Comments on JNC 7: including N'O'D'

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Comments on JNC 7 including N.O.D.

• Ray Townsend, MD
• 4 on NHLBI most-wanted list
• September 28, 2005

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48 year old T2DM man

• Feels OK
• Diabetes is under good control
• Takes only one med (for DM)
• BMI is 30.6 kg/m2
• Im working on it (BMI was 31.3 a year ago)
• Blood pressure is 134/82 mm Hg
• Does he have hypertension?

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Blood Pressure Classification
JNC 7
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Classification and Management of BP for adults
Treatment determined by highest BP
category. Initial combined therapy should be
used cautiously in those at risk for orthostatic
hypotension. Treat patients with chronic kidney
disease or diabetes to BP goal of lt130/80 mmHg.
JNC 7 slideset
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CON 1

• Definition of hypertension amongst those with a
  compelling indication is confusing

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60 year old diabetic woman

• Surveillance visit
• Feels well
• Bp 134/78 mm Hg
• Heart rate 64 bp
• Exam pretty unremarkable
• Insurer asked for EST done (and normal)

• Meds
• 2 anti-diabetic meds
• atorvastatin
• 100 mg losartan
• 25 mg HCTZ
• 25 mg spironolactone
• 10 mg amlodipine
• 100 mg metoprolol XL

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• Hypertension is ... the level of blood pressure
  at which the benefits of action (i.e. therapeutic
  intervention) exceed those of inaction.
• Evans and Rose Brit Med Bull 19712737-42

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CON 2

• Its not clear when you stop adding or titrating
  when does drug toxicity (and cost) equal or
  outweigh benefit?

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Weighty Topic in hypertension
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JNC 7 on metabolic syndrome

• No special consideration in drug treatment of
  this entity reference is only to the generic
  treatment algorithm
• The peculiarities of the diagnostic criteria of
  this condition contain several metabolic aspects
  where a diuretic (the preferred agent) is
  probably not the best choice

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CON 3

• More evidence needed in (particulars of) drug
  treatment of metabolic syndrome, particularly in
  light of ACE/ARB benefits on development of
  type 2 diabetes during treatment

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Risk adverse

• What is the point in treating hypertension?
• To reduce the RISK of target organ damage
• How is CV risk factored into JNC 7 treatment
  recommendations?

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Treatment Strategies andRisk Stratification
JNC 6
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To be fair

• The compelling indications do much to identify
  patients with enhanced risk
• Diabetes, proteinuria/CKD, MI etc.

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CON 4

• More is needed in terms of risk management and
  choice of agent(s) and non-hypertensive
  medications

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49 year old AA with an eGFR 48

• Hypertension for many years not well managed for
  the first 5 years better now
• Positive family history of CKD/dialysis
• Not diabetic, 1 proteinuria
• BP is 136/76 mm Hg

• ACE
• Loop
• DHP-CCB
• Beta-blocker

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JNC 7 recommendation
Hypertension 2003421225
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The evidence
BP in USUAL group 141/85 mm Hg BP in LOWER group
128/78 mm Hg
JAMA 20022882421-2431
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CON 5

• The data on GFR preservation, in the absence of
  significant proteinuria, are wanting (but there
  are other target organs at risk)

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Average response to guidelines?
JNC 7
ATP III
Guidelines 4 dummies
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History

• Report (JAMA, 1977)
• 1980 Report (Archives)
• 1984 Report (Archives)
• 1988 Report (Archives)
• JNC V (Archives, 93)
• JNC VI (Archives 97)
• JNC 7 (Hypertension 03)

• 6 pages
• 6 pages
• 13 pages
• 16 pages
• 30 pages
• 34 pages
• 47 pages

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Where are the big gains?
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CON 6

• The Report is pretty thorough, but can we do
  better in terms of reader friendliness?

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JNC 7 ALL HAT (NHLBI)?
ALL HAT
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JNC 7 Primary Rx recommends
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But what about?

• The metabolic consequences of diuretic use?
• More diabetes
• More hypokalemia
• (higher) cholesterol and triglyceride
• Higher uric acid levels

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From the ALL HAT report

• Among individuals classified as non-diabetic
  the incidence of new-onset diabetes was
• 11.6 (chlorthalidone)
• 9.8 (amlodipine) and
• 8.1 (lisinopril)
• Overall these metabolic differences did not
  translate into more cardiovascular events or
  mortality

JAMA 20022882989
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Pepine JACC 200544509-512
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PIUMA study

• observational registry of M M
• initially untreated essential hypertension
  subjects
• initiated June 1986
• hypertension by standard definitions
• EKG used Cornell voltage
• 24 hour ABPM done
• diabetes glucose gt 7 mmol/L (126 mg/dl)
• n875 subjects

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Verdecchia Hypertension 200443963-970
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PIUMA study (Verdecchia)
Hypertension 200443963-970
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What factors predict N.O.D. ??

• chronic heart failure
• left ventricular hypertrophy
• U.S. residency
• Hispanic ethnicity
• black race
• previous stroke
• increased body mass index
• low serum high-density lipoprotein

• high non-fasting serum glucose
• elevated systolic blood pressure
• increased age
• female gender
• and history of antihypertensive drug use
• Narayan JAMA 2003
• Cooper-DeHoff Circ 2003
• Lindholm J Hypertens 2002

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Which factor should I focus on?

• Pretreatment glucose

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CON 7

• New onset diabetes may not be as benign as
  indicated by the short follow up in ALL HAT
• However, sight should not be lost of blood
  pressure control (which generally trumps blood
  sugar control in RCTs)

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For further contact etc .

• Positive comments
• townsend_at_mail.med.upen.edu
• Criticisms?
• Dial 1-800-hows my lecture
• Or email Dr Moser