Transcript Slides

One Giant Leap for Preventive
Cardiovascular Care
GUEST EXPERT:
John M. Flack M.D, M.P.H., F.A.H.A., F.A.C.P., F.A.S.H.
Professor and Chair
Chief, Hypertension Section (GIM)
Department of Medicine
Southern Illinois University
Vice President, ASH Specialist Board
Specialist in Clinical Hypertension
This material has been provided by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization
supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily
reflect CMS policy. Publication number 11SOW-WV-HH-MMD-022916
Disclosures
• Grants: Glaxo Smith Kline, Bayer
• Consulting: FDA, Medtronic, Back Beat Medical,
Forest, Lundbeck, Regeneron/Sanofi, Medicines
Company
Objectives
 To understand the compelling rationale for treating and controlling
hypertension
 To understand the short-falls in contemporary hypertension control
 To understand a ten-step approach to optimizing the diagnosis,
evaluation and control of hypertension
 To understand the approaches used for patient engagement during
hypertension management
 To understand the necessary testing needed for effective riskstratification and optimal therapeutic decision-making
Epidemiology and
Blood Pressure Control Rates
Age-adjusted Hypertension Awareness, Treatment and Control
Rates by Race-Ethnicity Group (NHANES 2011 – 2012)
Healthy
People
2020
goal (62.1%)
Awareness
Treatment
Controlled
Adapted from Yoon SS et al. Hypertension 2015;65:54-61.
NHB= non-Hispanic black; NHW= non-Hispanic white; MA= Mexican American
Age-adjusted Percentage of Uncontrolled Hypertension Among Adults
Taking Prescription Medication for Hypertension (NHANES 2011 – 2012)
GROUP
%
OVERALL
29.6
NHB
35.3
NHW
27.9
MA
33.8
Adapted from Yoon SS et al. Hypertension 2015;65:54-61.
NHB= non-Hispanic black; NHW= non-Hispanic white;
MA= Mexican American
Age-adjusted Blood Pressure Levels in Hypertensive Adults Taking
Prescription Medication for Hypertension
(NHANES 2011 – 2012) by Race-Ethnicity Group
NHB
SBP
DBP
134.3
73.5
D = 1.7
D = 4.4
NHW
129.9
71.8
MA
133.8
72.1
Adapted from Yoon SS et al. Hypertension 2015;65:54-61.
NHB= non-Hispanic black; NHW= non-Hispanic white; MA= Mexican
American, SBP= systolic blood pressure; DBP= diastolic blood pressure.
Evidence-Based Medicine: Caveats
“Data are not facts; facts are not information; information is
not truth; truth is not wisdom. The wise application of
empirical facts to the care of patients requires both
information and judgment”.
Reilly B, Hart A, Evans AT. Disease-A-Month Vol. 44(8):349-420.
Upper Normal BP Levels by Type of BP Monitoring & Time of Day
Office BP Monitoring
Ambulatory BP Monitoring
Self BP Monitoring1
140 / 90
130 / 80 (24-hour)
135 / 85 (awake)
120 / 75 (sleep)
135 / 852
Adapted from Pickering TG and White WB. Journal of American Society of Hypertension
2008, 2(3):110-124
1125-130
2 Should
/ 75-80 for high risk patients having target office BP < 130 / 80
use average of no fewer than 12 readings taken at various times of the day over an
extended period of time.
HTN Types
At or below goal
Am Heart J. 2014 Jun;167(6):775-88.e1. doi:10.1016/j.ahj.2014.02.008. Epub 2014 Feb 28.
Refractory Hypertension:
A Subgroup of Apparent Treatment Resistant Hypertension
Definition:
Uncontrolled BP1 despite prescription
of ≥ 5 antihypertensive drugs
1SBP
≥ 140 and / or DBP ≥ 90 mm Hg.
Hypertension Outcome Trials: Meta-Analyses,
Mendelian RCTs, and the SPRINT Study
BP Difference Trials
Law MR. BMJ 2009;338:1-19.
SPRINT Trial: Intensive Versus Standard BP Control
(N=9361)
Primary outcome = MI, acute coronary syndromes, stroke,
heart failure or CVD death
High-risk persons ≥ 50 years
SBP ≥ 130 – 180
BP Target
<120
Median f/u=
3.26 years
BP Target
<140
121.5 mm Hg1
D = 13.1
134.6 mm Hg2
 25% Primary Outcome3
 27% All-cause Mortality3
Adapted from SPRINT Research Group. NEJM 2015;373(22):2103-2116.
1 prescribed 2.8 meds; 2 prescribed 1.8 meds; 3 P <0.003.
Ten Step Approach to Effective Hypertension Management
 Obtain accurate BP readings
– Train personnel on standard measurement techniques
– Preferably use an automated BP device
– Must have available multiple BP cuff sizes
– Average multiple measurements rather than using a single BP
measurement
Ten Step Approach to Effective Hypertension Management
Cont.
 Instruct the patient on taking home BP readings
– Should make treatment decisions on no fewer than the average of
12 temporally spaced measurements
– Check the home device measurements in clinic against those
obtained using the clinic-based devices
 Correlate the clinical exam, EKG and imaging studies (if available)
with BP measurements
– Exam: hypertensive retinopathy, S4 gallop, cardiac enlargement
– EKG: left atrial enlargement (inverted or biphasic P wave in V1)
Ten Step Approach to Effective Hypertension Management
Cont.
 Take an informative history
– Diet/Lifestyle: dietary sodium intake, alcohol consumption, physical
activity
– Medication adherence: directly query about this (eg, how often do
you miss doses) and encourage them to bring all their meds to
each visit
– Pressure-related symptoms: headache, sleep disturbance,
nervousness, chest pain, poor exercise tolerance, weakness,
fatigue)
BP Comparison:
Low vs. High Salt Diet
Pimenta E et al., Hypertension 2009;54:475-481
Ten Step Approach to Effective Hypertension Management
Cont.
 Obtain a database on the patient that allows risk stratification, informs
drug selection and identifies other CVD risk factors
– Electrolytes, BUN and creatinine
– Hemoglobin A1C
– EKG
– Fasting lipoproteins
– Urine albumin:crea ratio
Ten Step Approach to Effective Hypertension Management
Cont.
 Establish a BP target
– Communicate the target to the patient
– Put the BP target in the chart
– Seek to attain the BP target over many weeks to several months
– Avoid therapeutic inertia
 To the degree possible emphasize the benefits of diet/lifestyle change
– Decreasing dietary sodium intake and physical activity increase will
provide the biggest return on effort undertaken
Ten Step Approach to Effective Hypertension Management
Cont.
 Embrace combination drug therapy rather than chasing the single
drug to do the impossible
– Absent or inadequate diuresis is a common reason for poor BP
response to combination drug regimens
– Diuretics are nearly always needed when prescribing more than
two non-diuretic antihypertensive drugs
– The most effective, by far, drug combinations contain either a
thiazide diuretic or calcium antagonist as “anchor” drugs
Ten Step Approach to Effective Hypertension Management
Cont.
 When BP > 15 – 20/10 mm Hg above goal, in treatment naïve
patients initiate combination (2 drug) therapy
– There is never an indication to initiate more than two
antihypertensive drugs simultaneously in treatment naïve patients
– If already on therapy, scrutinize the drug regimen looking for “poor
combinations”, the absence or inadequate diuretic therapy,
diuretics mismatched to the level of kidney function, and possibly
harmful drug interactions
Ten Step Approach to Effective Hypertension Management
Cont.
 Be patient and forewarn patients that they may feel worse (before
they feel better) as BP falls
– No need to up-titrate antihypertensive drugs any more frequent
than ~ 4 weeks
– Over-aggressive drug titration can cause rapid BP reductions that
lead to symptoms (eg, weakness, fatigue) and/or target-organ
ischemia
– Some patients initially feel bad/worse when their BP falls and, if not
warned, they will stop taking their newly prescribed, effective
antihypertensive drugs
Targets During Hypertension Treatment
of Any Type
BP Control
1Deleterious
Safety
Availability
Acceptance /
Tolerability
drug interactions, contraindications 2º to co-morbid conditions.
Diuretics
Effective and Safe Use of Diuretics:
A Key to Successful Antihypertensive Drug therapy
 Diuretics should be matched to the level of kidney function
– HCTZ is effective down to EGFR ~ 45 ml/min/1.73 m2; chlorthalidone is effective
down to EGFR ~ 30 ml/min/1.73 m2
 Loop diuretics and metolazone, a thiazide-like long-acting diuretic, are effective at
EGFR levels below where traditional thiazides work
 Aldosterone antagonists and amiloride are highly effective BP lowering agents that
are woefully underutilized in contemporary HTN treatment
 If one of the first two drugs in a combination drug regimen is not a diuretic,
the third drug almost assuredly should be one
 Often more than one diuretic is needed for effective BP lowering
Chlorthalidone Lowers Ambulatory Systolic Blood Pressure
More than Hydrochlorothiazide at Week 8 (N=30)
Chl (25 mg)
HCTZ (50 mg)
0
-4
D mm Hg -8
-7.4
-6.4
-12
-16
-12.4
24 hr ABPM D
-13.5
p = 0.054
Nighttime ABPM D
p = 0.009
Office BP reductions in SBP trended greater for Chlorthalidone -17.1 vs. 10.8 mm
Hg (P=NS)
Ernst ME, et al. Hypertension 2006;47:352-358.
Spironolactone Induced Reduction in Systolic Blood Pressure (BP) Diastolic BP
at 6-weeks, 3- and 6-months Follow-up in Subjects with Resistant Hypertension
(N=76)
BP Response (mm Hg)
0
6wk
3mo
-10
-10
6mo
-10
-12
-20
-21
-23
-30
-25
BP reduction was significant at all time points compared to baseline
Nishizaka MK, et al. American Journal of Hypertension 2003;16(11):925-930.
Combination Therapy:
The Good and Not So Good
Table 6. Undesirable Antihypertensive Drug Combinations
Combination
Comments
ACE inhibitor + ARB
• Modest incremental BP lowering when one is added to
the other
• Heightened risk for hyperkalemia and kidney
dysfunction
• No incremental reduction in pressure-related CVD risk
• Increased hypotensive symptoms
Beta blocker + ACE Inhibitor
• Minimal incremental BP lowering (in the absence of a
diuretic)
Beta blocker + nondihydropyridine CCB
• Risk of both bradycardia and depressed LV systolic
function, especially in older persons
Beta blocker + central
adrenergic inhibitor (e.g.,
clonidine)
• Modest incremental BP lowering
• Significant risk of bradycardia and orthostatic
hypotension
Alpha blocker + central
adrenergic inhibitor
• Significant risk for orthostatic hypotension
• Both agents antagonize the sympathetic nervous
system
Abbreviations: ACE, angiotensin-converting enzyme; ARB; angiotensin receptor blocker; BP,
blood pressure;
CCB, calcium channel blocker; CVD, cardiovascular disease; LV, left ventricular
Flack JM, Sica DA, Bakris G, Brown AL et al for the International Society on Hypertension in
Blacks. Hypertension 2010; 56:780 – 800.
Treatment Initiated with 2-Drug Therapy
No
Diuretic
(preferred)
CCB
(preferred)
RAS blocker
(alternative)
Beta-blocker
(optional)
Aldosterone
Antagonist
RAS blocker
or
CCB
RAS blocker
or
Diuretic
Diuretic
or
CCB
Diuretic
or
Non-DHP CCB
Diuretic
or
CCB
CCB
or
RAS blocker
Diuretic
or
RAS blocker
CCB
or
Diuretic
Non-DHP CCB
or
Diuretic
CCB
or
Diuretic
Aldosterone antagonist or Potassium-sparing diuretic or
Alpha-blocker or Beta-blocker
RAS blocker or
Beta Blocker or
Alpha Blocker
Flack JM, Sica DA, Bakris G, Brown AL et al for the International Society on
Hypertension in Blacks. Hypertension 2010; 56:780 – 800.
Effect of Vitamin D on Blood Pressure
and Body Weight in African Americans
Figure 2. Impact of High Dose Vitamin D Supplementation
(≥2000 IU/D) to Longitudinal SBP Change in an Urban
Hypertensive Cohort
(N=696, Median Follow-up = 5.8 Months)
Vitamin D Impact: BP
Baseline Vitamin D
Level1 (ng/ml):
≤15
>15
SBP D, mm Hg
4
0.8
0
-4
-8.8
-8
-12
Reference Vitamin D supplementation category <2000 IU/D.
Mixed effect general linear models were adjusted for age, sex, initial SBP
level, baseline vitamin D level, antihypertensive drug therapeutic intensity and
weight loss.
95% confidence intervals are also displayed.
Figure 1. Impact of High Dose Vitamin D Supplementation
(≥2000 IU/D) to Longitudinal Weight Change in an Urban
Hypertensive Cohort
(N=696, Median Follow-up = 5.8 Months)
Vitamin D Impact: Body Weight
Baseline Vitamin D
Level1 (ng/ml):
≤15
>15
1
Weight D, lbs
0
-1.4
-1
-2
-3.7
-3
-4
-5
-6
Reference Vitamin D supplementation category <2000 IU/D.
Mixed effect general linear models were adjusted for age, sex, initial SBP level
and antihypertensive drug therapeutic intensity.
95% confidence intervals are also displayed.
Effect of Vitamin D Supplementation on Blood Pressure During the
Treatment Period (Baseline to 3 mo)
Vitamin D Dose, IU/d
Parameter
Placebo
1000
2000
4000
72
68
73
70
Baseline SBP, mean (SE)
122.2 (2.2)
124.7 (2.1)
122.8 (2.0)
130.4 (2.4)
3 mo SBP, mean (SE)
124.9 (2.4)
122.5 (2.0)
120.0 (2.4)
126.6 (2.6)
Difference SBP, mean (SE)
1.7 (2.1)
−0.66 (2.1)
−3.4 (2.0)
−4.0 (2.1)
Baseline DBP, mean (SE)
78.0 (1.3)
79.8 (1.3)
77.6 (1.4)
79.8 (1.6)
3 mo DBP, mean (SE)
78.9 (1.8)
78.0 (1.6)
76.0 (1.8)
78.0 (1.6)
Difference DBP, mean (SE)
0.7 (1.6)
−2.5 (1.6)
−1.8 (1.4)
−1.8 (1.50)
n (at baseline)
3 mo Change in BP
per 1000 IU/d
P
Value
−1.4 (0.7)
0.04
−0.5 (0.5)
0.37
BP indicates blood pressure; DBP, diastolic blood pressure; IU, international unit; and
SBP, systolic blood pressure.
Forman JP et al. Hypertension 2013;61:779-785.
Major Recommendations in the ISHIB Consensus Statement on the
Management of High Blood Pressure in African Americans
 Comprehensive lifestyle modifications1 should be recommended if BP
 115 / 75 mm Hg
 Goal or target BP levels should be viewed as ceilings not floors
 Chlorthalidone is the preferred thiazide-(like) diuretic (not HCTZ)
 Significant emphasis placed on hypertension treatment in special
situations
– Limited financial resources
– Resistant hypertension
 De-emphasized monotherapy and focused on combination therapy
1Weight
loss if overweight, dietary change (low fat, low sodium, high potassium, adequate
calcium), limit alcohol, regular physical activity, avoid / stop smoking
Flack JM , Sica DA, Bakris G, Brown AL et al for the International Society on
Hypertension in Blacks. Hypertension 2010; 56: 780 – 800.
ISHIB Risk Stratification Scheme:
Primary Prevention
 BP > 135 / 85 mm Hg without:
– Target-organ injury
– Pre-clinical CVD
– CVD
Flack JM , Sica DA, Bakris G, Brown AL et al for the International Society on
Hypertension in Blacks. Hypertension 2010;56:780 – 800.
Key Therapeutic Recommendations: Primary Prevention
BP < 145 / 90 mm Hg
 Optional comprehensive
lifestyle modifications up
to 3 months
 Antihypertensive drugs
– Preferred:
Thiazide diuretic
or
CCB
– Alternative:
RAS blocker
– Optional:
Beta blocker
1Preferred
BP > 15 / 10 above goal
 Initiate two-drug therapy
 Antihypertensive drugs
– Preferred:
CCB + RAS blocker
or
Thiazide + RAS blocker1
– Alternative:
Thiazide + Beta blocker
or
Thiazide + CCB
– Optional:
Thiazide + Aldo-antagonist
drug combination in edematous and / or volume overload states. BP=blood
pressure, CCB=calcium channel blocker, RAS=renin angiotensin system, Aldoantagonist=aldosterone antagonist
Flack JM , Sica DA, Bakris G, Brown AL et al for the International Society on Hypertension in
Blacks. Hypertension 2010; 56: 780 – 800.
Summary
• Multiple sources of data – Law meta-analysis, Mendelian RCTs
and the SPRINT study - support BP treatment thresholds for
treatment initiation and on-therapy targets considerably lower than
140 / 90 and that early treatment is superior to treatment initiated
later
• There are no convincing data to suggest that African Americans
should be treated less intensively than the general population – in
fact, the totality of data suggests just the opposite
• Accurate BP measurement, patience, patient engagement and
careful selection of pharmacological agents are key to BP control
• Skilled use of diuretics is indispensable in complex HTN
management
Q&A Session
 Please submit your questions/comments for Dr.
Flack or the HHQI team using WebEx’s Chat or Q&A
features.
 If using the Chat feature, please send your question
or comment to All Panelists.
 We will address as many questions/comments as
time will allow.
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