Transcript 2-Feldman Presentation

Hypertension
Pre-Test Questions
Which of the following statements
is NOT true?
1.
2.
3.
4.
5.
6.
Most patients who have hypertension are not at goal.
Those patients who are normotensive at age 55 have
a 90% probability of becoming hypertensive.
In persons older than 50 years, systolic blood
pressure greater than 140 mmHg is a more important
CVD risk factor than diastolic blood pressure.
Those with a systolic BP of 130-149 mmHg or a
diastolic BP of 90-99 should be considered as prehypertensive.
If blood pressure is > 20/10 mmHg above goal,
consideration should be given to initiating more than
one agent, one of which should be a thiazide-type
diuretic.
None of the above
Juan is a 31 year old Hispanic male who comes to
see you complaining of a cough and mild fatigue.
On taking his vital signs his blood pressure is noted
to be elevated to 146/92 mm Hg.
Which of the following is the most appropriate
course of action?
1. Recommend that he begin therapy with a
thiazide diuretic
2. Recommend that he begin therapy with an
ACE inhibitor or ARB
3. Recommend that he avoid salt and return for a
re-check on his blood pressure
4. None of the above
Melanie is a 47 year old obese African American female
smoker who comes in for a visit. You have taken care of this
patient for over three years. Her only other major co-morbidity
is asthma for which she takes a combination
LABD/corticosteroid inhaler. One year ago, she was diagnosed
with hypertension and started on a thiazide diuretic. This visit
her BP is 149/94 mm Hg which is consistent with her two
previous visits.
Which of the following is NOT a reasonable choice for
continuation of her care?
1.
2.
3.
4.
5.
Recommendations for lifestyle and dietary modification
Increase her dosage of the thiazide diuretic
Add an ACE inhibitor
Add a b-blocker
A and C
W.C. is a 57-year-old man with type 2 diabetes first
diagnosed 2 years ago. Other medical problems include
obesity and hypothyroidism. He has a history of heavy
alcohol use but quit drinking alcohol 2 years ago. He
presents now for routine follow-up and is noted to have a
blood pressure of 168/100 mm Hg. He is asymptomatic.
Which of the following is the most appropriate
treatment option?
1.
2.
3.
4.
5.
Begin therapy with a calcium channel blocker
Begin therapy with a combination of an ACE
inhibitor and a thiazide diuretic
Discuss lifestyle and dietary modifications
1&3
2&3
Brad is a 54-year-old obese man with moderate to severe hypertension. You
initially prescribed amlodipine and adjusted the dose upward to 10 mg/day,
but his systolic blood pressure remained considerably elevated (192/88 mm
Hg). You added atenolol, 50 mg/day, and his systolic blood pressure was
still not controlled (170/80 mm Hg). The patient takes 400 mg of ibuprofen
once or twice a day for low back pain and over-the-counter sleep aids. He
drinks alcohol in moderate amounts and smokes a pack of cigarettes a day.
Results of routine laboratory tests, including fasting plasma glucose and
lipid levels, are within normal limits. The patient has noted bothersome
pedal edema and admits to feeling somewhat depressed lately.
What would NOT be appropriate for this patient with refractory
hypertension?
1.
2.
3.
4.
5.
Recommend significant lifestyle modification including smoking
cessation.
Ask patient and family whether or not he snores.
Continue his present medications
Add a thiazide-type diuretic
Add an ACE inhibitor or ARB
Management of Patients
with Hypertension; Defining
the Barriers to Control
David Feldman, MD/PhD, FACC, FAHA
Director of Heart Failure and Cardiac
Transplantation
The Ohio State University
Learning Goals





Recognize the economic burden of
hypertension.
Understand that hypertension is an antecedent
to many cardiovascular events.
Aggressive screening and management is
required to reach the goals of the evidencebased guidelines.
Recognize some of the most important barriers
to overcome in order to improve blood pressure
control.
Explore therapeutic combinations that can
prevent disease progression and improve
morbidity and mortality.
The word Michigan means
1.
2.
3.
4.
Beautiful Lake
Beautiful Sunset
Large Lake
Majestic Resting Place
ANSWER:
The word Michigan means
1.
2.
3.
4.
Beautiful Lake
Beautiful Sunset
Large Lake
Majestic Resting Place
Derived from the Indian words, "Michi-gama"
How many miles of costal shoreline
exists in Michigan?
1.
2.
3.
4.
1,426 miles
3,126 miles
2,426 miles
Your kidding right, …am I on that show,
“Are you smarter than a fifth grader”?
ANSWER:
How many miles of costal shoreline
exists in Michigan?
1.
2.
3.
4.
1,426 miles
3,126 miles
2,426 miles
Your kidding right, …am I on that show, “Are you
smarter than a fifth grader”?
There is more fresh water coastline in Michigan than in any
other state. In addition, you cannot go anywhere in
Michigan that you are not within 85 miles of one of the
Great Lakes.
http://michigan.gov/mdot/
Your Patients
What % of the hypertensive patients in your
practice are under control based on JNC 7?
1.
2.
3.
4.
25-50%
50-75%
>75%
<25%
Significance of Hypertension
•HTN affects approximately 50 million individuals in the US and 1 billion
people worldwide.
• HTN is the most common primary diagnosis in the USA with
35 million office visits per year.
• Framingham Heart Study—Individuals who are normotensive at
55 years of age have a 90% lifetime risk of developing HTN
• Relationship between BP and risk of CVD is continuous,
consistent, and independent of other risk factors
• Only 35% of hypertensive patients on treatment are under control.
• For those age 40-70, each increased increment of 20 mmHg in
systolic BP or 10 mmHg in diastolic BP doubles the risk
of CVD across the entire BP range of 115/75 to 185/115.
JNC 7: U.S.

90% lifetime risk for men who reach age
55 and women who reach age 65.

Prevalence is 33.1% (65 million).

2004 direct costs = $55.5 Billion

If co-morbidities are added (ESRD, CAD,
CHF, DM, CVA) cost is $108 Billion.
JNC 7 U.S.; Are you Surprised?

30% of adults do not know they have
hypertension.

40% of those who are hypertensive are
not on treatment.

66% of those who are being treated
have a BP greater than 140/90 mmHg.
Co-morbidities
Which of these co-morbidities are most
prevalent in your practice?
1.
2.
3.
4.
Diabetes
Heart Failure
Renal Insufficiency
Coronary Artery Disease
Benefits of Lowering Blood Pressure
•Anti-HTN Therapy associated with:
• 35 – 40% mean decrease in stroke
• 20 – 25% decrease in MI
• More than 50% decrease in HF
•Patients with Stage 1 HTN/Additional Risk Factors:
• Achieving a sustained 12 mmHg decrease in systolic
BP 10 years will prevent 1 death for every 11 pts treated
•The majority of Patients will require 2 or more anti-HTN
drugs.
JNC 7: Treatment Algorithm for Hypertension
Lifestyle modifications
Not at goal blood pressure (<140/90 mm Hg)
(<130/80 mm Hg for those with diabetes or chronic kidney disease)
Initial drug choices
Without compelling indications
Stage 1 hypertension
(SBP 140–159 or DBP 90–99 mm Hg)
Thiazide-type diuretic for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Stage 2 hypertension
(SBP 160 or DBP 100 mm Hg)
Two-drug combination for most
(usually thiazide-type diuretic and
ACEI or ARB or BB or CCB).
With compelling indications
Drugs for compelling indications
Other antihypertensive drugs
(diuretic, ACEI, ARB, BB, CCB) as
needed.
Not at goal blood pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensinconverting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker;
CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
Drug Therapy for HTN
What percentage of your patients are
on more than one medication to
control there hypertension?
1. 20%
2. 40%
3. 60%
4. 80%
JNC 7: The Fine Print

Cracking open the door beyond diuretics for first
line in a patient without co-morbid conditions
 Along with promoting a thiazide diuretic for
Stage 1 HTN, the committee added this
surprising sentence: “May consider ACEI,
ARB, BB, CCB.”

The ‘Compelling Indication’ Category - JNC put
emphasis on evidence showing benefits with
specific antihypertensive agents for certain
medical conditions. Again, taking a small
sidestep from the NHLBI dictum of diuretics first.
Case PresentationPrehypertension:
The Executive Physical
Vicki Struthers


36 White Female
Presents for an Executive
Physical
PMH






Recently returned to work 10
weeks after the birth of first
child
Total Cholesterol: 160 mg/dL
HDL 66 mg/dL;
Low-density lipoprotein (LDL):
120 mg/dL
Family History of Diabetes
Mellitus
No History of Smoking
*Hypothetical case based on a typical patient expected to present in clinical practice
Vicki Struthers – by the numbers


Tests Ordered Before
Your Visit Today
ECG- LBBB,


CR 0.9 mg/dL, NA 135
mmol/L, Glucose 97
mg/dL, HCT 35, TSH 2.1,



Labs
Vitals
HR 98 bpm, BP 148/91
mm/Hg, BMI 23
No Rx, NKDA
Vicki Struthers –Parasternal Long
Axis Echo
What Should We Be Thinking About?
Clinician Intervention
What are the treatment alternatives for
Vicki?
1.
2.
3.
4.
Diet and Lifestyle Modification
Drug Therapy
Both
Have her fill out “her bucket list” and
enjoy the last year of her life.
Implementation of Drug Therapy
What initial drug regimen should be
considered for Vicki?
1. Calcium Channel Blocker or Diuretic
2. Calcium Channel Blocker and a
Diuretic
3. ACEI (or ARB) and a Diuretic
4. ACEI (or ARB) and a Beta-Blocker
Vicki Struthers 12 Years Later




At 1 YR- “I take my
medicine”, Structured
Exercise program
Law salt, Low fat Diet
AT 12 YRS- Running 10Ks,
Daughter in Middle school.
Blood Pressure 118/70
WHAT SHOULD WE BE
THINKING ABOUT?
Clinical Practice
Recommendation
Exercise may be beneficial in lowering
blood pressure and reducing
cardiovascular risk.
Strength of Evidence:
Three reviews of 50 observational studies found the
risk of CV disease was lowered in those who were
physically active. Conversely, a review of 43
epidemiological studies found that physical inactivity
was associated with a doubling of cardiovascular
disease.
Key Diet History Questions
for Patients with HTN

Do you use a salt shaker?

Do you taste your food before you add salt?

How often do you eat salty foods, such as chips, pretzels,
salted nuts, canned and smoked foods?

Do you read labels for sodium content?

How many servings of fruits and vegetables do you eat
everyday?

How often do you eat or drink dairy products? What kind?

How often do you eat out? What kinds of restaurants?

Do you like to drink alcohol? How much?

How often do you exercise, including walking?
Application of the Guidelines
in Practice
According to the JNC-7 Guidelines,
how would Vicki be classified?
1.
2.
3.
4.
Normal Blood Pressure
Pre-Hypertensive
Stage one Hypertension
Stage two Hypertension
True or False
• Those people whose BP is
classified as pre-hypertensive
should be initially treated with
lifestyle modification from the time
they are identified.
1. True
2. False
ANSWER:
• Those people whose BP is classified as prehypertensive should be initially treated with
lifestyle modification from the time they are
identified.
1. True
2. False
• Those people whose BP is classified as
prehypertensive should be initially treated with
lifestyle modification from the time they are
identified.
HTN True or False
• ACE Inhibitors should be initial drug
therapy for most, either alone or
combined with other drug classes.
1. True
2. False
ANSWER
• ACE Inhibitors should be initial drug therapy
for most, either alone or combined with other
drug classes.
1. True
2. False
• Thiazides should be initial drug therapy for
most, either alone or combined with other
drug classes.
When the First Drug Doesn’t Work

JNC 7 pushes for rapid progression to combination
therapy before fully exploring mono-therapy.

This approach is not an issue for those with Stage 2,
but for Stage 1. Different mechanisms may cause HTN
in different patients; and heterogeneous mechanisms
from multiple class of agents may be necessary.

Alternative approach: if there is a partial response, then
increase the dose or add a second agent. If there is no
response at all, then try an alternate class. The goal
here being to find the simplest way to control BP.
JNC 7: Classification and Management of
Blood Pressure for Adults
Initial Drug Therapy
BP
Classification
SBP*
(mm
Hg)
DBP*
(mm
Hg)
Lifestyle
Modification
Normal
<120
and <80
Encourage
120–139
or 80–89
Yes
Prehypertension
Stage 1
hypertension
Stage 2
hypertension
140–159
160
or 90–99
or 100
Without
Compelling
Indications
No
antihypertensive
drug indicated.
Yes
Thiazide-type
diuretic
for most. May
cosider ACEI,
ARB, BB, CCB,
or combination.
Yes
Two-drug
combination
for most (usually
thiazide-type
diuretic
and ACEI or ARB
or
BB or CCB).
JNC 7. May 2003. NIH publication 03-5233.
With
Compelling
Indications
Drug(s) for compelling
indications.
Drug(s) for compelling
indications.
Other antihypertensive
drugs (diuretic, ACEI,
ARB, BB, CCB) as
needed.
Case Presentation #2
Nate Biddleson






55 AA male presents for
follow-up after his original
Executive Physical.
PMH
Blood pressure on
presentation 145/95, now
140/90
Non-smoker , no Known CAD
Fasting glucose 142
(repeated from previous visit)
Initial Therapy; Diet
modification, Increased
exercise, take “some
vacation”, and started 25 mg
of HCTZ
What Would You Do Now?
1. Start an ACEI (or ARB)
2. Start a Calcium Channel Blocker
3. Decrease HCTZ to 12.5 mg, and then
Start a Calcium Channel Blocker and an
ACEI.
4. Decrease HCTZ to 12.5 mg, and then
Start a Calcium Channel Blocker and an
ACEI….then add an oral anti-glycemic
agent.
What Other Risk Stratification Should
I Do at this Juncture to Proactively
Assess my Patient?
Nate Biddleson

55 AA male presents for
follow-up 6 months after
his last appointment

PMH

Blood pressure on
presentation 125/75

Fasting glucose 98

Therapy; Salt
modification, Increased
exercise, HCTZ 12.5 mg,
CCB, ACEI and
sulfonourea/metformin
combination.
High-Risk Hypertensive Patients Require
Multiple Agents to Get to Goal
Achieved
Systolic BP
AASK1
(134 mm Hg)
ABCD2,3
(132 mm Hg)
ALLHAT4
(135 mm Hg)
HOT2,5
(141 mm Hg)
IDNT6
(140 mm Hg)
RENAAL7
(140 mm Hg)
UKPDS2,8
(144 mm Hg)
1
2
3
4
Number of BP Medications
AASK=African-American Study of Kidney Disease and Hypertension; ABCD=Appropriate Blood Pressure Control in
Diabetes; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trials; HOT=Hypertensive
Optimal Treatment; IDNT=Irbesartan Diabetic Nephropathy Trial; RENAAL=Reduction of Endpoints in Non-Insulin Diabetes
Mellitus with the Angiotensin II Antagonist Losartin; UKPDS=United Kingdom Prospective Diabetes Study.
1Wright JT et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147.
3Estacio RO et al. N Engl J Med. 1998;338:645-652. 4The ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997.
5Hansson L et al. Lancet. 1998;351:1755-1762. 6Lewis EJ et al. N Engl J Med. 2001;345:851-860. 7Bakris GL et al. Arch
Intern Med. 2003;163:1555-1565. 8UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.
Compelling Indications for Consideration
of One Drug Class vs. Another

Heart Failure:


Post- MI:

Thiazide/loop, BB, ACEI, ARB,
Aldosterone antagonist
BB, ACE, Aldosterone antagonist

High CVD risk:

Thiazide, BB, ACE, ARB

DM:

Thiazide, BB, ACE, ARB, CCB

 ACE, ARB. For creatinine 2-3 try
CRF
loop diuretic
 Cr > 1.5 in men
 Cr > 1.3 in women
Thiazides






Chlorothiazide (Diuril)
Chlorthalidone
Hydrochlorthiazide
(Microzide, Hydrodiuril)
Polythiazide (Renese)
Indapamide (Lozol)
Metolazone (Mykrox,
Zaroxolyn)
*All trade / brand / generic names are specific to the USA
Loop Diuretics
• Bumetanide (Bumex)
• Furosemide (Lasix)
• Torsemide (Demadex)
Potassium-sparing Diuretics
• Amiloride
(Midamor)
• Triamterene (Dyrenium)
*All trade / brand / generic names are specific to the USA
Aldosterone Receptor Blockers
• Eplerone (Inspra)
• Spironolactone
(Aldactone)
Combined a and b-blockers
• Carvedilol (Coreg)
• Labetalol (Normodyne, Trandate)
*All trade / brand / generic names are specific to the USA
Beta-Blockers








Atenolol
Betaxolol
Bisoprolol
Metoprolol
XL)
Nadolol
Propranolol
Timolol
Nebivolol
(Tenormin)
(Kerlone)
(Zebeta)
(Lopressor,
Toprol
(Corgard)
(Inderal/XL)
(Blocadren)
(Bystolic)
*All trade / brand / generic names are specific to the USA
ACE Inhibitors










Benzapril
Captopril
Enalpril
Fosinopril
Lisinopril
Moexipril
Perindopril
Quinapril
Ramipril
Trandolapril
(Lotensin)
(Capoten)
(Vasotec)
(Monopril)
(Prinivil, Zestril)
(Univasc)
(Aceon)
(Accupril)
(Altace)
(Mavik)
*All trade / brand / generic names are specific to the USA
Angiotensin II Receptor Blockers







Candesartan (Atacand)
Eprosartan (Tevetan)
Irbesartan (Avapro)
Losartan
(Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan
(Diovan)
*All trade / brand / generic names are specific to the USA
Calcium Channel Blockers

Dihydropyridines






Amlodipine (Norvasc)
Felodipine (Plendil)
Isradipine (Dynacirc)
Nicardipine (Cardene
SR)
Nifedipine (Adalat,
Procardia)
Nisoldipine (Sular)
• DHPs have been particularly known to have a negative
inotropic effect.
Calcium Channel Blockers

Non-Dihydropyridines:
Diltiazem (Cardizem,
 Dilacor, Tiazac)
 Verapamil (Calan,
Isoptin)

Constipation
Conduction Abnormalities
*All trade / brand / generic names are specific to the USA
Alpha1 Blockers

Doxazosin
Prazosin
Terazosin

Direct Vasodilators

Hydralazine (Apresoline)
Minoxidil
(Loniten)



(Cardura)
(Minipress)
(Hytrin)
*All trade / brand / generic names are specific to the USA
Centrally Acting Drugs
Clonidine
 Methyldopa
 Reserpine
 Guanfacine

(Catapres)
(Aldomet)
(generic)
(generic)
*All trade / brand / generic names are specific to the USA
True or False
• Normal blood pressure is defined as
SBP < 135 and DBP < 90.
1. True
2. False
ANSWER
• Normal blood pressure is defined as SBP <
135 and DBP < 90.
1. True
2. False
• Normal blood pressure is defined as SBP <
120 and DBP < 80. People with SBP 120 –
139 OR DBP 80 – 89 should be considered
prehypertensive.
True or False
• Key lifestyle modification measures
that, if initiated in all pre-hypertensive
and hypertensive individuals, are likely
to lower BP, include all except…..
1. Weight reduction
2. Adkins Eating Plan
3. Dietary sodium reduction
4. Physical activity
ACC/AHA Practice Guidelines
Pyramid Approach to HF Stages
Refractory
End-Stage HF
Marked symptoms at rest
despite maximal
medical therapy*
D
HF with Current or Prior Symptoms
C
Known structural heart disease
Shortness of breath and fatigue
Reduced exercise tolerance
Structural Heart Disease
B
Previous MI
LV systolic dysfunction
Asymptomatic valvular disease
High Risk for Developing HF
A
Hypertension
CAD
Diabetes mellitus
Family history of cardiomyopathy
Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43
Implementation of Drug Therapy
What initial drug regimen should be
considered for Vicki?
1. Calcium Channel Blocker or Diuretic
2. Calcium Channel Blocker and a
Diuretic
3. ACEI (or ARB) and a Diuretic
4. ACEI (or ARB) and a Beta-Blocker
Case Number Three
Clark Galloway


42 White Male
Presents for a Executive
Physical
Past Medical History (PMH)






“Borderline” Hypertension
(HTN)
“…too Busy to Exercise”
Cholesterol Total: 223 mg/dL
High-density lipoprotein
(HDL): 24 mg/dL
Parents deceased related to
“some heart failure thing”
+TOB (smoker)
*Hypothetical case based on a typical patient expected to present in clinical practice
Clark Galloway – by the numbers



Tests Ordered Before Your Visit
Today
ECG (electrocardiogram)- normal sinus rhythm
(NSR), No Q wave, normal intervals, No STT
Abnormalities
Echocardiogram (Echo) -next slide


Serum Creatinine (SCr) 1.1mg/dL, Sodium (Na)
140 mmol/L, Fasting Glucose 140 mg/dL,
Hematocrit (HCT) 44, Thyroid-Stimulating
Hormone (TSH) 1.1, Fasting Blood Glucose taken
on two separate days 128 mg/DL and 138 mg/DL



Labs
Vitals
Heart Rate: 82 beats per minute (bpm), Blood
Pressure: 142/86 mmHg, Body Mass Index (BMI):
26
No Prescription Medicine (Rx), No Known Drug
Allergies (NKDA)
Clark Galloway –Parasternal Long
Axis Echo
According to the JNC-7 Guidelines…
What type of Hypertension is this?
1. Pre-hypertension with Co-morbidities
2. Type One Hypertension
3. Type One Hypertension with Comorbidities
4. Type Two Hypertension with Comorbidities
What Lifestyle changes should
we ask him to consider and
should we start any
medications at this time?
Clark Galloway 12 Years Later




At 1 YR- “I was too busy
to exercise and I don’t like
medicine… I felt fine”
AT 5 YRS- Promoted,
gained 15 lbs, and joined a
cigar club
AT 8 YRS- First MI, LVD,
uncontrolled DM, ED
AT 12 YRS- Next Appt.
with you.
What percentage of your
patients are noncompliant?
1.
2.
3.
4.
10%
25%
50%
70%
New Medical Profile





Left Ventricular Ejection Fraction (LVEF)
<20%
VO2 MAX 11
BP 108/50 mmHg, HR 95 bpm
Shortness of Breath (SOB) at rest, Chest
Pain (CP) 2-3/day, Paroxysmal nocturnal
dyspnea (PND)
9 kg weight gain despite two calls to office
this wk
ACC/AHA Practice Guidelines
Pyramid Approach to HF Stages
Refractory
End-Stage HF
Marked symptoms at rest
despite maximal
medical therapy*
D
HF with Current or Prior Symptoms
C
Known structural heart disease
Shortness of breath and fatigue
Reduced exercise tolerance
Structural Heart Disease
B
Previous MI
LV systolic dysfunction
Asymptomatic valvular disease
High Risk for Developing HF
A
Hypertension
CAD
Diabetes mellitus
Family history of cardiomyopathy
Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43
Hypertension in Patients With HighRisk Conditions



~3/4 of adults with diabetes have BP
130/80 mmHg or use prescription
medications for HTN1
~2/3 of patients with HF have a past or
current history of HTN2
More than 50%–75% of patients with chronic
kidney disease have BP >140/90 mmHg3
1. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics. Bethesda, MD: US Department of Health
and Human Services, NIH, 2005. Available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed Oct. 2006. 2. Hunt SA et
al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Available at
http://www.acc.org/qualityandscience/clinical/guidelines/failure/update/index.pdf. Accessed Oct. 2006. 3. National Kidney Foundation.
Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic
Kidney Disease. Available at http://www.kidney.org/professionals/KDOQI/guidelines_bp/guide_1.htm. Accessed Oct. 2006.
Chronic Kidney Disease
Goals: 1) Slow deterioration of renal function
2) Prevent CVD
• Often need 3 or more drugs
• Target < 130/80
• Drugs: ACE-Inhibitors/ARBs—Favorable effects on
progression
-- Increase in Creatinine of 35% is acceptable
• Advanced Renal Disease:
GFR < 30, CR 2.5 – 3.0 mg/dl
Increased dose of loop diuretics usually needed in
combo with other drugs
Incidence of Coronary Heart Disease (CHD)
Events in Patients With and Without Diabetes
P<.001
50
45.0
Incidence During
7-Year Follow-up* (%)
Nondiabetics with no prior MI
40
30
Nondiabetics with prior MI
Diabetics with no prior MI
Diabetics with prior MI
P<.001
18.8
20.2
n=69
n=1,304
n=169
n=890
3.0
0.5
7.8
3.2
20
10
3.5
0
Events per
100 Person-years
*Among 1373 nondiabetic subjects and 1059 diabetic subjects, from a Finnish population-based study.
Haffner SM et al. N Engl J Med. 1998;339:229-234.
Causes of Death in Persons With
Diabetes, Based on US Studies
Cardiac Disease
Cerebrovascular
Disease
Diabetes
Malignant Neoplasms
Pneumonia/Influenza
All Other
0
10
20
1990 US death certificates with mention of diabetes, all ages.
1990 US death certificates with mention of diabetes, age at death 45 years.
30
Deaths (%)
40
50
Moss SE et al. Am J Public Health. 1991;81:1158-1162. Ochi JW et al. Diabetes Care. 1985;8:224-229. Kleinman JC et al. Am J
Epidemiol.1998;128:389-401. Bender AP et al. Diabetes Care.1986;9:343-350.
60
The Diabetic Hypertensive Patient Is
at Especially High Risk…

For CV disease


For myocardial infarction (MI)


“Two thirds to three fourths of people with diabetes
mellitus die of some form of heart or blood vessel
disease”1
Patients with diabetes without a previous MI have as
high a risk of MI as patients without diabetes with a
previous MI2
For congestive heart failure (CHF)

In the DIGAMI trial, 66% of total mortality among
patients with diabetes was due to HF3
DIGAMI=Diabetes Insulin-Glucose Infusion in Acute MI.
American Heart Association. Heart and Stroke Statistical—2004 Update. Dallas, TX: AHA; 2003; 2Haffner SM et al. N Engl J
Med. 1998;339:229-234; 3Malmberg K et al. Eur Heart J. 1996;17:1337-1344.
UKPDS: Blood Pressure Control Study in Type 2
Diabetes Effect of Intensive BP Lowering on Microand Macrovascular Complications Risk
0
MI
Any
Diabetesrelated
Endpoint
Diabetesrelated
Death
Retinopathy
Renal
Failure
Stroke
Vision
Deterioration
HF
Risk Reduction (%)
-10
-20
21
-30
-40
P=.13
24
P=.0046
32
P=.019
34
P=.0038
42
P=.29
-50
44
P=.013
47
P=.0036
-60
Benefits of 144/82 vs 154/87
-70
1,148 hypertensive patients with type 2 diabetes were allocated to tight (144/82 mm Hg, n=758) or less tight
(154/87 mm Hg, n=390) and followed for a median of 8.4 years.
UKPDS Group. UKPDS 38. BMJ. 1998;317:703-713.
56
P=.0043
UKPDS: Benefits of Glycemic vs BP
Control With ACEIs or b-Blockers
20
Risk of Event (%)
HF
Stroke
MI
Diabetic Death
0
+7
-8
-9
-12
-20
-21
-32
-40
-44
Glycemic control
-60
-56
ACEI or b-Blocker
ACEI=Angiotensin-converting enzyme inhibitor. UKPDS Group. BMJ. 1998;317:703-713. Lancet. 1998;352:837-853.
What would you do with Clark?
1. Start an ACEI and low dose Betablocker
2. Admit to the hospital to Start an ACEI
AND low dose Beta-blocker
3. Admit to the hospital to Start an ACEI
AND low dose Beta-blocker AND get
a consultant.
4. Send him to the Emergency Room
ASAP
Clinical Practice
Recommendation
Treating high blood pressure to JNC-7
GOALS with anti-hypertensive
medications reduces the risk of
cardiovascular disease and death.
Strength of Evidence:
Level of Evidence 1
Grade A
True or False
If BP is >20/10 mmHg above goal,
initiate therapy with a single agent
and lifestyle modification.
1. True
2. False
ANSWER
If BP is >20/10 mmHg above goal, initiate
therapy with a single agent and lifestyle
modification.
1. True
2. False
• If BP is >20/10 mmHg above goal, initiate
therapy with two agents, one usually should
be a thiazide-type diuretic.
True or False
Most patients will only require one
antihypertensive drug to achieve goal
BP.
1. True
2. False
ANSWER
Most patients will only require one
antihypertensive drug to achieve goal
BP.
1. True
2. False
• Most patients will require 2 or more
antihypertensive drugs to achieve
goal BP
Clinician Input
When we first encountered Clark,
what are the things we could have
done that would have made a
difference?” AND
“Do you have patients like Clark in
your practice?”
Failures of Patient Education

50% of patients discontinue their antihypertensive within one year of initiating
treatment.

DASH diet for hypertension:


limit sodium

Increase fruits and vegetables (8-10/d)

Increase low fat dairy (3-4/d)
Focus on diet history for hypertensive
patients
Noncompliance

Estimates of noncompliance with medical
treatment in general:




Noncompliance causes 125,000 deaths a year twice the mortality rate from MVAs
30% of hospital admissions for people over the age
of 65 are directly caused by noncompliance.
Half of all prescriptions are taken incorrectly,
contributing to prolonged or additional illnesses.
Noncompliance increases with the number of meds
and doses per day; at 4 times a day, only 40% get it
right.
Selected Factors that Influence Dissemination
and Implementation of Healthcare

Systems of Care
Access to care
 Coverage
 Marketing
influences


Provider
Lack of knowledge
 Lack of conviction
 Forgetfulness
 Innovation bias
 Marketing
influences


Patient Level
Preferences
 Symptoms
 Marketing
Influences

Differences Between More and Less
Successful Providers
More Successful
Less Successful
Involved patients in decision-making.
Referenced technical aspects of
drug benefits.
Used med changes to educate /
engage.
Patient-maintained record card to
monitor compliance.
Less information sharing – “only if
asked”.
Felt time constraint did not permit
Progressively introduce effective dose discussing adverse effects of
meds.
and number of meds.
Awareness of patient ability to afford /
role of formulary (e.g., VA)
Least expensive appropriate med
when possible.
Greater attention to gender,
comorbidities, age when prescribing.
Felt knowledge of side effects
would hinder compliance.
Shared Traits of More and Less
Successful Providers

Several BP readings to confirm HTN, multiple visits.
Unless BP very high or comorbidities present.
High awareness of national BP guidelines.
Concurrence on HTN treatment goals, especially for
comorbidities, e.g., diabetes, etc.
Likely to begin HTN treatment with 2-3 months of lifestyle
management.




Not sufficient to attain desired BP
Difficulty / reluctance in treating older patients to JNC
standards.


Questioned value of aggressively treating older (80+
years) patients with other severe problems
Would look at any BP reduction as partial success


Causes of Resistant HTN
Improper Measurement
Volume Overload
Excess Sodium
Volume retention from Renal Disease
Inadequate Diuretic Therapy
Drug-Induced/Other Causes
Noncompliance
Inadequate Doses
Inappropriate Combos
NSAIDS; COX 2 inhibitors
Cocaine, amphetamines, other illicits
Sympathomimetics (decongestants etc.)
OCPs
Steroids
Erythropoietin
Cyclosporine and tacrolimus
Licorice
Ephedra
ma haung
Bitter Orange
Obesity
EtOH
Additional Challenge in Treatment of
HTN: Medication Adherence


Adherence to a drug regimen is an important component of
BP control
 Approximately 50% of patients with poor BP control have
adherence problems (defined by taking <80% of
medication)
Several drug-related factors can influence medication
adherence, including:
 Adverse events
 Frequency of adverse events has been inversely
correlated with adherence rates
 Dosing frequency
 Reduction in dose frequency can lead to improved
adherence
Feldman R et al. Can J Public Health. 1998;89:I-16–I-18.
Strategies to Improve Management
of Patients With HTN and DM
ACC/AHA HF
Guidelines1
In-hospital
Initiation2,3
Increasing
Outpatient
Compliance2,3
I IIa IIb III
• Clinical trial
evidence
incorporated into
recommendations
for patient care
• Implement evidence-based
care and therapies
• Majority of patients eligible
for treatment
• Early benefit of therapy not
missed
• Higher persistence rates
postdischarge
• Improve quality of
care and outcomes
1. Hunt SA et al. Circulation. 2005;112:1825–1852. 2. Fonarow GC. Rev Cardiovasc Med. 2002;3:S2–S10. 3. Gattis W et al. J
Am Coll Cardiol. 2004;43:1534–1541.
Improved Adherence Has Been
Associated With Improved Outcomes


In the BHAT trial, patients who took 75% of their
prescribed βblocker regimen were 2.6 times more
likely to die within the first year of follow-up,
compared with more compliant patients1
In the COMPASS study, patients treated with oral
nitrates had better efficacy with once-daily dosing2

Mean weekly number of chest pain episodes:


94% decrease in once-daily group
30% decrease in twice-daily group (P<.0001 compared to oncedaily group)
Beta-Blocker Heart Attack Trial (BHAT): multicenter, randomized, double-blind trial comparing propranolol vs placebo in 3837 patients
aged 30–69 years surviving acute MI. Patients 5–21 days post-MI were randomized to propranolol or placebo and were followed for an
average of 25 months. Adherence data were available for 2175 patients (1081 randomized to propranolol).
Compliance With Oral Mononitrates in Angina Pectoris Study (COMPASS): open, nonblinded, randomized, parallel-group study in 101
patients aged 40–75 years; compared patient compliance (using electronic measurement) and treatment effectiveness in patients with
stable angina pectoris treated with oral nitrates administered once daily vs twice daily.
1. Horwitz R et al. Lancet. 1990;336:542–545. 2. Kardas P et al. Am J Cardiol. 2004;94:213–216.
SUMMARY-CHALLANGE
1. Every patient in my practice will be screened
for hypertension.
2. I understand that hypertension is a significant
risk factor for cardiovascular disease.
3. Every patient in my practice will be treated to
goal to decrease the risk of CV death.
4. My treatment plans will include helping
patients comply with lifestyle and medication
changes. I will make an extra effort to
demonstrate to my patients how important their
hypertension is to me and will provide
additional time if needed.
JNC-7

The Seventh Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure.

Full text available: Hypertension,
2003;42:1206-1252
References
• JNC 7 report: available via NIH (Publication 035233)
• JAMA 289 (19), May 21 2003 (online)
• Adapted slides from Dr. Omar Khan’s AAFP
01/2006 update (online)
• AAFP monograph: #305
• AHA/ACC Hypertensive Guidelines
• Weber, MA. The JNC 7 Report: Challenges and
Dilemmas in Writing Guidelines. J. Clin
Htn.;5(4):p282, 2003.
Hypertension
Post-Test Questions
Which of the following statements
is NOT true?
1.
2.
3.
4.
5.
6.
Most patients who have hypertension are not at goal.
Those patients who are normotensive at age 55 have
a 90% probability of becoming hypertensive.
In persons older than 50 years, systolic blood
pressure greater than 140 mmHg is a more important
CVD risk factor than diastolic blood pressure.
Those with a systolic BP of 130-149 mmHg or a
diastolic BP of 90-99 should be considered as prehypertensive.
If blood pressure is > 20/10 mmHg above goal,
consideration should be given to initiating more than
one agent, one of which should be a thiazide-type
diuretic.
None of the above
Juan is a 31 year old Hispanic male who comes to
see you complaining of a cough and mild fatigue.
On taking his vital signs his blood pressure is noted
to be elevated to 146/92 mm Hg.
Which of the following is the most appropriate
course of action?
1. Recommend that he begin therapy with a
thiazide diuretic
2. Recommend that he begin therapy with an
ACE inhibitor or ARB
3. Recommend that he avoid salt and return for a
re-check on his blood pressure
4. None of the above
Melanie is a 47 year old obese African American female
smoker who comes in for a visit. You have taken care of this
patient for over three years. Her only other major co-morbidity
is asthma for which she takes a combination
LABD/corticosteroid inhaler. One year ago, she was diagnosed
with hypertension and started on a thiazide diuretic. This visit
her BP is 149/94 mm Hg which is consistent with her two
previous visits.
Which of the following is NOT a reasonable choice for
continuation of her care?
1.
2.
3.
4.
5.
Recommendations for lifestyle and dietary modification
Increase her dosage of the thiazide diuretic
Add an ACE inhibitor
Add a b-blocker
A and C
W.C. is a 57-year-old man with type 2 diabetes first
diagnosed 2 years ago. Other medical problems include
obesity and hypothyroidism. He has a history of heavy
alcohol use but quit drinking alcohol 2 years ago. He
presents now for routine follow-up and is noted to have a
blood pressure of 168/100 mm Hg. He is asymptomatic.
Which of the following is the most appropriate
treatment option?
1.
2.
3.
4.
5.
Begin therapy with a calcium channel blocker
Begin therapy with a combination of an ACE
inhibitor and a thiazide diuretic
Discuss lifestyle and dietary modifications
1&3
2&3
Brad is a 54-year-old obese man with moderate to severe hypertension. You
initially prescribed amlodipine and adjusted the dose upward to 10 mg/day,
but his systolic blood pressure remained considerably elevated (192/88 mm
Hg). You added atenolol, 50 mg/day, and his systolic blood pressure was
still not controlled (170/80 mm Hg). The patient takes 400 mg of ibuprofen
once or twice a day for low back pain and over-the-counter sleep aids. He
drinks alcohol in moderate amounts and smokes a pack of cigarettes a day.
Results of routine laboratory tests, including fasting plasma glucose and
lipid levels, are within normal limits. The patient has noted bothersome
pedal edema and admits to feeling somewhat depressed lately.
What would NOT be appropriate for this patient with refractory
hypertension?
1.
2.
3.
4.
5.
Recommend significant lifestyle modification including smoking
cessation.
Ask patient and family whether or not he snores.
Continue his present medications
Add a thiazide-type diuretic
Add an ACE inhibitor or ARB