Transcript Benign Nephrosclerosis - Illinois Association of Free and Charitable

HYPERTENSION AROUND THE WORLD:
STRATEGIES FOR CONTROLLING HYPERTENSION
IN CHALLENGING SITUATIONS
George Bakris, MD, F.A.S.N., FA.H.A., F.A.S.H.
Professor of Medicine
Director, ASH Comprehensive Hypertension Center
University of Chicago Medicine
Chicago, IL
WHAT IS HYPERTENSION AND HOW IS IT
DIFFERENT FROM HIGH BLOOD PRESSURE
• Hypertension is a genetically predisposed sustained
elevation in blood pressure that occurs usually between
the 3rd-6th decade of life and not associated with a
correctable hemodynamic or endocrine cause.
• Elevated blood pressure is a periodic increase in
pressure related to excess stress and resolves with
relaxation or rest
HIGH BLOOD PRESSURE IN THE UNITED STATES
 Having high blood pressure puts you at risk for heart disease and
stroke, which are leading causes of death in the United States.
 About 75 million American adults (32%) have high blood
pressure—that’s 1 in every 3 adults.
 About 1 in 3 American adults has prehypertension—blood
pressure numbers that are higher than normal—but not yet in the
high blood pressure range.
 Only about half (54%) of people with high blood pressure have
their condition under control.
 High blood pressure was a primary or contributing cause of death
for more than 410,000 Americans in 2014—that's more than
1,100 deaths each day.
 High blood pressure costs the nation $48.6 billion each year. This
total includes the cost of health care services, medications to
treat high blood pressure, and missed days of work.
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm-2016
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm-2016
Prevalence of Hypertension by
Gender, Race, and Survey
U.S.: 1988-2006
Adapted from: Lloyd-Jones D, et al. Heart Disease and Stroke
Statistics – 2009 Update. Circulation. 2009;119:e1-161.
5
Awareness, Treatment, and Control Rates
by Race/Ethnicity
%
NHANES 2003–2004
Age adjusted.
NHANES=National Health and Nutrition Examination Survey; hypertension=average BP ≥140/90 mm Hg, or
patient was taking antihypertensive medications.
Ong KL et al. Hypertension. 2007;49:69-75.
Prevalence, Awareness, Treatment, for 1988–1994 & and Control 1999–2008
Egan B et.al. JAMA 2010;303:2043-2050
GLOBAL BURDEN OF HYPERTENSION*
2025 PROJECTION
Year 2000
Year 2025
• 26.4% of world adult
population had
hypertension
• 29.2% of world adult population
will have hypertension
• Total of 972 million
adults
• Highest prevalence is
in established market
economies (eg, North
America, Europe)
• Total of 1.56 billion adults
(60%  overall; 24%  in
developed nations, 80%  in
developing nations)
• Highest prevalence will be in
economically developing
continents (e.g., Asia, Africa)
will account for 75% of
world’s hypertensive
patients
*As defined by a blood pressure >140/90 mm Hg; >130/80 mm Hg in diabetes and renal
impairment
Kearney PM et al. Lancet. 2005;365:217-223.
DOES HYPERTENSION CAUSE ESRD?
Age-Adjusted Rate of ESRD
Per 100,000 Person-Years
HTN Linked To Chronic Renal Disease
Among 332,544 Men Screened for MRFIT
250
200
150
100
110
100-109
90-99
85-89
80-84
50
0
180
160-179
140-159 130-139
120-129
Systolic BP (mm Hg)
Klag, MJ et al NEJM 1996;334:13-18
<120
<80
17 Year Follow-Up from VA
Hypertension Clinics on ESRD
H. M. Perry, Jr., et.al Early predictors of 15-year end-stage renal disease
in hypertensive patients. Hypertension 25 (4 Pt 1):587-594, 1995.
HYPERTENSION: THE 2 ND MOST COMMON CAUSE
OF ESRD
Primary Diagnosis For Patients Who Start Dialysis
Other
10%
700
600
Glomerulonephritis
13%
Hypertension
27%
Diabetes
50.1%
No of Patients
Projection
95% CI
500
Number of
Dialysis 400
Patients 300
200
520,240
281,355
243,524
100
0
R2 = 99.8%
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
United States Renal Data System. Annual data report. 2007.
Risk of coronary events in people with CKD compared with
diabetes: a population-level cohort study
NHANES 2003−2006
48-month follow-up
N=1,268,029
Tonelli M et al. Lancet 2012;380:807
PREVALENCE, AWARENESS, TREATMENT, AND CONTROL OF
HYPERTENSION IN TOTAL KEEP COHORT BY CKD STAGE
WITH140/90 MM HG AS THRESHOLD. (N=10,819)
100
90
80
Prevalence
70
%
60
50
Awareness
40
30
20
10
Treatment
10.9
12.7
20.3
21.3
Stage 1
(eGFR 90+)
Stage 2
(eGFR 60-89)
Stage 3
(eGFR 30-59)
Stages 4+5
(eGFR <30)
Sarafidis P et.al. Am J Med 2008;121:332-340
Control
<130/80
mmHg)
KEY POINTS TO ACHIEVE SUCCESS WITH BP
GOAL
• Need patient buy-in-best way is to educate as to
disease and consequences with data
• Need to see patient more frequently in beginning and
encourage communication in the interim-Send a signal
you care and disease is important
PATIENT FACTORS OF COMPLIANCE
• Influences on compliance involve
• The patient, the disorder, the treatment, and the therapeutic
environment
• Study: Why patients discontinue treatment
• 11% due to undesirable side effects
• 25% thought their doctor told them to
• 46% thought they were cured
• 6% due to cost
• Improving issues of compliance requires a multipronged approach
1. Mallion JM, Schmitt D. J Hypertens. 2001 Dec;19(12):2281-2283
2. Gallup G Jr, Cotugno HE. Am J Med. 1986; 81(suppl 6c): 20-24.
3. Whelton PK, et al. JAMA. 2002;288:1882-1888.
BARRIERS TO ACHIEVING GOAL BLOOD
PRESSURE
Cultural norms
Insufficient attention to health education by health care practitioners
Lack of reimbursement for health education
Lack of access to places for physical activity
Larger servings of food in restaurants
Lack of availability of healthy food choices in many schools, worksites,
and restaurants
• Lack of exercise programs in schools
• Large amounts of sodium added to foods by the food industry and
restaurants
• Higher cost of food products that are lower in sodium and calories
•
•
•
•
•
•
Whelton PK, et al. JAMA. 2002;288:1882-1888.
AHA BP MEASUREMENT
RECOMMENDATIONS 2005
Recommendations for Blood Pressure Measurement in Humans
and Experimental Animals
Part 1: Blood Pressure Measurement in Humans: A Statement
for Professionals From the Subcommittee of Professional and
Public Education of the American Heart Association Council on
High Blood Pressure Research
Hypertension 2005;45:142-161. Note: 19 pages!
Systolic BP Differences Between Research Nurses
During a 24 Month Study: Effect of Training (T).
T
15
T
T
T
Difference
21 mm Hg!
Nurse 2
10
Nurse 4
Systolic
Difference
from
Group
Mean
(mm Hg)
5
Nurse 3
0
12
-5
Difference
0 mm Hg!
Nurse 1
-10
Month of Study
Modified from Bruce et al, Observer bias in blood pressure studies.
J. Hypertension 1988; 6: 375-380
BP RECOMMENDATIONS:
• Multiple readings are needed for classification and to guide
treatment.
• Automated devices can take multiple readings but accuracy must
be validated on each patient before they can be relied upon for
individual accuracy.
• Home BP readings predict risk better than office.
• 24 hour BP measurements MAY be better at predicting risk.
• Failure of BP to decline during sleep increases risk.
• In obese adults and children appropriate cull selection is of
paramount importance.
NY Times: What’s wrong with this picture?
Noisy
Fan?
Ear Pieces
in wrong?
Watching
Manometer
Room
too
cold?
Stetho head
at center
of arm
Eyes
closed?
Not at
Using
eye
Cuff over
Diaphragm
level
Clothes
Tubing Stetho
Observer’s
+10/+5
too
long.
No Back
Arms not flopping
Lg Cuff above
Support
Resting on Manometer Cuff? Heart Level
Table
+10/+6
+2 mm / inch
too far away
Left arm
Legs Crossed Arm not
supported 100 mm Hg
+10/+5
DIFFERENCE BETWEEN OFFICE AND TRIAL BP READINGS
1.
2.
Routine Office BP measurements
“automated office BP” (AOBP). Like the SPRINT method, AOBP
measurement assesses BP after the patient has rested for 5
minutes, but adding to that a fully automated sequence of 5
readings over a 5-minute period, all with the patient resting quietly
alone4.
AOBP method corresponds more closely with mean daytime ambulatory
BP (using ambulatory-awake monitoring)
BP recorded in research studies using the standard BP measurement
guidelines, which mandate a rest period prior to measurement (with or
without AOBP), is on average 10/7 mmHg lower than BP measured in
routine clinical practice .
Bakris G Circulation, Sept 2016
LIFESTYLE MODIFICATION
Modification
Weight reduction
Approximate SBP reduction
(range)
5-20 mm Hg/10-kg weight loss
Adopt DASH eating plan
8-14 mm Hg
Dietary sodium reduction
2-8 mm Hg
Physical activity
4-9 mm Hg
Moderation of alcohol
consumption
2-4 mm Hg
Chobanian A et.al. JNC 7 Hypertension Dec 2003.
SALT
The INTERSALT Study
52 centers, averages for urinary Na+ excretion (reflects dietary Na+
intake) and blood pressure rise with age
DASH-Sodium
Results
High Na+ – 150 mmol/d
(3.3 g/d)
Int Na+ – 100 mmol/d
(2.5 g/day)
Low Na+ – 50 mmol/d
(1.5 g/day)
Sacks FM et al. N Engl J Med 2001;344:6.
Relationship between Salt Intake and
Deaths from Strokes in 12 European
countries.
Perry IJ, Beevers DG. Salt intake and stroke: a possible direct effect. J Hum Hypertens 1992; 6: 23–25.; He FJ and MacGregor G.
J Hum Hypertens 2009;23:363-384
Facts About Salt Intake in US
• Average daily consumption is about
4500 mg/day.
• Recommendation is 2400 mg.
• Patients, in general have no concept
about their salt intake
http://www.americanheart.org/presenter.jhtml?identifier=4708
Changes in salt intake as measured by 24 h urinary sodium
excretion (UNa), blood pressure, stroke and ischemic heart
disease (IHD) mortality in England from 2003 to 2011.
*p<0.05, ***p<0.001 for trend.
He FJ et.al. BMJ Open 2014;4:e004549. doi:10.1136/ bmjopen-2013-004549
19 Year Survival Curve in Japan- The thick
line indicates survival for the participants with
the Reduced-Salt Japanese Diet
Thick line-Reduced-Salt Japanese Diet
Thin-line-Regular Japanese Diet
Nakamura et.al. Br J Nutrition (2009);101:1696–1705
Daily Recommended Intake 1 teaspoon salt = 2,400 mg Sodium
• ¼ teaspoon salt
= 600 mg sodium
• ½ teaspoon salt
= 1,200 mg sodium
• ¾ teaspoon salt
= 1,800 mg sodium
• 1 teaspoon salt = 2,400 mg sodium
• 1 teaspoon baking soda = 1000 mg sodium
• 1 teaspoon soy sauce = 1000 mg sodium
Common Food Sources
•
•
•
•
•
•
•
•
•
•
Table Salt
Cured meats – deli meats, sausages, ham
Baking soda- bicarbonate of soda
Baking powder
Antacids
Snack foods – salted nuts, chips, pretzels, crackers
Canned soups and bouillon cubes
Cheeses
Condiments – pickles, ketchup, mustard
Seasonings and flavor enhancers – MSG
• Ethnic Foods – Asian-( Chinese, Japanese)
Saltiest Side Dishes
5. Saltiest Mexican Entrée
Chili's Buffalo Chicken Fajitas-5,690 mg sodium, 1,730 calories
4. Saltiest Kids' Meal
Così Kid's Pepperoni Pizza- 6,405 mg sodium, 1,901 calories
3. Saltiest Seafood Entrée
Romano's Macaroni Grill Grilled Teriyaki Salmon- 6,590 mg sodium, 1,230 calories,
2. Saltiest Appetizer
Papa John's Cheesesticks with Buffalo Sauce- 6,700 mg sodium, 2,605 calories,
1. The Saltiest Dish in America
Romano's Macaroni Grill Chicken Portobello-7,300 mg sodium, 1,020 calories, 66 g fat
http://health.msn.com/nutrition/articlepage.aspx?cp-documentid=100203758&page=3
THE AFRICAN-AMERICAN STUDY OF
KIDNEY DISEASE AND HYPERTENSION
For The AASK Study Group Investigators
Wright JT Jr et.al. JAMA, 2002
Baseline Characteristics by Randomized Group
Blood Pressure Goal Intervention
Characteristic
Age, mean (SE), y
Female, No. (%)
Blood Pressure, mean (SE), mm Hg
Systolic
Diastolic
Mean arterial pressure
GFR, mean (SE) mL/min per 1.73 m2
Serum creatinine, mean (SE), mg/dL
Male
Female
Urine protein/creatinine ratio, mean (SE)
Male
Female
Urine protein, mean (SE), g/24 h
Male
Female
With urinary protein to creatinine ratio
of at least 0.22, No. (%)
Lower
(n = 540)
Usual
(n = 554)
54.5 (10.9)
205 (38.0)
54.7 (10.4)
219 (39.5)
152 (25)
96 (15)
115 (17)
46.0 (12.9)
149 (23)
95 (14)
113 (15)
45.3 (133.2)
2.17 (0.75)
1.72 (0.55)
2.20 (0.77)
1.81 (0.57)
0.33 (0.50)
0.28 (0.48)
0.32 (0.52)
0.37 (0.58)
0.61 (1.01)
0.36 (0.63)
181 (33.5)
0.61 (1.08)
0.46 (0.81)
176 (31.8)
Mean Arterial Pressure During Follow-up
130
Lower BP Goal (Achieved: 128/78)
Usual BP Goal (Achieved: 141/85)
MAP (mm Hg)
120
110
100
90
80
0
4
12
20
28
36
44
Follow-up Month
Wright JT Jr. et.al. JAMA 2002
52
60
Composite Clinical Events: Declining GFR Event,
ESRD or Death by BP Goal
40
Low (Achieved: 127/77)
Usual BP ((Achieved: 140/85)
% with Events
35
Low vs. Usual:
RR=2%, (p=0.85)
30
25
20
15
10
5
0
0
6
12
18
24
30
36
42
48
54
60
Follow-Up Time (Months)
RR=Risk Reduction
Wright JT Jr, et.al. JAMA, 2002
Composite Clinical Events: Declining GFR Event,
ESRD or Death by BP Goal
Baseline UP/Cr 0.22
% with Events
70
Low (Achieved: 127/77)
Usual BP ((Achieved: 140/85)
60
50
Low vs. Usual:
RR= -31%, (p=0.11)
40
30
20
10
0
0
6
12
18
24
30
36
42
48
54
60
Follow-Up Time (Months)
RR=Risk Reduction
Composite Clinical Events: Declining GFR Event,
ESRD or Death by BP Goal
Baseline UP/Cr>0.22
% with Events
70
Low (Achieved: 127/77)
Usual BP ((Achieved: 140/85)
60
50
Low vs. Usual:
RR=17.8%, (p=0.18)
40
30
20
10
0
0
6
12
18
24
30
36
42
48
54
60
Follow-Up Time (Months)
RR=Risk Reduction
Blood Pressure Control Throughout
AASK Cohort Period
Only Trial
Mixed Trial and Cohort
Only Cohort
30
40
50
Composite
20
ESRD or
Doubling SCr
10
Cumulative Incidence (%)
60
Cumulative Incidence of Events
(Doubling SCr, ESRD, or Death)
0
Death
0
1
2
3
1064
986
5
6
7
8
9
10
490
331
176
Follow-up Time (Years)
Appel L et al. Arch Intern Med 2008
Number at Risk: 1094
4
918
831
739
635
555
Comparison of clinic systolic BP
(SBP) and nighttime ambulatory SBP
N=617
Pogue V, et.al Hypertension2009;53(1):20-7.
KNOW THE MOST EFFECTIVE
AFFORDABLE AGENTS WITHIN
THE CLASS
* P-values reported are Bonferroni adjusted
CERTAIN GENERICS HAVE DOCUMENTED
POTENCY ISSUES
• Angiotensin receptor blockersExample-Losartan-well documented impurities create side
effects not associated with drug-branded agent does fine.pick another ARB-irbesartan tends to be much better.
• Diuretics
Mean Office SBP Change
Week 2
Week 4
Week 6
HCTZ : -4.5±2.1 HCTZ : -7.6±2.8
HCTZ
:
-9.3±3.2
Chlor : -15.7±2.2 Chlor : -17.4±2.9
Chlor : -19.6±3.4
p=0.001*
p=0.069*
p=0.109*
* P-values reported are Bonferroni adjusted
Ernst ME, et al. Hypertension 2006; 47:352-358
Week 8
HCTZ : -10.8±3.5
Chlor : -17.1±3.7
p=0.842*
FACTORS TO ENSURE BP REDUCTION AND
CONTROL AMONG THOSE WITH LIMITED
RESOURCES
1. Educate, which should lead to
2. Enpowerment, which should lead to
3. Enabling, which should lead to improved control