SPRINT Arrives in the Canadian Hypertension World: The 2016 CHEP Guidelines

HTC_Logo_2015_PMSThe big hypertension, and even nephrology, story of 2015 was the release of the SPRINT trial. The Systolic Blood Pressure Intervention Trial (SPRINT) trial compared an intensive systolic blood pressure (BP) target of 120 mm Hg to a standard target of 140 mm Hg in patients at high cardiovascular risk. It was halted early after interim analyses showed a significant decrease in cardiovascular events and all-cause mortality in the intensive arm.  Though there has been fierce discussion of where we go from here given that the prevailing trend of softening BP targets (eg, JNC 2014 recommended a target of 140 mm Hg for most and 150 mm Hg for elderly, ESH/ESC recommended 140 mm Hg for everyone), the early release of SPRINT results has not been accompanied by a similar change in treatment guidelines. The exception is the Canadian Hypertension Education Program (CHEP) guidelines, which are updated annually (see previous blog coverage here).

  CHEP 2015 JNC 8 ESH/ESC 2013 KDIGO 2012
Non-proteinuric CKD 140/90 140/90 140/90 140/90
Proteinuric CKD 140/90 140/90 140/90 130/80
Diabetic, non proteinuric CKD 130/80 140/90 140/90 140/90
Diabetic, proteinuric CKD 130/80 140/90 140/90 130/80
Elderly 150/901 150/902 140/90 Individualized tailored treatment

Table 1: The state of hypertension guidelines pre-SPRINT (numbers refer to blood pressure target in mm Hg)

1 Elderly defined as > 80 years age, non-diabetic, with no CKD

2 Elderly defined as > 60 years age

At the Canadian Hypertension Congress, CHEP updated the guidelines, but following the release of SPRINT findings, an additional expedited review was conducted to incorporate its findings in the 2016 recommendations.  To recap, there were three new recommendations for diagnosis:

  • Automated office blood pressure (AOBP), taken without patient-health provider interaction using a fully automated device is the preferred method of measuring in-office BP (see #NephMadness coverage of this topic here).
  • A non-fasting lipid panel is acceptable as part of the routine panels (previously fasting lipids were required).
  • In patients with secondary hypertension arising from primary hyperaldosteronism being considered for potential adrenalectomy, assessment for lateralization should be done using adrenal vein sampling.

For treatment, the one new recommendation so far had been to consider an increase in dietary potassium as a means to lower blood pressure (see our coverage from #KidneyWk for why that makes sense). Furthermore, the expedited review of the SPRINT findings have resulted in an additional treatment recommendation:

For high-risk patients, aged ≥50 years, with systolic BP levels ≥ 130 mmHg, intensive management to target a systolic BP ≤ 120 mmHg should be considered. Intensive management should be guided by AOBP.  Patient selection for intensive management is recommended and caution should be taken in certain high-risk groups.

What is considered high risk? At least one of:

  • Clinical or sub-clinical cardiovascular disease.
  • Chronic kidney disease (non-diabetic nephropathy, proteinuria <1 g/d, or estimated glomerular filtration rate 20-59 mL/min/1.73m2).
  • Estimated 10-year global cardiovascular risk >15%.
  • Age ≥ 75 years.

Patients with one or more clinical indications should consent to intensive management. In addition, CHEP suggests caution in certain groups:

Limited or No Evidence 

  • Heart failure (ejection fraction <35%) or recent myocardial infarction (within last 3 months).
  • Indication for, but not currently receiving, a beta-blocker.
  • Frail or institutionalized elderly.

Inconclusive evidence

  • Diabetes mellitus.
  • Prior stroke.
  • eGFR < 20 mL/min/1.73 m2.

Contraindications

  • Patient unwilling or unable to adhere to multiple medications.
  • Standing SBP <110 mmHg.
  • Inability to measure SBP accurately.
  • Known secondary cause(s) of hypertension.
  CHEP 2015 JNC 8 ESH/ESC 2013 KDIGO 2012
Non-proteinuric CKD 140/90 140/90 140/90 140/90
Proteinuric CKD 140/90 140/90 140/90 130/80
Diabetic, non proteinuric CKD 130/80 140/90 140/90 140/90
Diabetic, proteinuric CKD 130/80 140/90 140/90 130/80
Elderly 150/901 150/902 140/90 Individualized tailored treatment
Select high risk patients3 SBP 120      

Table 2: The state of hypertension guidelines post-SPRINT (numbers refer to blood pressure target in mm Hg) so far

1 Elderly defined as > 80 years age, non-diabetic, with no CKD

2 Elderly defined as > 60 years age

3 See text for definition of high risk, and patient populations in whom caution is suggested

The full paper is available here, and details and educational material will soon be available at the Hypertension Canada website.

Dr. Swapnil Hiremath
AJKD Blog Contributor

Disclosure: SH is a member of the task force for the Canadian Hypertension Education Programme. The opinions expressed here are that of the author, and do not represent the CHEP guidelines or process.

 

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