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 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
(Persistent urinary albumin excretion of 30-300mg/24hrs)
van den Hoogen et al. N Engl J Med 2000;342:1.
Vasan RS et al. N Engl J Med 2001;345:1291.
Relationship Between Hypertension and IHD Mortality
Lewington S, et al. Lancet 2002; 360:1903–13
National Health and Nutrition Examination Survey
Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74
SBP < 140 mmHg and DBP < 90 mmHg
Hajjar I, et al. JAMA. 2003;290:199-206.
Ong KL et al Hypertension 2007: 49;69-75
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
Factors Contributing to Poor Blood Pressure Control
Took no action
Prescribed add-on therapy
From: Taylor Nelson Healthcare, Epson, Surrey England - Cardiomonitor 1992
Blood Pressure (BP) Classification and Management*
Life-Initial Drug Therapy BP SBP, DBP, styleCompelling Indications Classification mm Hg*mm Hg* Changes Without With
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.
Rafey et al
Does the patient have primary or secondary (reversible) hypertension?
Is target organ damage present?
Are other cardiovascular (CV) risk factors present?
<30 or >55 years of age
Refractory to 3-drug regimen
Evidence of diffuse vascular disease
ARF with ACEI
Duplex renal arteries
Renal vein renin
Renal artery stenosis
Adrenal and adrenal-like
Liddle’s syndrome, Gordon’s syndrome
Acute intermittent porphyria
Thyroid (hyper, hypo)
Coarctation of Aorta
Chronic Kidney Disease and hypertension:
Angioplasty and Stent for Renal Artery Lesions
Cardiovascular Outcomes in Renal Atherosclerotic Lesions
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.
and Key Messages
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.
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)
Number of BP meds
Updated from Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
Reduction of WCE in Clinical Practice
Blood Pressure (mmHg)
Myers M, et al, Journal of Hypertension 2009 27(2) 280-286
White coat effect
Work in progress
ComprehensiveEvaluation of Hypertension
Central BP /PWV
H & P
Comprehensive Management Plan Based on Risk Estimates
Clinical situations in which ABPM may be helpful:
Davidson et al Arch Intern Med. 2006;166:846-852
24 Hour Ambulatory Blood Pressure Monitoring
Measures of Arterial Stiffness
Aortic PWV (distance/time)
How PWV is measured...
Velocity = Distance/Time
Elderly stiff arteries with ISH : Increased PW velocity (12 m/sec)
Young compliant arteries :Normal PW velocity (8 m/sec)
(1) Ventricular-Vascular coupling
(2) coronary blood flow
(1) Ventricular-vascular mismatch
(2) The reflected wave increases or “augments” central SBP during late systole:
Arterial stiffness measures
CBP (central BP)
AIX (Augmentation Index)
PVW(Pulse wave velocity)
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.
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
Augmentation Index (%)
R = 0.24, P <0.0001
Future Developments in Hypertension
Home BP monitoring
Dries et al. Circulation 2005;112:2403Wang et al. Circ Res 2008;103:502
Internet Based Hypertension Clinic Program:Achieve individual blood pressure goals
Secure Data Transfer
Hypertension Clinic Review
CONTROLLED BLOOD PRESSURE
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The EverOnTM System