Board Basics 3: Errata and Revisions

(Updated November 2015)

Corrections and changes have been made in the Board Basics 3 App.

The Eighth Joint National Committee (JNC 8) Hypertension Management Guidelines

The Eighth Joint National Committee (JNC 8) guidelines for the management of high blood pressure were published in late 2013 and provide evidence-based recommendations for treatment of patients with hypertension. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. Erratum in: JAMA. 2014;7;311(17):1809. [PMID: 24352797]

Primary JNC 8 recommendations are summarized below:

1. In the general adult population <60 years of age, pharmacologic treatment is recommended when the systolic BP is ≥140 mm Hg or the diastolic BP is ≥90 mm Hg. The goal of therapy should be <140/90 mm Hg.
2. In patients ≥60 years of age, therapy is recommended if the systolic BP is ≥150 mm Hg or the diastolic BP is ≥90 mm Hg. The goal of treatment is <150/90 mm Hg, although patients with a BP of <140/90 mm Hg on well-tolerated therapy do not need to have their treatment changed.
3. The initiation threshold and goal for pharmacologic treatment in those ≥18 years of age with diabetes mellitus or chronic kidney disease is 140/90 mm Hg (which differs from the previously recommended level of 130/80 mm Hg). The American Diabetes Association (ADA), however, recommends a threshold and goal of 140/80 mm Hg in patients with diabetes mellitus.
4. In the general non-black population, thiazide diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) all may be considered for initial treatment of hypertension, and all reduce the complications of hypertension. The JNC 8 guidelines include patients with diabetes mellitus in this recommendation.
5. For black patients, initial therapy should be a thiazide diuretic or CCB, including those with diabetes mellitus. As a group, black patients have less BP reduction with equivalent ACE inhibitors dosing compared with non-black patients. Furthermore, black patients initially treated with ACE inhibitors rather than CCBs have about a 50% higher rate of stroke, and combined cardiovascular outcomes are better with a thiazide diuretic than with an ACE inhibitor.
6. For all patients (regardless of race or the presence or absence of diabetes mellitus) >18 years of age with chronic kidney disease (including those with and those without proteinuria), initial therapy should be an ACE inhibitor or ARB because these agents are renoprotective and improve renal outcomes. In black patients with chronic kidney disease but without proteinuria, the initial agent can be a CCB, thiazide diuretic, ACE inhibitor, or ARB. If the initial choice is not an ACE inhibitor or ARB, then one of these should be the second drug added if necessary to lower the BP to target (<140/90 mm Hg).
7. An ACE inhibitor and an ARB should not be used together.

Please reference the JNC 8 guideline summary provided above when reviewing the following MKSAP 16 Board Basics 3 content:

Cholesterol Management Guideline Updates

In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) jointly released new cholesterol guidelines, supplanting the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines published in 2002. The major changes from the previous guidelines are outlined below.

Cardiovascular risk assessment: In patients 20-79 years of age, assess traditional cardiovascular risk factors every 4-6 years; in those 40-79 years, estimate the 10-year risk using the Pooled Cohort Equations. (A calculator based on these equations is available here: http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp.) If low-risk (<7.5%), advise lifestyle interventions. For 10-year risk ≥7.5%, assess blood cholesterol and obesity measures if indicated. (Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print] [PMID: 24222018])

Cholesterol management: Compared with ATP III, the new recommendations base treatment of hyperlipidemia on a person’s risk for developing atherosclerotic cardiovascular disease (ASCVD) instead of the level of LDL cholesterol or other lipid measurement. (Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print] [PMID: 24222016])

The four groups expected to benefit from statin therapy include patients who have any of the following:

• Clinical ASCVD
• LDL cholesterol ≥190 mg/dL (4.92 mmol/L)
• Diabetes mellitus and age 40 to 75 years with an LDL cholesterol of 70 to 189 mg/dL (1.81-4.90 mmol/L) and no ASCVD
• No ASCVD or diabetes and estimated 10-year ASCVD risk ≥7.5%

The 10-year risk for ASCVD is estimated by using the Pooled Cohort Equations, which were derived from data from multiple longitudinal study databases, including the Framingham cohort.

For patients in any one of the four statin benefit groups, therapy with a statin is indicated, with the intensity determined by specific group, age, whether the LDL cholesterol is ≥190 mg/dL (4.92 mmol/L), and the 10-year risk for ASCVD.

• High-intensity statin therapy is recommended for patients with LDL cholesterol of ≥190 mg/dL (4.92 mmol/L) if <75 years of age; ASCVD if <75 years of age; or diabetes if 40-75 years of age with an LDL cholesterol of 70 to 189 mg/dL (1.81-4.90 mmol/L) and 10-year ASCVD risk ≥7.5%.
• Moderate-intensity statin therapy is recommended for patients with ASCVD if >75 years of age; or in patients with diabetes if 40-75 years of age with an LDL cholesterol of 70-189 mg/dL (1.81-4.90 mmol/L) and 10-year risk <7.5%. Patients without an LDL cholesterol of ≥190 mg/dL (4.92 mmol/L), ASCVD, or diabetes, but who have 10-year risk ≥7.5%, should be treated with moderate- to high-intensity statin therapy depending on the presence of comorbidities.
• For patients with LDL cholesterol levels <190 mg/dL (4.92 mmol/L) who are not in one of the above groups, additional risk factors as well as physician and patient preference may be considered to inform treatment decisions. For example, the physician and patient may decide together to initiate statin therapy if the patient has a strong family history of ASCVD, even if the patient is not in one of the four statin benefit groups.

High-intensity statin therapy lowers LDL cholesterol on average by approximately ≥50%. Moderate-intensity statin therapy lowers LDL cholesterol on average by approximately 30% to ≤50%.

Statins are preferred for therapy since they were used in the primary trials showing benefit from pharmacotherapy, and there is less evidence for using other lipid-lowering drugs, including fibrates, niacin, bile acid sequestrants, and ezetimibe. Despite the limited evidence for the use of these non-statin drugs, they are sometimes prescribed when patients are intolerant of statins.

This major change from previous cholesterol guidelines was prompted by the observation that the key studies showing the benefit of treating hyperlipidemia used fixed doses of statins and did not vary these doses to reach specific target LDL cholesterol levels, the beneficial effects of statin therapy were not related to pretreatment LDL cholesterol levels, and those with the greatest benefit were those at high risk for ASCVD even if LDL cholesterol was not high. For patients at low risk for ASCVD, benefit was limited even if the LDL cholesterol was significantly elevated. Therefore, the new guidelines recommend that treatment decisions be based on the patient's likely benefit rather than on a pretreatment or target LDL cholesterol level.

ATP III recommendations state that the metabolic syndrome should be considered a secondary target for risk reduction therapy, but metabolic syndrome was not specifically addressed in the 2013 ACC/AHA guidelines.

Please reference the ACC/AHA cholesterol management guideline summaries provided above when reviewing the following MKSAP 16 Board Basics 3 content:

Cardiovascular Medicine

Page 14: Chronic Stable Angina, Prevention: "Treatment is indicated to achieve the following goals: LDL cholesterol <100 mg/dL, blood pressures <140/90 mm Hg, and hemoglobin A1c <7%." (Added June 2014)

Page 49: Peripheral Arterial Disease, Therapy (Added June 2014)

Endocrinology and Metabolism

Page 73: Diabetes Mellitus, Therapy, Study Table: Treatment of Type 1 and Type 2 Diabetes Mellitus: Row discussing "Hypertension" (Added June 2014)

Page 73: Diabetes Mellitus, Therapy, Study Table: Treatment of Type 1 and Type 2 Diabetes Mellitus: Rows discussing "High serum total cholesterol level" and "High serum LDL-cholesterol level" (Added June 2014)

Page 78: Hyperlipidemia, Screening (Added June 2014)

Page 78-79: Hyperlipidemia, Diagnosis (Added June 2014)

General Internal Medicine

Page 129, Study Table: Routine Adult Immunizations: the "Pneumococcal" row should now appear as two rows and should read:

In October, 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendations for pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functional asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions are defined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, the nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiple myeloma. For adults ≥19 years of age with an immunocompromising condition, functional asplenia, a CSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial dose of 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose of PPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic or functional asplenia or with an immunocompromising condition. For adults ≥19 years of age with immunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants who have previously received at least one dose of PPSV-23, a single PCV-13 dose should be given ≥1 year after their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccination should receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed since their last PPSV-23 dose. (Added April 2013)

Page 133: Hypertension, Diagnosis (Added June 2014)

Page 133: Hypertension, Drug Therapy (Added June 2014)

Page 135, Test Yourself: In the diagnosis of primary aldosteronism, the measurement should be plasma aldosterone to renin activity ratio. Plasma renin activity to aldosterone ratio is incorrect. (Added November 2014)

Infectious Disease

Page 174, under Therapy of Hospital-Acquired and Ventilator-Associated Pneumonia, in the second-to-last sentence in the paragraph, indicating therapy for Pseudomonas aeruginosa, ceftriaxone should be replaced with ceftazidime. (Added June 2014)

Page 175, the Test Yourself Answer should say, "Diagnose HAP and prescribe vancomycin and ceftazidime." (Added June 2014)

Page 197, Study Table: Common ART Side Effects, tenofovir should be classified as an NRTI, not an NNRTI. (Added June 2014)

Page 198, Study Table: Prophylaxis for Patients with HIV Infection: The table row for "Pneumococcal pneumonia" should read:

See new information above clarifying the use of pneumococcal vaccination in patients with immunocompromising conditions. (Added April 2013)

Nephrology

Page 205, Study Table: Compensatory Response to a Primary Acid-Base Disturbance, the "Metabolic alkalosis" row, under "Expected Compensation" should state, "0.7 mm Hg ↑ in arterial PCO₂ for each 1 meq/L ↑ in [HCO₃–]" (Added June 2015)

Page 207: The first two paragraphs under Hyponatremia, Diagnosis should be replaced with the following:

"The first step in assessing low serum sodium is determining if true hyponatremia is present. Pseudohyponatremia is a laboratory artifact caused by severe hyperlipidemia or hyperproteinemia, which leads to a report of an inappropriately low serum sodium level. In pseudohyponatremia, the measured osmolality is normal and the observed increased osmolal gap cannot be accounted for by the presence of an osmotically active solute.

If true hyponatremia exists, classify it as hyperosmolar or hypo-osmolar. Hypertonic hyponatremia is caused by the presence of an osmotically active substance such as glucose (most common), BUN, alcohols, mannitol, sorbitol, or glycine, which expands the extracellular volume and lowers the serum sodium concentration.

Hypo-osmolar hyponatremia is the most common form and is further classified based on the patient’s volume status." (Added April 2013)

Page 207, Study Table: Evaluating Hypo-osmolar Hyponatremia, under the Differential Diagnosis column heading: the first cell should read, "GI or kidney fluid losses, dehydration, mineralocorticoid deficiency" and the third cell should read, "SIADH, hypothyroidism, glucocorticoid deficiency" (Added June 2014)

Page 214, Study Table: Drug Therapy for CKD: the second row of the table should read: "Serum protein-creatinine ratio ≥0.2 mg/mg" (Added June 2014)

Page 214: Chronic Kidney Disease, Therapy, Study Table: Drug Therapy for CKD: Rows discussing "Serum protein-creatinine ratio ≥200 mg/mg" and "Lipids" ACC/AHA guidelines (Added June 2014)

Oncology

Page 248, Study Table: Colon Cancer Screening, the second row under "Risk Profile" should state, "First-degree relative with colon cancer at age ≤50 years" (Added June 2015)

Pulmonary and Critical Care Medicine

Page 280, the COPD Therapy paragraph before "Don't Be Tricked" bullets: the first sentence should read: "All patients with COPD require smoking cessation (to slow loss of lung function), annual influenza vaccination, and pneumococcal vaccination according to current guidelines."

See new information above clarifying the use of pneumococcal vaccination in patients with immunocompromising conditions. (Added April 2013)