Transcript Blood Pressure Control at The Department of Veterans Affairs

Meeting of the Balkan Excellent Centers
“Insights in resistant hypertension and
Erectile dysfunction and hypertension”
Michael Doumas
Internist
Aristotle University
Thessaloniki, Greece
Abstract
Two large projects are currently underway in our department: a) IRIS project (Insights in
ResIstant hypertenSion), and b) EROS project (ERectile dysfunctiOn and hypertenSion).
The IRIS project aims to evaluate several aspects of the current management of resistant
hypertension and additionally to identify ideal candidates for interventional therapy. We
focus on use of out-of-office blood pressure measurements, lifestyle modification, drug
adjustment, and the effort to simplify a diagnostic algorithm for the exclusion of primary
aldosteronism, the most common cause of secondary hypertension in patients with
resistant hypertension. Finally, we evaluate several tests as potential predictors of
response to interventional therapy.
The EROS project aims to evaluate the prevalence of sexual dysfunction in patients with
hypertension, cardiovascular risk factors, and overt cardiovascular disease. In addition,
we aim to identify contributing pathophysiological factors and to evaluate the effect of
antihypertensive drugs on sexual function, especially when used in combination. Finally,
we try to evaluate the role of sexual dysfunction in cardiovascular disease prediction and
the best way to identify asymptomatic coronary artery disease in hypertensive patients
with recent onset sexual dysfunction.
IRIS project
Insights in ResIstant hypertenSion
Evaluation and management of
Resistant Hypertension
• Measurement
• Adherence to treatment
• Lifestyle
• Drug-induced
• Secondary hypertension
• Drug therapy adjustments
Doumas, Int J Hypertens 2011
Truly resistant hypertension
ABPM or HBP
• Brown
2001
85/118
72%
• Muxfeldt
2005
313/497
63%
• Douma
2008
192/289
67%
• De Souza
2010
175/236
75%
• De la Sierra
2011
8295
62,5%
• Douma
2008
1.286/1.913
66%
Prevalence of primary aldosteronism
in patients with resistant hypertension
30
(%)
25
22
20
20
19
17
15
11
10
7
5
0
Birmingham
USA
Seattle
USA
Oslo
Prague
Norway Czech Rep.
Shanghai
China
Thessaloniki
Greece
Calhoun DA, Annu Rev Med 2013; 64: 233-247
Douma, Lancet, 2008
Doumas M. In Tsioufis, Schmieder, Mancia, eds, book 2016; in press
Patients with clinical suspicion for primary aldosteronism (PA)
•Resistant hypertension
•Moderate-severe hypertension
•Hypokalemia (spontaneous or induced)
•Adrenal incidentaloma
Screen (ARR)
ARR>30
and aldosterone >15 ng/dl
ARR<30
Exclude PA
Confirmation (Fludrocortisone, IV saline, Captopril, Oral sodium loading)
Unsuppressed
aldosterone
Suppressed aldosterone
Exclude PA
Lateralization (AVS, Imaging, Scintigraphy)
Bilateral
MRAs
Unilateral
Adrenalectomy
or
MRAs in patients ineligible for, or unwilling, surgery
EROS project
ERectile dysfunctiOn and hypertenSion
Pathophysiology of sexual dysfunction
Atheromatic
lesions resulting
in vascular
insufficiency
and subsequent
erectile
dysfunction
Doumas, Porto Heli 2016
Manolis, J Hypertens 2008
Prevalence of erectile dysfunction
Hypertensives
9%
14%
Severe
Moderate
Mild
None
12%
65%
2%
x2=35.92
5%
p<0.001
7%
Severe
Moderate
Mild
None
86%
Normotensives
Doumas et al,
J Androl, 2005
Data from everyday clinical practice
34
30
26
22
18
14
10
6
Diuretics
B-blockers Ca-antag
Doumas et al,
J Androl, 2005
Ace-inh
ARBs
Erectile function score
switch from b-blockers to nebivolol
30
Doumas et al,
Asian J Androl 2006
p=0.002
p=0.002
20
22,09
17,22
10
0
Before
After
Patients on
antihypertensive medication
Lifestyle
modification
add PDE-5
unless
contraindicated
*unless contraindicated and/or
current treatment absolutely indicated
Curr Hypertens 2012
ED
No ED
Continue
current
treatment
Manolis, Doumas,
Substitute with
ARBs or
nebivolol *