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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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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

slide7
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

slide10
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

slide11
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

slide12
Blood Pressure (BP) Classification and Management*

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

Normal <120 and <80 encourage

Pre HYTN 120-139 or 80-89 Yes No Yesa

Stage 1 HYTN 140-159 or 90-99 Yes Yesb Yesc

Stage 2 HYTN >160 or >100 Yes Yesd Yese

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

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

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

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

d Two-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.

e Other antihypertensive drugs (diuretics, ACEI, ARB, b-blocker, CCB) as needed.

JNC VII. JAMA 2003;289:2560.

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
slide23
23

www.coralclinicaltrial.gov

slide24
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
slide30
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
slide32
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

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

slide39
Measures of Arterial Stiffness
  • Central Aortic Pressure
  • Pulse Wave Velocity (PWV)
  • Augmentation Index (AIx)
slide40
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

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?
slide44
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 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

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

slide53
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

slide54
“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
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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