Managing Blood Pressure in Adults

238 Pages·2014·5.03 MB·English

Managing
Blood Pressure
in Adults

Systematic Evidence Review From the
Blood Pressure Expert Panel, 2013

Contents
Foreword ............................................................................................................................................ vi
Blood Pressure Expert Panel .............................................................................................................. vii
Section 1: Background and Description of the NHLBI Cardiovascular Risk Reduction Project ............ 1
A. Background .............................................................................................................................. 1
Section 2: Process and Methods Overview ......................................................................................... 3
A. Evidence-Based Approach ....................................................................................................... 3
i. Overview of the Evidence-Based Methodology ................................................................. 3
ii. System for Grading the Body of Evidence ......................................................................... 4
iii. Peer-Review Process ....................................................................................................... 5
B. Critical Question–Based Approach ........................................................................................... 5
i. How the Questions Were Selected ................................................................................... 5
ii. Rationale for the Questions Selected ................................................................................ 5
Section 3: Inclusion/Exclusion Criteria for the Evidence Review ......................................................... 7
A. Literature Search Yield ............................................................................................................. 8
B. Populations Addressed in This Report ..................................................................................... 8
C. Definition of High Blood Pressure or Hypertension ................................................................... 8
D. Limitations ................................................................................................................................ 9
Section 4: Evidence Statements for Critical Question 1 (Pharmacotherapy and BP
Thresholds) .................................................................................................................................. 11
Section 5: Evidence Statements for Critical Question 2 (Pharmacotherapy Treatment and
BP Goals) .................................................................................................................................... 19
A. Statements for the General Population................................................................................... 19
B. Statements for the Population With Chronic Kidney Disease ................................................. 25
C. Statements for the Population With Diabetes ......................................................................... 28
Section 6: Evidence Statements for Critical Question 3 (Antihypertensive Agents) ........................... 33
A. Statements for the General Population................................................................................... 33
i. Summary of Evidence Statements for the General Population ........................................ 33
B. Other Drug Classes ................................................................................................................ 37
i. ACEIs Versus Other Drugs ............................................................................................. 38
ii. ARBs Versus Other Drugs .............................................................................................. 39
iii. Thiazide and Thiazide-Type Diuretics Versus Other Drugs ............................................. 40
iv. Beta Blockers Versus Other Drugs ................................................................................. 48
v. Calcium Channel Blockers Versus Other Drugs .............................................................. 50
vi. Combination Therapy ...................................................................................................... 52
vii. Other Drug Classes ........................................................................................................ 53
C. Statements for the Population With Chronic Kidney Disease ................................................. 54
i. Comments on Other Studies That Met the Eligibility Criteria But Were Not
Addressed in the Above Evidence Statements ................................................................ 56
D. Statements for the Adult Population With Diabetes ................................................................ 57
i. Diuretic Evidence Statements in Diabetes ...................................................................... 57
ii. Beta Blocker Evidence Statements in Diabetes .............................................................. 59
iii. Angiotensin-Converting Enzyme Inhibitors Evidence Statements in Diabetes ................. 60
iv. Calcium Channel Blockers Evidence Statements in Diabetes ......................................... 61
MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013 iii
v. Combination Therapy in Diabetes ................................................................................... 62
vi. Evidence Statements for Blacks With Diabetes ............................................................... 63
Appendix A: Methods ................................................................................................................ A–1
Appendix B: Development of Evidence Tables and Summary Tables ....................................... B–1
Appendix C: Search Strategy Overview and Syntax of Queries .................................................C–1
Appendix D: Summary Tables ..................................................................................................D–1
Appendix E: Abbreviations and Acronyms ................................................................................ E–1
Appendix F: Names of Studies .................................................................................................. F–1
References ................................................................................................................................R–1
List of Tables
Table 1. Evidence Quality Grading System ......................................................................................... 4
Table 2. Angiotensin-Converting Enzyme Inhibitors (ACEIs) Versus Calcium Channel Blockers
(CCBs) ......................................................................................................................................... 33
Table 3. ACEIs Versus Angiotensin II Receptor Blockers (ARBs) ..................................................... 33
Table 4. Beta Blockers Versus ACEIs ............................................................................................... 34
Table 5. Beta Blockers Versus CCBs ............................................................................................... 34
Table 6. Beta Blockers Versus ARBs ................................................................................................ 34
Table 7. CCBs versus ARBs ............................................................................................................. 35
Table 8. Thiazide and Thiazide-Type Diuretics Versus Beta Blockers .............................................. 35
Table 9. Thiazide and Thiazide-Type Diuretics Versus ACEIs .......................................................... 35
Table 10. Thiazide and Thiazide-Type Diuretics Versus CCBs ......................................................... 36
Table 11. Thiazide and Thiazide-Type Diuretics Versus ARBs ......................................................... 36
Table 12. Thiazide and Thiazide-Type Diuretics Versus Alpha Blockers ........................................... 36
Table 13. Combination Therapy: ACEI/CCB Versus ACEI/Diuretic ................................................... 37
Table A–1. Quality Assessment Tool for Controlled Intervention Studies ........................................ A–7
Table B–1. Evidence Quality Grading System ................................................................................ B–3
Table C–1. Examples of Simple Queries ........................................................................................ C–1
Table C–2. Attributes, Their Values, and Explanation ..................................................................... C–2
Table C–3. Common Macro Queries Used in Search Strategies .................................................... C–2
Table D–1a. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at SBP Thresholds <140 mmHg ........................................................ D–1
Table D–1b. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at SBP Thresholds >140 mmHg ........................................................ D–2
Table D–1c. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at SBP Thresholds ≥160 mmHg ........................................................ D–3
Table D–1d. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at DBP Thresholds ≥90 mmHg .......................................................... D–8
Table D–1e. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at DBP Thresholds ≥95 mmHg ........................................................ D–13
Table D–1f. Evidence From Randomized Controlled Trials on Initiating Antihypertensive
Pharmacological Therapy at Mixed SBP and DBP Thresholds ................................................ D–14
Table D–2a. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a SBP Goal of <130 mmHg ......................................................... D–16
Table D–2b. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a SBP Goal of <140 mmHg ......................................................... D–17
Table D–2c. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a SBP Goal of ≤150 mmHg ......................................................... D–19
Table D–2d. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a SBP Goal of <160 mmHg (also includes lower goals) ............. D–22
iv MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013
Table D–2e. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a DBP Goal of <80 mmHg........................................................... D–26
Table D–2f. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a DBP Goal of <85 mmHg........................................................... D–27
Table D–2g. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to a DBP Goal of <90 mmHg........................................................... D–28
Table D–2h. Evidence From Randomized Controlled Trials on Treatment with Antihypertensive
Pharmacological Therapy to Mixed SBP and DBP Goals ......................................................... D–33
Table D–2i. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to SBP Goals in Patients With Diabetes .......................................... D–35
Table D–2j. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to DBP Goals in Patients With Diabetes .......................................... D–38
Table D–2k. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to Mixed BP Goals in Patients With Diabetes .................................. D–40
Table D–2l. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to Mixed BP Goals in Patients With Chronic Kidney Disease .......... D–41
Table D–2m. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy MAP Goals in Patients With Chronic Kidney Disease ..................... D–42
Table D–2n. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to Mixed BP Goals in Patients With Chronic Kidney Disease,
Analyzed by Baseline Proteinuria Subgroups .......................................................................... D–46
Table D–2o. Evidence From Randomized Controlled Trials on Treatment With Antihypertensive
Pharmacological Therapy to MAP Goals in Patients With Chronic Kidney Disease, Analyzed
by Baseline Proteinuria Subgroups .......................................................................................... D–47
Table D–3a. Initial Treatment With Diuretics Versus Other Drugs ................................................. D–50
Table D–3a-1. Diuretic Combination Therapy Versus Other Drugs ............................................... D–60
Table D–3b. Initial Treatment With Beta Blockers Versus Other Drugs ......................................... D–62
Table D–3c. Initial Treatment with ACEIs Versus Other Drugs ..................................................... D–71
Table D–3d. Initial Treatment With Calcium Channel Blockers Versus Other Drugs ..................... D–77
Table D-3e. Initial Treatment With Angiotensin Receptor Blockers Versus Other Drugs ............... D–92
List of Figures
Figure C-1. PRISMA Diagram for Question 1.................................................................................. C–7
Figure C-2. PRISMA Diagram for Question 2................................................................................ C–12
Figure C-3. PRISMA Diagram for Question 3................................................................................ C–16

MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013 v
Foreword
In 1977, the National Heart, Lung, and Blood Institute (NHLBI) issued the first of several clinical practice
guidelines (CPGs) as part of its core mission, which is to provide global leadership for a research, training, and
education program to promote the prevention and treatment of heart, lung, and blood diseases and enhance the
health of all individuals so that they can live longer and more fulfilling lives. Guidelines from the National High
Blood Pressure Education Program, the National Cholesterol Education Program, the Obesity Education
Initiative, as well as from other similar programs and initiatives, have addressed a variety of topics, including,
but not limited to, cholesterol, blood pressure, obesity, asthma, and von Willebrand disease. Over the years,
health care systems and providers have used these guidelines for the prevention, detection, evaluation, and
treatment of cardiovascular disease (CVD) risk factors, and lung and blood diseases.
In 2008, NHLBI convened expert panels to update the existing clinical guidelines on cholesterol, blood pressure,
and overweight/obesity by conducting rigorous systematic evidence reviews. At the same time, three
crosscutting work groups—on lifestyle, risk assessment, and implementation—were convened to develop
additional systematic evidence reviews to support the work of the expert panels. The impetus for these
guidelines was the recognition that, despite the enormous progress over the last 60 years, CVD remains the
leading cause of death in the United States.
While the updates were underway, the Institute of Medicine (IOM) issued two reports that established new “best
practice” standards for generating systematic evidence reviews and developing clinical guidelines. The reports
underscore that these are two distinct, yet related, activities that require careful intersection and coordination.
Accordingly, NHLBI’s role in the guidelines updates transitioned to completing a systematic evidence review for
each topic and collaborating with other organizations to prepare and issue the related clinical guidelines.
Since implementing the new collaborative partnership model for developing guidelines based upon NHLBI-
sponsored systematic evidence reviews, four of the five Expert Panels/Work Groups have worked successfully
with the American Heart Association (AHA), the American College of Cardiology (ACC), The Obesity Society
(TOS), and other professional societies to develop new CVD prevention CPGs for lifestyle, risk assessment,
cholesterol, and obesity. The new guidelines—published in November 2013 by the AHA, ACC, and TOS, and
endorsed by other professional societies—provide a valuable updated roadmap to help clinicians and patients
manage CVD prevention and treatment challenges.
We appreciate the outstanding work and dedication of the expert panels and work groups that developed the
systematic evidence reviews that formed the basis for the guidelines. These systematic evidence reviews are the
products of one of the most rigorous evidence-based systematic reviews conducted to date. We look forward to
continuing to develop accurate and timely evidence reviews, fueled by our investment in primary research on the
prevention and treatment of CVD as well as implementation science, to improve public health.
The following systematic evidence report is available as a public resource.
Gary H. Gibbons, M.D.
Director
National Heart, Lung, and Blood Institute
vi MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013
Blood Pressure Expert Panel
Panel Co-Chairs
Paul A. James, M.D. Suzanne Oparil, M.D.
University of Iowa University of Alabama at Birmingham School of
Medicine
Members
Barry L. Carter, Pharm.D. Laura P. Svetkey, M.D., M.H.S.
University of Iowa Duke University
William C. Cushman, M.D. Sandra J. Taler, M.D.
Veterans Affairs Medical Center and the Mayo Clinic College of Medicine
University of Tennessee
Raymond R. Townsend, M.D.
Cheryl Dennison Himmelfarb, R.N., A.N.P., Ph.D. University of Pennsylvania
F.A.A.N., Johns Hopkins University School of Nursing
Jackson T. Wright, Jr., M.D., Ph.D.
Joel Handler, M.D. Case Western Reserve University
Kaiser Permanente
Ex-Officio (National Institutes of Health) Voting
Daniel T. Lackland, Dr.P.H.
Members
Medical University of South Carolina Lawrence J. Fine, M.D., Dr.P.H., F.A.H.A.
Andrew S. Narva, M.D.
Michael L. LeFevre, M.D., M.S.P.H.
University of Missouri
National Heart, Lung, and Blood Institute
Eduardo Ortiz, M.D., M.P.H.
Thomas D. MacKenzie, M.D., M.S.P.H.
Denver Health and Hospital Authority and the
University of Colorado School of Medicine Methodology Team
Olugbenga Ogedegbe, M.D., M.P.H., M.S., F.A.H.A.
Science Applications International Corporation
New York University School of Medicine Cory V. Evans, M.P.P.
Janusz Wnek, Ph.D.
Sidney C. Smith, Jr., M.D., F.A.C.C., F.A.H.A.,
F.E.S.C. RTI International
University of North Carolina at Chapel Hill Linda J. Lux, M.P.A.

MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013 vii