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Diagnostic Evaluation of the Hypertensive Patient- How much is enough?. Thomas Pickering MD, DPhil Behavioral Cardiovascular Health and Hypertension Program Columbia Presbyterian Medical Center New York.

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diagnostic evaluation of the hypertensive patient how much is enough

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

Thomas Pickering MD, DPhil

Behavioral Cardiovascular Health and Hypertension Program

Columbia Presbyterian Medical Center

New York

diagnostic evaluation of the hypertensive patient how much is enough2

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

How high is the blood pressure?

Why is it high?

What is the risk?

diagnostic evaluation of the hypertensive patient how much is enough3

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

How high is the blood pressure?

How should it be measured?

how should the blood pressure be measured

How should the Blood Pressure be Measured?

  • In the Clinic
    • By the doctor?
    • By a nurse?
    • By an automated device?
    • Outside the Clinic
    • Home monitoring?
    • Ambulatory monitoring?
slide5

60

60

50

50

40

40

30

30

20

20

Clinic

24-hr

10

10

Daytime

Nighttime

0

0

190

110

130

190

150

110

170

130

150

170

Ambulatory BP and Cardiovascular Disease

in the Elderly with Systolic Hypertension:

The Syst-Eur Study (N = 808)

High risk group- Clinic BP underestimates risk

Placebo

Active treatment

Cardiovascular disease

(per 1000 patient - year)

Low risk group- WCH Clinic BP overestimates risk

Staessen et al. JAMA 1999; 282: 539-46.

the white coat effect in the real world little et al bmj 2002 325 254

The White Coat Effect in the Real World(Little et al, BMJ 2002; 325: 254)

173 hypertensive patients in 3 general practices in the UK

Clinic (MD and RN), self-monitoring, and ABPM

White coat effect estimated as difference between other measures of BP and daytime BP:-

Physician 19/11 mmHg

Nurse 1 5/8 mmHg

Nurse 2 5/6 mmHg

Self-monitoring in clinic 10/13 mmHg

Self-monitoring at home 5/6 mmHg

slide8

Clinic Pressure

White Coat Hypertension

Sustained Hypertension

140/90

True Normotension

Masked Hypertension

135/85 Ambulatory Pressure

slide9

A Diagnosis of Hypertension

based exclusively on Physician readings is no longer acceptable

  • Measurement error
  • Small number of readings
  • Effects of recent activities
  • Expense & Inconvenience
  • White coat effect
prospective studies showing that home bp predicts cv morbidity better than clinic bp
Prospective Studies Showing that Home BP Predicts CV Morbidity Better than Clinic BP

Author Year Population N Comments

Imai 1996 Population 1789 ABP & HBP predict, not CBP

Bobrie 2004 Treated 4939 HBP predicts, not CBP

Sega 2005 Population 2051 HBP predicts better than CBP

prospective studies showing that home bp predicts cv morbidity better than clinic bp11
Prospective Studies Showing that Home BP Predicts CV Morbidity Better than Clinic BP

Author Year Population N Comments

Imai 1996 Population 1789 ABP & HBP predict, not CBP

Bobrie 2004 Treated 4939 HBP predicts, not CBP

Sega 2005 Population 2051 HBP predicts better than CBP

Home monitoring

should be recommended

for all patients

call to action for the reimbursement of home bp monitoring

Call to Action for the Reimbursement of Home BP Monitoring

Supported by

American Heart Association

American Society of Hypertension

Preventive Cardiovascular Nurses Association

change of blood pressure with age nhanes black women
Change of Blood Pressure with Age (NHANES- Black Women)

Systolic

Blood Pressure

mm Hg

Diastolic

Age

slide15

Relations Between SBP, DBP and Stroke in Different Age Groups (Prospective Studies Collaboration Lancet 2002; 360: 9349)

slide16

Relations Between SBP, DBP and Stroke in Different Age Groups (Prospective Studies Collaboration Lancet 2002; 360: 9349)

Even at ages 80-89 DBP risk

chd deaths versus sbp and dbp in mrfit
CHD Deaths Versus SBP And DBP In MRFIT

CHD Deaths Per 1000 Pt-Years

Diastolic Pressure (mm Hg)

Systolic Pressure

(mm Hg)

Neaton et al. Arch Intern Med. 1992;152;56.

chd deaths versus sbp and dbp in mrfit18
CHD Deaths Versus SBP And DBP In MRFIT

CHD Deaths Per 1000 Pt-Years

Diastolic Pressure (mm Hg)

Systolic Pressure

(mm Hg)

Neaton et al. Arch Intern Med. 1992;152;56.

diagnostic evaluation of the hypertensive patient how much is enough19

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

How high is the blood pressure?

Why is it high?

What is the risk?

jnc 7 identifiable causes of hypertension
JNC 7: Identifiable Causes of Hypertension
  • Sleep apnea
  • Drug-induced or related causes
  • Chronic kidney disease
  • Primary aldosteronism
  • Renovascular disease
  • Chronic steroid therapy and Cushing’s syndrome
  • Pheochromocytoma
  • Coarctation of the aorta
  • Thyroid or parathyroid disease
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
dyslipidemia and the risk of hypertension halperin et al hypertens 2006 47 45
Dyslipidemia and the risk of Hypertension (Halperin et al Hypertens 2006: 47:45)
  • 3110 men followed for 14 years in Physicians’ Health Study
  • Baseline lipids analyzed by quintiles

LDL Chol HTN Risk by 39%

Tot Chol HTN Risk by 23%

Baseline

HDL Chol HTN Risk by 32%

slide23
Antihypertensive Effect of Pravastatin in Patients with Hypertension and Hypercholesterolemia (Glorioso et al; Hypertens 1999: 34:1281)

Systolic pressure mmHg

Placebo Placebo

Placebo Statin

Statin Placebo

LDL cholesterol mmol/l

0 4 8 12 16 20 24 28 32 36 40 Weeks

ascot main results blood pressure lowering arm bpla lipid lowering arm lla

ASCOT: Main Results (Blood Pressure-Lowering Arm: BPLA & Lipid-Lowering Arm: LLA)

Effects of intervention on events

Endpoint BPLA* LLA** Blood Pressure Lipids

Primary 10%- NS 36%

Death 11% 13%- NS

Stroke 23% 27%

Total events/ 16% 21% procedures

* BPLA- ACEI/CCB vs. BB/Diuretic

** LLA- Statin vs. placebo

cardiovascular risk factors in prehypertension trophy
Cardiovascular Risk Factors in “Prehypertension” (TROPHY)

None -4%

Three or more- 59%

One- 14%

Two- 22%

(Nesbitt et al, AJH 2005;18:980)

cardiovascular risk factors in prehypertension trophy26
Cardiovascular Risk Factors in “Prehypertension” (TROPHY)

None -4%

Three or more- 59%

Cholesterol >200

HDL <40

TG >150

BMI > 25

Glucose >110

Insulin >20

Heart rate >80

Hematocrit >43 or 41

One- 14%

Two- 22%

(Nesbitt et al, AJH 2005;18:980)

overlap of four common conditions
Overlap of Four Common Conditions

Obesity

Hypertension

Diabetes

Sleep Disordered Breathing

overlap of four common conditions28
Overlap of Four Common Conditions

Obesity

Metabolic Syndrome

Hypertension

Diabetes

Sleep Disordered Breathing

association between sdb and hypertension shhs parent study nieto et al jama 2000 283 1829
Association Between SDB and Hypertension- SHHS Parent Study(Nieto et al, JAMA 2000;283,1829)

Adjusted for BMI etc.

Not adjusted for BMI

Odds Ratio of HTN

Apnea-Hypopnea Index per Hour

slide30
Sleep Disordered Breathing Predicts Hypertension- the Wisconsin Study(Peppard et al, NEJM 2000; 342: 1378)

Odds Ratio for Hypertension*

Apnea-Hypopnea Index

*Adjusted for baseline BP, BMI, age etc.

slide31
No Relationship between Isolated Systolic Hypertension & Sleep Apnea: SHHS Study(Haas, Pickering et al, Circ 2005)

P<0.002

Odds Ratio for HTN

NS

<1.5 1.5-5 5-15 15-30 >30 AHI

prevalence of sdb in hypertension
Prevalence of SDB in Hypertension

%

50

SHT

40

% of SDB

AHI > 15/hr

30

WCHT

20

High

MHT

NT

10

Clinic BP

140/90 mmHg

0

Low

High

Low

Awake ABP

135/85 mmHg

abnormalities associated with the metabolic syndrome

Abnormalities Associated with the Metabolic Syndrome

Central Obesity

Hypertension

Non-dipping pattern of 24 hr BP

Salt sensitive

Dyslipidemia

High triglycerides

Low HDL cholesterol

Increased small dense LDL

Insulin resistance

Type II diabetes

Increased NEFAs

Endothelial dysfunction

Increased PAI-I

Increased platelet aggregation

Microalbuminuria

Obstructive Sleep apnea

high prevalence of sleep apnea in resistant hypertension logan et al j hypertens 2001 19 2271
High Prevalence of Sleep Apnea in Resistant Hypertension (Logan et al J Hypertens 2001:19:2271)
  • 41 consecutive patients with 3 drug-resistant hypertension evaluated with PSG and ABPM
  • Clinic BP was 168/94 on 3.6 drugs; most were obese
  • 83% had OSA (AHI >10); commoner in men (96%) than women (65%)
  • ABPM showed that 64% were non-dippers; no difference in dipping between those with and without OSA
situations in which renin aldosterone measurement may be helpful
Situations in which Renin/Aldosterone Measurement May Be Helpful
  • Suspected secondary hypertension, e.g. hypokalemia (measure off drugs)
  • Refractory hypertension (measure on drugs)
  • Intolerance to multiple drugs (measure off drugs)
diagnostic evaluation of the hypertensive patient how much is enough36

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

How high is the blood pressure?

Why is it high?

What is the risk?

jnc 7 cvd risk factors
JNC 7: CVD Risk Factors
  • Hypertension*
  • Cigarette smoking
  • Obesity* (BMI >30 kg/m2)
  • Physical inactivity
  • Dyslipidemia*
  • Diabetes mellitus*
  • Microalbuminuria or estimated GFR <60 ml/min
  • Age (older than 55 for men, 65 for women)
  • Family history of premature CVD

(men under age 55 or women under age 65)

*Components of the metabolic syndrome.

jnc 7 target organ damage
JNC 7: Target Organ Damage
  • Heart
    • Left ventricular hypertrophy
    • Angina or prior myocardial infarction
    • Prior coronary revascularization
    • Heart failure
  • Brain
    • Stroke or transient ischemic attack
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy
why is echocardiography useful in hypertensive patients
Why Is Echocardiography Useful In Hypertensive Patients?

“No other biological variable (except advancing age) predicts cardiac risk better than left ventricular hypertrophy”.

(De Simone et al, J Hypertens 12;1129, 1994)

how common is lvh in hypertensive patients

How Common is LVH in Hypertensive Patients?

ECG LVH in about 5% of ht patients

Echo LVH in 15-30% of unselected ht patients

Echo LVH in 20 to 60% of ht patients in referral centers

indications for echocardiography in hypertensive patients
Indications for Echocardiography in Hypertensive Patients
  • Coexistent Heart Disease
  • Resistant Hypertension
  • Decision to Start Treatment Uncertain
echocardiographic lvmi as a predictor of cv risk schillaci et al hypertens 2000 35 580
Echocardiographic LVMI as a Predictor of CV Risk (Schillaci et al, Hypertens 2000; 35: 580)

CV Events per 100-pt years

Quintiles of LVMI

microalbuminuria

Microalbuminuria

Category Spot collection 24 hour

mg/mg creatinine mg/24 hr

Normal <30* <30

Microalbuminuria 30-300 30-300

Albuminuria >300 >300

Normal levels a bit lower in men (25 vs 35)

microalbuminuria relation to other cv risk factors
Microalbuminuria Relation to other CV Risk Factors
  • Hypertension
  • Hyperlipidemia
  • Central obesity
  • Smoking
  • LVH
  • Coronary Disease
  • Non-dipping BP pattern
slide45
Urine Albumin Predicts CV and Non-CV Mortality in the General Population (Hillege et al Circ 2002; 106: 1777)

Cardiovascular

Hazard Ratio for Death

Non-cardiovascular

Urinary Albumin (mg/L)

microalbuminuria and chd risk in hypertension borch johnsen et al atvb 1999 19 1992
Microalbuminuria and CHD risk in Hypertension (Borch-Johnsen et al ATVB 1999;19:1992)

Relative risk of CHD

High

Urine albumin

Low

<140 140-160 >160

Systolic Pressure

effects of enalapril and nitrendipine on urine albumin bianchi et al ajh 1991 4 291
Effects of Enalapril and Nitrendipine on Urine Albumin (Bianchi et al AJH 1991; 4:291)

Nitrendipine

Urine albumin (mg/24 hr)

Enalapril

Weeks

diagnostic evaluation of the hypertensive patient how much is enough48

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

  • In all patients
  • Sleep history
  • BMI
  • Out-of-office Blood Pressures (home monitoring)
  • Microalbuminuria
diagnostic evaluation of the hypertensive patient how much is enough49

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

  • In selected patients
  • Plasma renin/aldosterone
  • Out-of-office Blood Pressures (ambulatory monitoring)
  • Echocardiogram
slide50

National Heart, Lung, andBlood Institute

National High Blood PressureEducation Program

Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

slide51

Clinical Significance of Hypertensive

Target Organ Damage

Hypertension

Heart Brain Kidneys Arteries

LVH

Silent

Wall

Micro-

infarction

thickening

albuminuria

Syst

/

Diast

Deep white

dysfunction

Plaque

matter

Silent

lesions

ischemia

Silent Target Organ Damage

Chronic

Coronary

Cerebro

Peripheral

Heart

vascular

Renal

Vascular

Disease

Disease

Failure

Disease

Clinically Overt Target Organ Disease

slide52

Classification of Risk in Hypertension

Blood Pressure mm Hg

Other Risk Factors & Grade 1 Grade 2 Grade 3

Disease History 140-159/90-99 160-179/100-109 >180/>110

I No other risk factors LOW RISK MED RISK HIGH RISK

II 1-2 risk factors MED RISK MED RISK V. HIGH RISK

III 3 or more risk factors HIGH RISK HIGH RISK V. HIGH RISK

TOD or Diabetes

IV ACC V. HIGH RISK V. HIGH RISK V. HIGH RISK

classification of obesity by bmi

Classification of Obesity by BMI

Obesity class BMI

Underweight <18.5

Normal 18.5-24.9

Overweight 25.0-29.9

Obesity grade I 30.0-34.9

II 35.0-39.9

Extreme obesity III >40

total hdl cholesterol as predictors of ed wei et al am j epidemiol 1994 140 930

Total & HDL Cholesterol as Predictors of ED(Wei et al, Am J Epidemiol 1994;140:930)

3250 healthy men attending Cooper Clinic in Dallas

71 developed new onset ED during a 2 year follow-up.

Strongest predictors were total and HCDL cholesterol.

the massachussets male aging study feldman et al j urol 151 54 1994

The Massachussets Male Aging Study(Feldman et al, J Urol 151,54, 1994)

Predictors of ED

1. Disease

39% with treated heart disease

28% with treated diabetes

15% with treated hypertension

(10% in general population)

predictors of stroke and mi piuma study verdecchia et al circ 2001 103 2579

Predictors of Stroke and MI- PIUMA Study(Verdecchia et al Circ 2001; 103; 2579)

Stroke Myocardial Infarction

Age Age

Gender Gender

Diabetes Diabetes

24-hr Mean BP24-hr Pulse Pr

Cholesterol

Smoking

rationale one size does not fit all

Rationale- One Size Does Not Fit All

Level of risk varies greatly in hypertensive patients

Responsiveness to treatment varies greatly in hypertensive patients

rationale one size does not fit all60

Rationale- One Size Does Not Fit All

Level of risk varies greatly in hypertensive patients

Responsiveness to treatment varies greatly in hypertensive patients

Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria

rationale one size does not fit all61

Rationale- One Size Does Not Fit All

Level of risk varies greatly in hypertensive patients

Responsiveness to treatment varies greatly in hypertensive patients

Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria

Need tests to improve prediction of treatment response, e.g. renin

recommendations for clinical use of abpm jnc 7 who ish

Recommendations for Clinical Use of ABPM: JNC 7 & WHO-ISH

JNC 7 WHO-ISH

ABPM endorsed Yes Yes

Indications:

White Coat HTN Yes Yes

Labile BP Yes Yes

R/O hypotensive episodes Yes Yes

Resistant HTN Yes Yes

Autonomic dysfunction Yes No

slide63

60

60

50

50

40

40

30

30

20

20

Clinic

24-hr

10

10

Daytime

Nighttime

0

0

190

110

130

190

150

110

170

130

150

170

Ambulatory BP and Cardiovascular Disease

in the Elderly with Systolic Hypertension:

The Syst-Eur Study (N = 808)

Placebo

Active treatment

Cardiovascular disease

(per 1000 patient - year)

Staessen et al. JAMA 1999; 282: 539-46.

slide64

60

60

50

50

40

40

30

30

20

20

Clinic

24-hr

10

10

Daytime

Nighttime

0

0

190

110

130

190

150

110

170

130

150

170

Ambulatory BP and Cardiovascular Disease

in the Elderly with Systolic Hypertension:

The Syst-Eur Study (N = 808)

High risk group- Clinic BP underestimates risk

Placebo

Active treatment

Cardiovascular disease

(per 1000 patient - year)

Staessen et al. JAMA 1999; 282: 539-46.

two types of hypertension

Two Types of Hypertension

1. Systolic and Diastolic Hypertension

- Younger and obese patients

- Evidence for increased sympathetic nerve activity

2. Isolated Systolic Hypertension

- Older and lean patients

- No evidence for increased sympathetic nerve activity

- Attributable to increased arterial stiffness

patient evaluation
Patient Evaluation
  • Evaluation of patients with documented HTN has three objectives:
  • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.
  • Reveal identifiable causes of high BP.
  • Assess the presence or absence of target organ damage and CVD.
slide68

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM
slide69

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM
  • Some type of out-of-office BP monitoring (home or ambulatory) is advisable in ALL patients
  • ABPM is indicated when there is a discrepancy between either successive clinic readings or clinic and home readings
slide70

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography
slide71

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography
  • Echocardiography is indicated if any of the following occur
    • Coexistent heart disease
    • Refractory hypertension
    • Decision to treat uncertain
slide72

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement
slide73

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

  • Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement
  • Renin measurement is indicated in the following situations:

- Suspected secondary hypertension

- Refractory hypertension

- Intolerance to multiple drugs