EDITORIAL
From Profusion to Confusion: The Saga of Managing Hypertension in Chronic Kidney Disease! Adrian Covic, PhD;1 David Goldsmith, PhD;2 Mihaela-Dora Donciu, PhD;1 Dimitrie Siriopol, PhD;1 Raluca Popa, PhD;1 Mehmet Kanbay, PhD;3 Gerard London, PhD4 From the Nephrology Department, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania;1 Renal Unit, Guy’s and St Thomas’ NHS Foundation Hospital, King’s Health Partners, London, UK;2 Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey;3 and Nephrology-Dialysis Department, Manhes Hospital, Fleury Merogis, France4
HYPERTENSION––AT A CRITICAL CROSSROADS? Hypertension (HTN), through its high incidence, prevalence, and dire consequences, remains a major contributor to the global burden of disease. The noncommunicable disease burden now exceeds that of infectious disease even in the developing world, with precious few resources anywhere to manage this burgeoning challenge.1 Nevertheless, HTN control rates remain unacceptably low. Currently, approximately 73 million Americans have HTN, and blood pressure (BP) is controlled in only around 50% of the cases.2 Between 1988–1994 and 2007–2010, the prevalence of uncontrolled high BP declined for all age groups. However, in 2007–2010, nearly one half of adults with HTN continued to have uncontrolled high BP.3 Good, clear guidance about how to screen for, detect, and treat HTN is needed for patients, health-care providers, insurance companies, public health bodies, agencies, and governments. The question we posed in 2014 was whether we have this guidance or whether the multiple overlapping and sometimes even contradictory statements recently issued do not in fact provide a perfect storm of confusion.
A HISTORIC PERSPECTIVE: ANALYZING THE JNC REPORTS The first report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) was published in 1977 and was based on rather limited and inconclusive (available in the mid-1970s) clinical information from a modern point of view. Currently, a total of eight JNC reports have been issued. They are briefly summarized in Table I. The guidelines industry was founded, and then flourished, with departmental, hospital, regional, national (eg, National Institute for Health and Clinical Excellence [NICE]), international-local (eg, North America, Australia, Europe), and then fully international guidelines groups and bodies, all highly active in assembling evidence and then analyzing and disseminating care
Address for correspondence: Adrian Covic, University Hospital “Dr. C. I. Parhon,” B-dul Carol I, no. 50, Iasi, Romania. E-mail: [email protected] DOI: 10.1111/jch.12508
instructions. Furthermore, each medical condition had its own guidelines, eg, dyslipidemia, HTN, kidney disease, and diabetes. Little initial effort was expended on appreciating that many real-life subjects often had more than one “risk factor” (eg, obesity, diabetes, HTN) and that the presence of these other comorbidities would likely affect therapeutic options and outcomes.
THE PRESENT TIME In contrast to the early JNC times, we are now experiencing an era of “too much information.” This is because in 2014 we were faced with six “guidance protocols,” essentially covering the same topic(s): detection and treatment of HTN. It is clear that these guidelines have different incentives (see below) and that they should give an exhaustive algorithm about how to treat HTN, but it is also clear that in some important areas there appears to be disagreement among these recommendations. The collision of these new recent guidelines has now made every clinical decision harder, so, the “new-old ironclad” question remains: “What should we do?” We now have to deal with the following guidelines, all at the same time: European Society of Hypertension/European Society of Cardiology (ESH/ESC) 20136 American Society of Hypertension/International Society of Hypertension (ASH/ISH) 20137 Eighth Joint National Committee (JNC 8) 20138 Canadian Hypertension Education Program (CHEP) 20149 NICE 201110 Kidney Disease: Improving Global Outcomes (KDIGO) 201211 AHA/ACC/CDC) scientific advisory document from November 2013.12 To misquote by paraphrasing St Francis of Assisi “where there was certainty, let us now sow doubt.” A number of articles had been issued on this matter highlighting the most important discrepancies, particularly the increase in threshold BP value for initiation of pharmacologic therapy.13–16 Indeed, as mentioned above, these guidelines were intended for different audiences and were written with different motivations. The ESH/ESC guideline evaluates all the relevant literature across the spectrum of HTN and provides concise recommendations that can be easily and rapidly consulted by physicians in their routine practice.6 ASH/ISH is a brief curriculum and set of The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
421
Editorial
TABLE I. Summary of JNC Reports4,5 Year
JNC Report
Main Features
1977
JNC 1
No systolic blood pressure (SBP) in its classification system; Drug therapy was recommended for patients with diastolic blood pressure (DBP) ≥105 mm Hg; Therapy “could be considered” even for patients with DBP between 90 mm Hg and 104 mm Hg;
1980
JNC 2
First-line medication: thiazide-type diuretic No SBP in the new classification system;
1984
JNC 3
Introduced the terms “mild,” “moderate,” and “severe hypertension” Addressed SBP, only as isolated systolic hypertension (≥160 mm Hg) or borderline isolated systolic hypertension; The first report recognizing the terms “high normal” when SBP was 130 mm Hg and DBP >80 mm Hg.11 In addition, in terms of BP treatment goal value, KDIGO uses the same classification system: when the urine albumin excretion is 300 mg/24 h, the SBP target is ≤130 mm Hg and the DBP is ≤80 mm Hg.11 For initial choice of drug, this protocol recommends, regardless of urine albumin excretion, an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor.11 The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
423
424
The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
BP ≥140/90 in patients with ≥1 of the following: TOD, CVD, CKD, DM, 10-year CV risk ≥20% BP ≥160/100 mm Hg and subsequent
with no evidence of TOD, CVD, renal disease, or DM, consider seeking specialist
SBP ≥160 mm Hg or DBP ≥100, in patients without macrovascular TOD or other CV risk factors (grade A) SBP ≥140 mm Hg and DBP ≥90 mm Hg, in patients with macrovascular target organ damage or other independent CV risk factors (grade A for DBP, grade C for SBP 140–160 mm Hg, grade A for SBP >160 mm Hg)
SBP ≥140 mm Hg, DBP ≥90 (expert opinion, grade E)
BP >140/90 mm Hg and lifestyle changes not effective BP ≥160/100 mm Hg (grade 2 HTN), drug treatment should be started immediately Drug treatment can be started immediately in all HTN patients in whom the practitioner believes it is necessary to achieve more rapid control of BP
SBP 140–159 mm Hg or DBP 90–99 mm Hg (grade
1 HTN) in patients at low to moderate risk (IIa, B)
SBP 160–179 mm Hg or DBP 100–109 mm Hg
(grade 2 HTN) and SBP ≥180 mm Hg or DBP ≥110 mm Hg
(grade 3 HTN) in patients with
any level of CV risk, a few weeks after or simultaneously
with initiation of lifestyle changes (I, A)
Threshold for starting treatment in the nonelderly
general population
of recommendation and its grade are stated in parentheses.
diabetes mellitus; eGFR, estimated glomerular filtration rate; HBPM, home blood pressure monitoring; HTN, hypertension; NS, no statement; SBP, systolic blood pressure; TOD, target organ damage. For ESH/ESC guidelines, the class of recommendation and level of evidence are stated in parentheses. For JNC 8 guidelines, the strength
Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; DBP, diastolic blood pressure; DM,
potential TOD
and a more detailed assessment of
evaluation of secondary causes of hypertension
than 40 years and stage 1 hypertension
For patients younger
average ABPM/HBPM ≥150/95 mm Hg
80 years
HBPM – BP ≥135/85 mm Hg
average daytime ABPM or average
BP ≥140/90 mm Hg + subsequent
80 years
SBP ≥140 mm Hg and/or DBP ≥90 mm Hg
NICE 201110
60 years
NS
20149
CHEP
80 years
Hg or both on repeated examination
SBP ≥140 mm Hg or DBP ≥90 mm
20138
JNC 8
NS
SBP >140 mm Hg and/or DBP >90 mm Hg
20137
20136
Definition of “elderly” population
Hypertension definition
ASH/ISH
ESH/ESC
TABLE II. Hypertension Definition, Classification, and BP Thresholds
DBP 90–99 mm Hg
SBP 140–159 mm Hg or
NS
NS
201312
AHA/ACC/CDC
Editorial
BP
From Profusion to Confusion: The Saga of Managing Hypertension in Chronic Kidney Disease! Adrian Covic, PhD;1 David Goldsmith, PhD;2 Mihaela-Dora Donciu, PhD;1 Dimitrie Siriopol, PhD;1 Raluca Popa, PhD;1 Mehmet Kanbay, PhD;3 Gerard London, PhD4 From the Nephrology Department, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania;1 Renal Unit, Guy’s and St Thomas’ NHS Foundation Hospital, King’s Health Partners, London, UK;2 Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey;3 and Nephrology-Dialysis Department, Manhes Hospital, Fleury Merogis, France4
HYPERTENSION––AT A CRITICAL CROSSROADS? Hypertension (HTN), through its high incidence, prevalence, and dire consequences, remains a major contributor to the global burden of disease. The noncommunicable disease burden now exceeds that of infectious disease even in the developing world, with precious few resources anywhere to manage this burgeoning challenge.1 Nevertheless, HTN control rates remain unacceptably low. Currently, approximately 73 million Americans have HTN, and blood pressure (BP) is controlled in only around 50% of the cases.2 Between 1988–1994 and 2007–2010, the prevalence of uncontrolled high BP declined for all age groups. However, in 2007–2010, nearly one half of adults with HTN continued to have uncontrolled high BP.3 Good, clear guidance about how to screen for, detect, and treat HTN is needed for patients, health-care providers, insurance companies, public health bodies, agencies, and governments. The question we posed in 2014 was whether we have this guidance or whether the multiple overlapping and sometimes even contradictory statements recently issued do not in fact provide a perfect storm of confusion.
A HISTORIC PERSPECTIVE: ANALYZING THE JNC REPORTS The first report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) was published in 1977 and was based on rather limited and inconclusive (available in the mid-1970s) clinical information from a modern point of view. Currently, a total of eight JNC reports have been issued. They are briefly summarized in Table I. The guidelines industry was founded, and then flourished, with departmental, hospital, regional, national (eg, National Institute for Health and Clinical Excellence [NICE]), international-local (eg, North America, Australia, Europe), and then fully international guidelines groups and bodies, all highly active in assembling evidence and then analyzing and disseminating care
Address for correspondence: Adrian Covic, University Hospital “Dr. C. I. Parhon,” B-dul Carol I, no. 50, Iasi, Romania. E-mail: [email protected] DOI: 10.1111/jch.12508
instructions. Furthermore, each medical condition had its own guidelines, eg, dyslipidemia, HTN, kidney disease, and diabetes. Little initial effort was expended on appreciating that many real-life subjects often had more than one “risk factor” (eg, obesity, diabetes, HTN) and that the presence of these other comorbidities would likely affect therapeutic options and outcomes.
THE PRESENT TIME In contrast to the early JNC times, we are now experiencing an era of “too much information.” This is because in 2014 we were faced with six “guidance protocols,” essentially covering the same topic(s): detection and treatment of HTN. It is clear that these guidelines have different incentives (see below) and that they should give an exhaustive algorithm about how to treat HTN, but it is also clear that in some important areas there appears to be disagreement among these recommendations. The collision of these new recent guidelines has now made every clinical decision harder, so, the “new-old ironclad” question remains: “What should we do?” We now have to deal with the following guidelines, all at the same time: European Society of Hypertension/European Society of Cardiology (ESH/ESC) 20136 American Society of Hypertension/International Society of Hypertension (ASH/ISH) 20137 Eighth Joint National Committee (JNC 8) 20138 Canadian Hypertension Education Program (CHEP) 20149 NICE 201110 Kidney Disease: Improving Global Outcomes (KDIGO) 201211 AHA/ACC/CDC) scientific advisory document from November 2013.12 To misquote by paraphrasing St Francis of Assisi “where there was certainty, let us now sow doubt.” A number of articles had been issued on this matter highlighting the most important discrepancies, particularly the increase in threshold BP value for initiation of pharmacologic therapy.13–16 Indeed, as mentioned above, these guidelines were intended for different audiences and were written with different motivations. The ESH/ESC guideline evaluates all the relevant literature across the spectrum of HTN and provides concise recommendations that can be easily and rapidly consulted by physicians in their routine practice.6 ASH/ISH is a brief curriculum and set of The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
421
Editorial
TABLE I. Summary of JNC Reports4,5 Year
JNC Report
Main Features
1977
JNC 1
No systolic blood pressure (SBP) in its classification system; Drug therapy was recommended for patients with diastolic blood pressure (DBP) ≥105 mm Hg; Therapy “could be considered” even for patients with DBP between 90 mm Hg and 104 mm Hg;
1980
JNC 2
First-line medication: thiazide-type diuretic No SBP in the new classification system;
1984
JNC 3
Introduced the terms “mild,” “moderate,” and “severe hypertension” Addressed SBP, only as isolated systolic hypertension (≥160 mm Hg) or borderline isolated systolic hypertension; The first report recognizing the terms “high normal” when SBP was 130 mm Hg and DBP >80 mm Hg.11 In addition, in terms of BP treatment goal value, KDIGO uses the same classification system: when the urine albumin excretion is 300 mg/24 h, the SBP target is ≤130 mm Hg and the DBP is ≤80 mm Hg.11 For initial choice of drug, this protocol recommends, regardless of urine albumin excretion, an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor.11 The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
423
424
The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
BP ≥140/90 in patients with ≥1 of the following: TOD, CVD, CKD, DM, 10-year CV risk ≥20% BP ≥160/100 mm Hg and subsequent
with no evidence of TOD, CVD, renal disease, or DM, consider seeking specialist
SBP ≥160 mm Hg or DBP ≥100, in patients without macrovascular TOD or other CV risk factors (grade A) SBP ≥140 mm Hg and DBP ≥90 mm Hg, in patients with macrovascular target organ damage or other independent CV risk factors (grade A for DBP, grade C for SBP 140–160 mm Hg, grade A for SBP >160 mm Hg)
SBP ≥140 mm Hg, DBP ≥90 (expert opinion, grade E)
BP >140/90 mm Hg and lifestyle changes not effective BP ≥160/100 mm Hg (grade 2 HTN), drug treatment should be started immediately Drug treatment can be started immediately in all HTN patients in whom the practitioner believes it is necessary to achieve more rapid control of BP
SBP 140–159 mm Hg or DBP 90–99 mm Hg (grade
1 HTN) in patients at low to moderate risk (IIa, B)
SBP 160–179 mm Hg or DBP 100–109 mm Hg
(grade 2 HTN) and SBP ≥180 mm Hg or DBP ≥110 mm Hg
(grade 3 HTN) in patients with
any level of CV risk, a few weeks after or simultaneously
with initiation of lifestyle changes (I, A)
Threshold for starting treatment in the nonelderly
general population
of recommendation and its grade are stated in parentheses.
diabetes mellitus; eGFR, estimated glomerular filtration rate; HBPM, home blood pressure monitoring; HTN, hypertension; NS, no statement; SBP, systolic blood pressure; TOD, target organ damage. For ESH/ESC guidelines, the class of recommendation and level of evidence are stated in parentheses. For JNC 8 guidelines, the strength
Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; DBP, diastolic blood pressure; DM,
potential TOD
and a more detailed assessment of
evaluation of secondary causes of hypertension
than 40 years and stage 1 hypertension
For patients younger
average ABPM/HBPM ≥150/95 mm Hg
80 years
HBPM – BP ≥135/85 mm Hg
average daytime ABPM or average
BP ≥140/90 mm Hg + subsequent
80 years
SBP ≥140 mm Hg and/or DBP ≥90 mm Hg
NICE 201110
60 years
NS
20149
CHEP
80 years
Hg or both on repeated examination
SBP ≥140 mm Hg or DBP ≥90 mm
20138
JNC 8
NS
SBP >140 mm Hg and/or DBP >90 mm Hg
20137
20136
Definition of “elderly” population
Hypertension definition
ASH/ISH
ESH/ESC
TABLE II. Hypertension Definition, Classification, and BP Thresholds
DBP 90–99 mm Hg
SBP 140–159 mm Hg or
NS
NS
201312
AHA/ACC/CDC
Editorial
BP
