific rationale for the
recommendations
• ATP I and II focused on patients with CHD
• ATP III thrust in on primary prevention in persons
with multiple risk factors
ATP III Guidelines
Risk Category
High Risk
CHD or Risk Equivalents
(10 YR >20%)
Moderate Risk
2+ risk factors
(10 YR 10-20%)
Moderate Risk
2+ risk factors
(10 year risk <10%)
Low Risk
0-1 risk factor
LDL Goal
<100
Drug Treatment
>100
(optional for very high <100 consider drug
risk <70)
treatment
<130
>130
<130
>160
<160
>190
Updates to ATP III (July 2004)
▪ Update on ATP III Guidelines based on the
review of 5 clinical trials of cholesterollowering statin treatment that were
conducted after the release of ATP III
UPDATE 1
▪ ATP III emphasizes therapeutic lifestyle changes:
▪ Low saturated fat and low cholesterol diet
▪ Increased physical activity
▪ Weight control
▪ These remain the cornerstone of treatment for
lowering cholesterol levels
UPDATE 2
▪ Modifications for high risk patients
▪ CHD, PVD, CVA, Diabetes or 2 or more risk factors
that give them 20% 10 year risk
▪ LDL <100
▪ Modifications for very high risk patients
▪ Had a recent heart attack or CHD combined with
diabetes or severe or poorly controlled risk factors
or metabolic syndrome
▪ LDL < 70
UPDATE 3
▪ High Risk patients recommend consider drug
treatment for LDL >100
▪ Optional drug treatment for LDL <100
▪ ATP III advises that the intensity of the LDL
lowering drug treatment in high risk and moderate
risk patient be sufficient to achieve at least 30%
reduction in LDL levels
UPDATE 4
▪ Moderately high risk patients - > 2 risk factors
together with a 10-20% 10 y risk
▪ Recommend drug treatment for LDL >130
▪ Overall goal for moderately high risk patient is still
LDL < 130 there is therapeutic option to set the
treatment goal at an LDL <100 and to use drug
treatment if LDL is 100-129
Cut Points for Total Cholesterol and LDL
Concentrations in Children and Adolescents
Category
Percentile
Total cholesterol
(mg per dL)
LDL (mg per dL)
Acceptable
< 75th
< 170
< 110
Borderline
75th to 95th
170 to 199
110 to 129
Elevated
> 95th
> 200
> 130
Am Family Physician. 2009 Apr 15;79(8):703-705. AAP Clinical Report on Lipid Screening in Children
Pediatric Lipid Screening Recommendations
Lipids
0 to 12 months 1 to 4 years
No routine lipid Obtain fasting
screening
lipid profile
only if family
history for CVD
is positive,
parent has
dyslipidemia,
child has any
other risk
factors or highrisk condition
5 to 9 years
Obtain fasting
lipid profile
only if family
history for CVD
is positive,
parent has
dyslipidemia,
child has any
other risk
factors or highrisk condition
9 to 11 years
Obtain
universal lipid
screen with
non-fasting
non-HDL
cholesterol
(total
cholesterol
minus HDL
cholesterol), or
fasting lipid
profile;
manage per
lipid
algorithms as
needed
12 to 17 years
Obtain fasting
lipid profile if
family history
newly positive,
parent has
dyslipidemia,
child has any
other risk
factors or highrisk condition;
manage per
lipid
algorithms as
needed
18 to 21 years
Measure one
non-fasting
non-HDL
cholesterol or
fasting lipid
profile in all:
review with
patient;
manage with
lipid
algorithms per
Adult
Treatment
Panel
guidelines as
needed
Published source: Pediatrics, December 2011 NHLBI Guidelines
U.S. Preventative Services Task Force (USPTF)
A—Strongly Recommended: The USPSTF strongly
recommends that clinicians provide [the service] to
eligible patients. The USPSTF found good evidence
that [the service] improves important health
outcomes and concludes that benefits substantially
outweigh harms.
B—Recommended: The USPSTF recommends that
clinicians provide [the service] to eligible
patients. The USPSTF found at least fair evidence
that [the service] improves important health
outcomes and concludes that benefits outweigh
harms.
C—No Recommendation: The USPSTF makes no
recommendation for or against routine provision of [the
service]. The USPSTF found at least fair evidence that [the
service] can improve health outcomes but concludes that the
balance of benefits and harms is too close to justify a general
recommendation.
D—Not Recommended: The USPSTF recommends against
routinely providing [the service] to asymptomatic patients. The
USPSTF found at least fair evidence that [the service] is
ineffective or that harms outweigh benefits.
I—Insufficient Evidence to Make a Recommendation: The
USPSTF concludes that the evidence is insufficient to
recommend for or against routinely providing [the
service]. Evidence that the [service] is effective is lacking, of poor
quality, or conflicting and the balance of benefits and harms
cannot be determined
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008.
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
Summary of Recommendations
Screening Men
• The USPSTF strongly recommends screening men aged 35 and
older for lipid disorders.
Grade: A recommendation
• The USPSTF recommends screening men aged 20 to 35 for lipid
disorders if they are at increased risk for coronary heart disease.
Grade: B recommendation
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008.
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
Summary of Recommendations
Screening Women at Increased Risk
• The USPSTF strongly recommends screening women
aged 45 and older for lipid disorders if they are at
increased risk for coronary heart disease.
Grade: A recommendation
• The USPSTF recommends screening women aged 20 to
45 for lipid disorders if they are at increased risk for
coronary heart disease.
Grade: B recommendation
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008.
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
Summary of Recommendations
Screening Young Men and All Women Not at Increased Risk
• The USPSTF makes no recommendation for or against routine
screening for lipid disorders in men aged 20 to 35, or in women
aged 20 and older who are not at increased risk for coronary
heart disease.
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008.
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
Framingham Risk Assessment Tool
• Background
• Derived from the Framingham Heart Study
• Validated method to predict 10-year risk of ‘hard’ coronary heart disease (nonfatal MI or
coronary death)
• Used in those without risk equivalents (e.g. CKD, DM)
• Score
• Low <10%, Moderate 10-20%, High >20%
• Limitations
• Predicts risk best
• ages 30-65
• Less precise in those with diabetes, pre-diabetes, severe HTN, LVH, younger men and women,
and some racial groups – Japanese-Americans, Hispanic men, and Native American women.
• Limited to estimation of 10-year risk
• Available at http://hp2010.nhlbihin.net/atpiii/calculator.asp
For primary prevention, at what age is
lipid screening no longer beneficial?
▪ Age is the single most important predictor of CVD
risk, so the chance of an event only increases with
age. PROSPER looked at patients 70-82 years of age
and found that adding a statin reduced mortality by
24% in this group.
How do you manage elevated cholesterol in
children and adolescents?
▪ Pediatric guidelines TG >200 or LDL >130 diet therapy
needs to be instituted by nutritionist
▪ Pediatric patients with LDL> 190 should be referred for
heterozygous familial hypercholesterolemia. Statin
therapy is indicated in most of these patients
What are the risks of lowering LDL too low?
▪ PROVE-IT looked at LDL as low as 40 in very
high risk patients in the setting of acute
coronary syndrome. Remember that children
have LDL levels in this low range which
provides enough cholesterol for normal
development
▪ Based on current trials there does not seem to
a level that is too low
Statins
▪ Inhibit HMG-CoA reductase
▪ Enzyme responsible for conversion of HMG-CoA to
mevalonate, and decreases hepatic biosynthesis of
cholesterol
▪ As a result, hepatocytes compensate by increasing
the number of LDL surface receptors to increase
LDL reuptake from the circulation
▪ End result is reduction of serum LDL concentration
Effects of Drugs on LDL, HDL, and TG
DRUG
Lower LDL
Higher HDL
Lower TG
Nicotinic Acid
5-25%
15-35%
20-50%
Fibrates
5-20%
10-20%
25-50%
Fish Oils
2-5%
No Change
30-40%
Statins
18-55%
5-15%
7-30%
Bile Acid Resins
15-30%
3-5%
0-15%
Niacin (Nicotinic Acid)
▪ Mechanism of action
▪ Increases activity of lipase, which breaks down lipids
▪ Reduces the metabolism of cholesterol and triglycerides
▪ ↑HDL 15–35%
▪ ↓TG 20–50%
▪ ↓LDL 5–25%
▪ Effective against highly atherogenic LDL lipoprotein (a)
▪ Caution: flushing (due to histamine release), hepatotoxicity,
hyperuricemia, hyperglycemia, pruritus
Effects of Drugs on LDL, HDL, and TG
DRUG
Lower LDL
Higher HDL
Lower TG
Nicotinic Acid
5-25%
15-35%
20-50%
Fibrates
5-20%
10-20%
25-50%
Fish Oils
2-5%
No Change
30-40%
Statins
18-55%
5-15%
7-30%
Bile Acid Resins
15-30%
3-5%
0-15%
Fibric Acid Derivatives (Fibrates)
▪ Mechanism of action
▪ Activates lipase, which breaks down cholesterol
▪ Suppresses release of free fatty acid from the adipose tissue, inhibits
synthesis of triglycerides in the liver, and increases the secretion of
cholesterol in the bile
▪ ↑HDL 10–20%
▪ ↓ TG 20–50%
▪ ↓ LDL 5–20% (with normal TG)
▪ May raise LDL-C (with high TG)
▪ Adverse Effects
▪ Dyspepsia, increased risk of gallstones
▪ When combined with statin, can produce rhabdomyolysis
Effects of Drugs on LDL, HDL, and TG
DRUG
Lower LDL
Higher HDL
Lower TG
Nicotinic Acid
5-25%
15-35%
20-50%
Fibrates
5-20%
10-20%
25-50%
Fish Oils
2-5%
No Change
30-40%
Statins
18-55%
5-15%
7-30%
Bile Acid Resins
15-30%
3-5%
0-15%
Bile Acid Resins
▪ Also called bile acid sequestrants because they sequester
bile acid in the gut so there is a decrease in cholesterol
production
▪ Nonsystemic
▪
▪
▪
▪
↓LDL 15–30%
↑ HDL 3–5%
↑ TG if =>400 mg/dL
Adverse Effects
▪ GI upset, constipation, drug interactions
Effects of Drugs on LDL, HDL, and TG
DRUG
Lower LDL
Higher HDL
Lower TG
Nicotinic Acid
5-25%
15-35%
20-50%
Fibrates
5-20%
10-20%
25-50%
Fish Oils
2-5%
No Change
30-40%
Statins
18-55%
5-15%
7-30%
Bile Acid Resins
15-30%
3-5%
0-15%
Essential fatty Acids (EFA)
Saturated vs. Unsaturated
Saturated Fatty Acids
Unsaturated Fatty Acids
▪ Have a negative impact on
▪ Have a positive impact on
lipoprotein levels
▪ Builds more rigid cell
membranes
lipoprotein levels
▪ Builds more flexible
membranes
Dietary Sources
Omega-6 Fatty Acids
Omega-3 Fatty Acids
▪ Sparingly
▪ Good
▪ Plant oils, sunflower,
▪ Green leafy vegetables,
safflower, corn, soy,
peanut oils, grain-fed
animals
flaxseed, canola oil,
walnuts, fish oil, marine
algae oil, grass-fed
animals
Effects of Drugs on LDL, HDL, and TG
DRUG
Lower LDL
Higher HDL
Lower TG
Nicotinic Acid
5-25%
15-35%
20-50%
Fibrates
5-20%
10-20%
25-50%
Fish Oils
2-5%
No Change
30-40%
Statins
18-55%
5-15%
7-30%
Bile Acid Resins
15-30%
3-5%
0-15%
Anticipated Changes to LDL Goals
• Optional goals will become new treatment goals
• LDL goal < 70 for very high risk
• High risk and moderate risk less clear
• Several clinical trials have shown consistent reduction in CHD events (patients
with CHD or ACS) when achieving LDL of 60-80mg/dL compared to LDL levels
of 100mg/dL
• PROVEIT-TIMI22, A-to-Z, TNT, IDEAL
• One study has also shown coronary atheroma regression when LDL levels are
lowered below 80mg/dL (average 60.8mg/dL) with high potency statins
• Asteriod
• Two studies have shown continuous risk reduction in patients with moderate
risk taking statins
• ASCOT, JUPITER
THE END