Transcript Hypertension Update 2009 - PACCAR Medical Education Center

Hypertension Update 2009
Adena Health System
2009 Cardiovascular Symposium
October 2009
Key Concepts
• Hypertension is common
• Hypertension increases cardiovascular
risk
• Effective treatment confers benefit
• Lessons from recent clinical trials
• Compelling indications for certain
antihypertensive agents and blood
pressure targets
2
Epidemiology
• Over 65 million Americans age 20 and older
have HTN
• Prevalence increases with age
• Prevalence of hypertension varies by ethnic
group several-fold higher in young African
Americans
– >60% of Caucasians over 60
– >70% of African American over 60
• Primary Hypertension 95%
• Secondary Hypertension 5%
Epidemiology
• Level of BP directly correlates with
LVH/microalbuminuria
• LVH and hypertension:
• Strong predictor of sudden death and MI
• Microalbuminuria and hypertension:
(Persistent urinary albumin excretion of 30-300mg/24hrs)
• Increased risk of CVD
• Marker for endothelial dysfunction
Mortality Due to CHD per Quartile
of Usual SBP
USA
Japan
van den Hoogen et al. N Engl J Med 2000;342:1.
5
Impact of
High-Normal
BP on the
Risk of CV
Disease
Vasan RS et al.
N Engl J Med
2001;345:1291.
6
Relationship Between Hypertension and IHD Mortality
Lewington S, et al.
Lancet 2002;
360:1903–13
Update Hypertension 2009
Main Themes
• What level of BP should we achieve?
• What does the hypertension workup
consist of ?
• How should we measure BP?
• Future directions……..personalized
medicine and home monitoring !
Historical Trends in HTN
National Health and Nutrition Examination Survey
Trends in awareness, treatment, and control of high blood
pressure in adults ages 18-74
1976-1980
1988-1991
1991-1994
1994-2000
2003-2004
Awareness
51%
73%
68%
70%
75%
Treatment
31%
55%
54%
59%
65%
Control
10%
29%
27%
34%
33%
SBP < 140 mmHg and DBP < 90 mmHg
Adapted from:
Hajjar I, et al. JAMA. 2003;290:199-206.
Ong KL et al Hypertension 2007: 49;69-75
Lessons Learned from ALLHAT and ASCOT-BPLA on
specific antihypertensive agents
• Effective blood pressure control, regardless of which (or how
many) agents are employed, is paramount to reduce CV
endpoints
• Current control rates, even in idealized study populations, is
sub-par. On a practical level, whatever potential benefits or
drawbacks occur as a result of a specific property of one agent
vs. another at equivalent blood pressure levels is drowned out
by the adverse events of those that remain uncontrolled
• At equivalent levels of blood pressure control, newer agents
offer a more appealing biochemical profile… the long-term
importance of which remains to be seen
10
Factors Contributing to Poor
Blood Pressure Control
18%
Took no action
Increased dose
Changed drug
Prescribed
add-on therapy
From: Taylor Nelson Healthcare, Epson, Surrey
England - Cardiomonitor 1992
11
Blood Pressure (BP) Classification
and Management*
BP
Classification
SBP,
DBP,
mm Hg*
mm Hg*
Normal
<120
and <80
LifeInitial Drug Therapy
style
Compelling Indications
Changes
Without
With
encourage
Pre HYTN
120-139 or 80-89
Yes
No
Yesa
Stage 1 HYTN
140-159 or 90-99
Yes
Yesb
Yesc
Yes
Yesd
Yese
Stage 2 HYTN
>160
or >100
SBP=systolic BP, DBP=diastolic BP; HYTN=hypertension, ACEI=Angiotensin-converting enzyme
inhibitor, ARB=angiotensin, CCB=calcium channel blocker
* Treatment determined by highest BP category
a Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg
b Thiazide-type diuretics for most; may consider ACEI, ARB, b-blocker, CCB or combination
c Other antihypertensive drugs (diuretics, ACEI, ARB, b-blocker, CCB) as needed
d Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or b-blocker of CCB.
Initiation of combined therapy should be used cautiously in those at risk for orthostatic hypotension.
e Other antihypertensive drugs (diuretics, ACEI, ARB, b-blocker, CCB) as needed.
JNC VII. JAMA 2003;289:2560.
What is the optimal target BP level…….
normal kidney donors?
Rafey et al
NKF 2008
Goals of the Hypertensive
Evaluation
• Does the patient have primary or
secondary (reversible) hypertension?
• Is target organ damage present?
• Are other cardiovascular (CV) risk
factors present?
14
JNC 7 Recommendations for Routine
Work-up of Hypertensive Patients
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
JNC 7 Recommendations for Routine
Work-up of Hypertensive Patients
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
Secondary Causes of Hypertension:
Renovascular Disease
Clinical Clues
Diagnosis
Treatment
Abrupt onset
<30 or >55 years of age
Refractory to 3-drug regimen
Evidence of diffuse vascular
disease
ARF with ACEI
Accelerated retinopathy
Epigastric bruit
Duplex renal
arteries
Captopril
renography
MRA
Angiogram
Renal vein renin
Angioplasty/stent
Surgery
Medical treatment
1
7
Etiologies for Secondary Hypertension
Renal
Renal parenchymal
Renal artery stenosis
Obstruction
PCKD
Other
Pre-eclampsia
Acute intermittent porphyria
Thyroid (hyper, hypo)
Drugs
Hypercalcemia
Endocrine
Cushing’s syndrome
Adrenogenital syndrome
Pheochromocytoma
Adrenal and adrenal-like
Acromegaly
Liddle’s syndrome, Gordon’s
syndrome
Coarctation of
Aorta
Secondary Hypertension
Chronic Kidney Disease and
hypertension:
• Present in more than 80% of patients
• Mechanism: Excessive salt retention and
increased peripheral resistance
– Exacerbates proteinuria
– Accelerated progression of CKD
• ACEI and ARBs slow progression of CKD
Angioplasty and Stent for
Renal Artery Lesions
ASTRAL
Cardiovascular Outcomes in
Renal Atherosclerotic Lesions
CORAL
www.coralclinicaltrial.gov
23
New Features
and Key Messages
• For persons over age 50, SBP is a more important
than DBP as CVD risk factor.
• Persons who are normotensive at age 55 have a 90%
lifetime risk for developing HTN.
• Starting at 115/75 mm Hg, CVD risk doubles with
each increment of 20/10 mm Hg throughout the BP
range.
• Those with SBP 120–139 mmHg or DBP 80–89 mm
Hg should be considered prehypertensive who
require health-promoting lifestyle modifications to
JNC VII
prevent CVD.
24
New Features and
Key Messages (Continued)
• Thiazide-type diuretics should be initial drug therapy
for most, either alone or combined with other drug
classes.
• Certain high-risk conditions are compelling
indications for other drug classes.
• Most patients will require two or more
antihypertensive drugs to achieve goal BP.
• If BP is >20/10 mmHg above goal, initiate therapy
with two agents, one usually should be a thiazideJNC VII
type diuretic.
25
Combination Therapy Needed to
Achieve Target SBP Goals
Trial/SBP Achieved
UKPDS (144 mm Hg)
RENAAL (141 mm Hg)
ALLHAT (135 mm Hg)
IDNT
(138 mm Hg)
HOT
(138 mm Hg)
INVEST (133 mm Hg)
ABCD
(132 mm Hg)
MDRD
(132 mm Hg)
AASK
(128 mm Hg)
1
2
3
Number of BP meds
Updated from Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
4
RAS Inhibitor use in Hypertensive
Blacks
• ACEIs/ARBs should be considered first line in patients (including
blacks) with nephropathy (esp. with proteinuria) and or heart failure
• Available data suggest that RAS inhibitors are less effective in
lowering BP in black hypertensives in the absence of adequate
doses of a diuretic or CCB (and in preventing clinical outcomes)
• ACEI also carry increased risk of angioedema , esp. in blacks
• In the absence of HF or CKD, particularly in Black hypertensives,
beta blockers, ACEI,and ARBs(and presently renin inhibitors) should
be prescribed only in combination with thiazide-type diuretics or
calcium channel blockers
Blood pressure measurement…
• Recognize the diagnostic limitations of
traditional office blood pressure
measurement..
• 24hr ambulatory BP measurement:
diagnostic utility and clinical correlations…
• Understand the physiology of the arterial
waveform, central BP measurement, vascular
stiffness indices and pulsology in clinical
practice
Center for Blood Pressure Disorders
Clinical Program: Goals
• Accurate BP Measurement
• Comprehensive Vascular Evaluation
Reduction of WCE in Clinical
180 –
Practice
170 –
Blood Pressure (mmHg)
160 –
152
150 –
140
140 –
134
132
130 –
120 –
110 –
100 –
90 –
80 –
0–
87
80
Research
Family
Physician Technician
Myers M, et al, Journal of Hypertension 2009 27(2) 280-286
75
BpTRU
77
Ambulatory
BP
n=309
BpTRU
• White coat effect
• Work in progress
Comprehensive Evaluation of
Hypertension
Nurse/MA
BpTRU
Peripheral
BP
Sphigmocor
Central BP
/PWV
Retinal
Exam
ABI
Urine protein
TOD
PVD
TOD
Limited Echo
TOD
Physician Evaluation
Lab Review
H&P
•Dyslipidemia
•Fasting
plasma
glucose
Comprehensive Management Plan Based on Risk Estimates
24 Hour Ambulatory Blood Pressure Monitoring
HBPM: New Recommendations
May 2008
Indications for 24 Hour ABPM
Clinical situations in which ABPM may be
helpful:
• Rule out white-coat HTN
• Apparent drug resistance (office resistance)
• To better define resistant HTN
• Hypotensive symptoms with
antihypertensives
• Episodic hypertension
• Autonomic dysfunction
Dipping Pattern and Decline in GFR
•322 consecutive patients
•137 dippers
•185 nondippers
•Follow-up 3.2 yrs
•Dippers mean change in GFR
1.3%
•Nondippers mean change in GFR
15.9% (P<0.001)
Davidson et al Arch Intern Med. 2006;166:846-852
Prevalence of Nocturnal Hypertension
in AASK Study
24 Hour Ambulatory Blood Pressure Monitoring
Measures of Arterial Stiffness
•
Central Aortic Pressure
•
Pulse Wave Velocity (PWV)
•
Augmentation Index (AIx)
How PWV is measured...
85 mm
FEMORAL
CAROTID
690 mm
55 msec
135 msec
EKG-QRS
EKG-QRS
Velocity = Distance/Time
QRScarotid
QRSfemoral
 time
Notchcarotid
Notchfemoral

distance
Aortic PWV
(distance/time)
55 msec
135 msec
80 msec
85 mm
690 mm
605 mm
7.6 m/sec
APWV measurement (cont.)
Aortic Stiffening and Early Wave
Reflection
Young compliant arteries : Normal PW velocity (8 m/sec)
Systole
Diastole
(1) Ventricular-Vascular coupling
(2)  coronary blood flow
Elderly stiff arteries with ISH : Increased PW velocity (12 m/sec)
Systole
(1) Ventricular-vascular mismatch
(2) The reflected wave increases or “augments” central SBP during late systole:
SphygmoCor
• Arterial stiffness measures
– CBP (central BP)
– AIX (Augmentation Index)
– PVW(Pulse wave velocity)
•
? Evidence to change management?
•
Does depend on accurate peripheral blood pressure measurement eg: BPtru /
manual BP
•
How to incorporate it with out interfering with the work flow?
TOP: Brachial (solid symbols)
and derived central aortic (open
symbols) systolic blood
pressure with time (mean, 95%
CI) for patients randomized to
receive atenolol ± thiazide- or
amlodipine ± perindopril-based
therapy.
BOTTOM: Systolic blood
pressure difference (brachial
minus central aortic; mean,
95% CI) with time. For
calculation of AUC, see the
Data Supplement. Numbers
below abscissa represent the
number of patients seen at
each time point. Time
represents the duration from
randomization into ASCOT to
patient follow-up visit at which
tonometry measurement was
made in the CAFE study.
PP indicates pulse pressure.
CAFE Investigators, for ASCOT Investigators. Circulation 2006;113:1213.
CAFÉ Study Results
AIx in CKD vs. non CKD
60
50
AIx (%)
40
30
20
10
0
-10
0
Non-CKD
CKD
1
CKD vs. non-CKD
•
•
AIx was significantly higher in the non-CKD patients compared to the CKD
patients (median AIx 27 % [18, 32] vs. 21 % [14, 29], P = 0.002).
AIx was similar in the CKD and non-CKD groups after adjusting for age,
gender, height, SBP and eGFR
40
30
20
10
0
R = 0.24, P <0.0001
-10
(%)
Augmentation
Augmentation Index
Index
50
60
Linear Regression of AIx by SBP
Female
Male
80
100
120
140
160
SBP
P_SP
180
200
220
30
20
10
0
-10
Augmentation Index
40
50
60
Linear Regression of AIx by PPP
Female
Male
20
40
60
80
P_PP
100
120
Future Developments in
Hypertension
Personal medicine
Home BP monitoring
Corin Variants in African-Americans with
Hypertension and Heart Disease
enzyme
enzyme
T555I
Q568P
cell membrane
Dries et al. Circulation 2005;112:2403
Wang et al. Circ Res 2008;103:502
Home Blood Pressure Monitoring
Graph from the daily readings
Internet Based Hypertension Clinic Program:
Achieve individual blood pressure goals
Secure Data
Transfer
Wireless/USB
Hypertension
Clinic Review
Phone/email:
CONTROLLED BLOOD PRESSURE
•Titrate medication dose
•Add medications
The EverOnTM
System
• Not another monitor, a
Patient Supervision
System
–
Continuously observes patient’s:
cardiac, respiratory, and motion status
–
Alerts nurses when attention is needed
–
Empowers more effective physician
decisions including earlier discharge
–
Improves documentation
“There is a clear, present and immediate
need for an innovative, high tech system that
can automatically, and without imposing
upon patient comfort, track movement and
vital signs and warn of possible life
threatening situations.”
Mark Meyers, President of California
Hospital Medical Center
Blood Pressure Monitoring –
Preliminary Data
Mean Blood Pressure
Vs. PTT from ECG
Mean Blood Pressure
Vs. PTT from EverOn
110
Baseline
Max Effort
Recovery
105
BP (mmHg)
BP (mmHg)
105
100
95
90
85
80
240
220
Baseline
Max Effort
Recovery
PTT EverOn (ms)
110
PTT from ECG
Vs. PTT from EverOn
100
95
90
85
250
260
270
280
215
Baseline
Max Effort
Recovery
210
205
200
195
80
190
200
210
PTT (ms)
220
230
190
240
PTT (ms)
250
260
270
280
PTT ECG (ms)
PTT ECG [ms]
PTT EverOn
[ms]
MAP
[mmHg]
SBP
[mmHg]
DBP
[mmHg]
Baseline
(rest)
282.3±17.6
-
81±4.7
123.9±4.4
62.1±6.4
Maximal
Effort
264.6±15.3
Δ=-17.7±4.4
Δ=-11.9±0.6
95.2±6.5
Δ=+14.2
138.8±9.2
Δ=+14.9
68±4.4
Δ=+5.9
Recovery
280.4±15.5
Δ=-1.9±5.8
Δ=-0.7±6.8
80.5±6
Δ=-0.5
125.8±9.9
Δ=+1.9
55.2±5.6
Δ=-6.9
Take Home Points …
Hypertension Update 2009
• Hypertension is sub optimally controlled in
the US
• Target BP may be lower than traditionally
thought
• Resistant hypertension should trigger a
workup for secondary causes
• Methods for BP measurement are evolving
• Home monitoring is the future for BP
management