Hypertension update 2009
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Hypertension Update 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.

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Hypertension update 2009

Hypertension Update 2009


Key concepts

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

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%


Epidemiology1

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

    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

    Impact of High-Normal BP on the Risk of CV Disease

    Vasan RS et al. N Engl J Med 2001;345:1291.

    6


    Hypertension update 2009

    Relationship Between Hypertension and IHD Mortality

    Lewington S, et al. Lancet 2002; 360:1903–13


    Update hypertension 2009 main themes

    Update Hypertension 2009Main 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

    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

    51%

    31%

    10%

    1988-1991

    73%

    55%

    29%

    1991-1994

    68%

    54%

    27%

    1994-2000

    70%

    59%

    34%

    2003-2004

    75%

    65%

    33%

    Awareness

    Treatment

    Control

    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


    Hypertension update 2009

    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

    Lessons Learned from ALLHAT and ASCOT-BPLA on specific antihypertensive agents

    10


    Hypertension update 2009

    18%

    Factors Contributing to Poor Blood Pressure Control

    Took no action

    Increased dose

    Changed drug

    Prescribed add-on therapy

    From: Taylor Nelson Healthcare, Epson, Surrey England - Cardiomonitor 1992

    11


    Hypertension update 2009

    Blood Pressure (BP) Classification and Management*

    Life-Initial Drug Therapy BP SBP, DBP, styleCompelling Indications Classification mm Hg*mm Hg* Changes Without With

    Normal<120and<80encourage

    Pre HYTN120-139or80-89YesNoYesa

    Stage 1 HYTN140-159or 90-99YesYesbYesc

    Stage 2 HYTN>160or >100YesYesdYese

    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

    aTreat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg

    bThiazide-type diuretics for most; may consider ACEI, ARB, b-blocker, CCB or combination

    cOther antihypertensive drugs (diuretics, ACEI, ARB, b-blocker, CCB) as needed

    dTwo-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.

    eOther 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

    What is the optimal target BP level…….normal kidney donors?

    Rafey et al

    NKF 2008


    Goals of the hypertensive evaluation

    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

    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 patients1

    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

    Secondary Causes of Hypertension: Renovascular Disease

    Clinical Clues

    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

    Diagnosis

    Duplex renal arteries

    Captopril renography

    MRA

    Angiogram

    Renal vein renin

    Treatment

    Angioplasty/stent

    Surgery

    Medical treatment

    17


    Etiologies for secondary hypertension

    Etiologies for Secondary Hypertension

    Renal

    Endocrine

    Renal parenchymal

    Renal artery stenosis

    Obstruction

    PCKD

    Cushing’s syndrome

    Adrenogenital syndrome

    Pheochromocytoma

    Adrenal and adrenal-like

    Acromegaly

    Liddle’s syndrome, Gordon’s syndrome

    Other

    Pre-eclampsia

    Acute intermittent porphyria

    Thyroid (hyper, hypo)

    Drugs

    Hypercalcemia

    Coarctation of Aorta


    Secondary hypertension

    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

    Angioplasty and Stent for Renal Artery Lesions

    ASTRAL


    Cardiovascular outcomes in renal atherosclerotic lesions

    Cardiovascular Outcomes in Renal Atherosclerotic Lesions

    CORAL


    Hypertension update 2009

    23

    www.coralclinicaltrial.gov


    Hypertension update 2009

    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 prevent CVD.

    New Features

    and Key Messages

    JNC VII

    24


    New features and key messages continued

    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 thiazide-type diuretic.

    JNC VII

    25


    Combination therapy needed to achieve target sbp goals

    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

    4

    Number of BP meds

    Updated from Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.


    Ras inhibitor use in hypertensive blacks

    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

    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

    Center for Blood Pressure DisordersClinical Program: Goals

    • Accurate BP Measurement

    • Comprehensive Vascular Evaluation


    Hypertension update 2009

    Reduction of WCE in Clinical Practice

    180 –

    170 –

    160 –

    150 –

    140 –

    130 –

    120 –

    110 –

    100 –

    90 –

    80 –

    0 –

    152

    140

    134

    132

    Blood Pressure (mmHg)

    87

    75

    80

    77

    Ambulatory BP

    BpTRU

    Family

    Physician

    Research

    Technician

    n=309

    Myers M, et al, Journal of Hypertension 2009 27(2) 280-286


    Bptru

    White coat effect

    Work in progress

    BpTRU


    Hypertension update 2009

    ComprehensiveEvaluation of Hypertension

    Nurse/MA

    Retinal Exam

    Urine protein

    Limited Echo

    BpTRU

    Sphigmocor

    ABI

    TOD

    Central BP /PWV

    TOD

    TOD

    Peripheral BP

    PVD

    Physician Evaluation

    • Lab Review

    • Dyslipidemia

    • Fasting plasma glucose

    H & P

    Comprehensive Management Plan Based on Risk Estimates


    24 hour ambulatory blood pressure monitoring

    24 Hour Ambulatory Blood Pressure Monitoring


    Hbpm new recommendations may 2008

    HBPM: New Recommendations May 2008


    Indications for 24 hour abpm

    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

    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

    Prevalence of Nocturnal Hypertension in AASK Study


    Hypertension update 2009

    24 Hour Ambulatory Blood Pressure Monitoring


    Hypertension update 2009

    Measures of Arterial Stiffness

    • Central Aortic Pressure

    • Pulse Wave Velocity (PWV)

    • Augmentation Index (AIx)


    Hypertension update 2009

    QRS-

    carotid

    QRS-femoral

     time

    Notch-carotid

    Notch-femoral

     distance

    Aortic PWV (distance/time)

    55 msec

    135 msec

    80 msec

    85 mm

    690 mm

    605 mm

    7.6 m/sec

    How PWV is measured...

    85 mm

    FEMORAL

    CAROTID

    690 mm

    55 msec

    135 msec

    EKG-QRS

    EKG-QRS

    Velocity = Distance/Time


    A pwv measurement cont

    APWV measurement (cont.)


    Aortic stiffening and early wave reflection

    Elderly stiff arteries with ISH : Increased PW velocity (12 m/sec)

    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

    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)

    SphygmoCor

    • ? 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?


    Hypertension update 2009

    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.


    Caf study results

    CAFÉ Study Results


    Aix in ckd vs non ckd

    AIx in 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

    CKD

    Non-CKD


    Linear regression of aix by sbp

    Linear Regression of AIx by SBP

    Augmentation Index (%)

    R = 0.24, P <0.0001

    SBP


    Linear regression of aix by ppp

    Linear Regression of AIx by PPP


    Future developments in hypertension

    Future Developments in Hypertension

    Personal medicine

    Home BP monitoring


    Corin variants in african americans with hypertension and heart disease

    Corin Variants in African-Americans with Hypertension and Heart Disease

    enzyme

    enzyme

    T555I

    Q568P

    cell membrane

    Dries et al. Circulation 2005;112:2403Wang et al. Circ Res 2008;103:502


    Home blood pressure monitoring

    Home Blood Pressure Monitoring


    Graph from the daily readings

    Graph from the daily readings


    Hypertension update 2009

    Internet Based Hypertension Clinic Program:Achieve individual blood pressure goals

    Secure Data Transfer

    Wireless/USB

    Hypertension Clinic Review

    Feedback

    • Phone/email:

    • Titrate medication dose

    • Add medications

    CONTROLLED BLOOD PRESSURE


    Hypertension update 2009

    “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

    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


    Blood pressure monitoring preliminary data

    Blood Pressure Monitoring – Preliminary Data


    Take home points hypertension update 2009

    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


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