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Treatment-Resistant Hypertension: Diagnosis and Management

Treatment-Resistant Hypertension: Diagnosis and Management. Power Over Pressure www.poweroverpressure.com. Not all patients with uncontrolled hypertension are treatment resistant. Uncontrolled Hypertension. Includes patients who lack blood pressure (BP) control for any reason: 1

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Treatment-Resistant Hypertension: Diagnosis and Management

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  1. Treatment-Resistant Hypertension: Diagnosis and Management Power Over Pressure www.poweroverpressure.com

  2. Not all patients with uncontrolled hypertension are treatment resistant • Uncontrolled Hypertension Includes patients who lack blood pressure (BP) control for any reason:1 • Inadequate treatment regimens • Poor adherence • Undetected secondary hypertension • True treatment resistance • Treatment-Resistant Hypertension • BP that remains above goal with maximum tolerated doses of ≥3 antihypertensive medications* of different classes; ideally, 1 of the 3 agents should be a diuretic1,2 • *Patients who require 4 antihypertensive agents to achieve BP control are also considered treatment resistant, according to some sources.1 Calhoun DA, et al. Circulation. 2008;117:e510-e526. Mancia G, et al. Eur Heart J. 2007;28:1462-1536. Power Over Pressure www.poweroverpressure.com

  3. Who is at risk? Patient Characteristics Associated With Treatment-Resistant Hypertension* Older age Obesity Female sex Diabetes Chronic kidney disease Excessive dietary salt ingestion Black race High baseline blood pressure Left ventricular hypertrophy *Based on analyses of data from the Framingham Study and The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Calhoun DA, et al. Circulation. 2008;117:e510-e526. Power Over Pressure www.poweroverpressure.com

  4. Which of these patients have treatment-resistant hypertension? Power Over Pressure www.poweroverpressure.com

  5. Which of these patients have treatment-resistant hypertension? Treatment-resistant hypertension is a diagnosis of exclusion, requiring a systematic approach to evaluation and management Power Over Pressure www.poweroverpressure.com Calhoun DA, et al. Circulation. 2008;117:e510-e526.

  6. The systematic approach to diagnosis begins with the definition… • BP that remains above goal, in spite of… Treatment-resistant hypertension is defined as:1,2 • compliance with maximum doses*… • of 3 antihypertensive medications†… • from different classes, ideally including a diuretic… BP Goal • Reversible causes identified and addressed • *All medications should be titrated to the maximum in-label doses or until BP control is achieved, except in • cases of intolerance, in which case treatments should be optimized to the maximum tolerated doses • †Patients who require 4 antihypertensive agents to achieve BP control are also considered treatment resistant, according to some sources.1 • Calhoun DA, et al. Circulation. 2008;117:e510-e526. • Mancia G, et al. Eur Heart J. 2007;28:1462-1536. Power Over Pressure www.poweroverpressure.com

  7. Treatment-resistant hypertension: a systematic approach to evaluation and management • Confirm Accuracy of BP Measurement • Utilize correct BP measurement technique • Rule out white-coat effect • Optimize Pharmacotherapy and Adherence • Regimen of 3 drugs of different classes, including a diuretic • Assess and improve adherence to the treatment regimen • Intensify pharmacologic therapy • Consider Referral to a Specialist • Treatment for secondary causes of hypertension • Hypertension specialist for intensive management of true treatment-resistant hypertension • Address Lifestyle Barriers to BP Control • Interfering substances • Dietary salt intake • Alcohol consumption • Obesity Power Over Pressure www.poweroverpressure.com • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392.

  8. Treatment-resistant hypertension: a systematic approach to evaluation and management • Confirm Accuracy of BP Measurement • Utilize correct BP measurement technique • Rule out white-coat effect • Optimize Pharmacotherapy and Adherence • Regimen of 3 drugs of different classes, including a diuretic • Assess and improve adherence to the treatment regimen • Intensify pharmacologic therapy • Consider Referral to a Specialist • Treatment for secondary causes of hypertension • Hypertension specialist for intensive management of true treatment-resistant hypertension • Address Lifestyle Barriers to BP Control • Interfering substances • Dietary salt intake • Alcohol consumption • Obesity Power Over Pressure www.poweroverpressure.com • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392.

  9. Technique is a common cause of pseudoresistance Tips for obtaining accurate office BP readings • A cuff that is too small may cause an erroneously elevated reading1,2 • Properly sized cuff rule-of-thumb: the cuff’s air bladder should encircle at least 80% of the patient’s arm circumference • Allow patient to sit quietly for 5 minutes with the arm supported at heart level before the reading is taken1,2 • Patient should remove clothing that constricts upper arm2 • The average of 2 readings taken a minute apart should be recorded as the patient’s blood pressure1 • If BP is significantly different between the 2 arms, use the higher reading to guide treatment decisions2 • Other factors that can effect BP readings include recent caffeine, nicotine, or alcohol consumption, full bladder, and background noise (including conversation)2 Makris A, et al. Int J Hypertens.2011:598694. Pickering T, et al. Hypertension. 2005;45:142-161. Power Over Pressure www.poweroverpressure.com

  10. Eliminating “white-coat” effect • What Is It? • Elevated BP in physician’s office, but significantly lower when measured at home1 • How Prevalent? • A recent Spanish study of 8,295 patients with treatment-resistant hypertension found that 37.5% actually had office-resistant hypertension2 • When to Suspect? • White-coat resistance may be present in patients with consistently elevated BP but no evidence of target organ damage3 • How to Screen? • Consider repeated at-home BP measurements to rule out white-coat resistance3 • Where available, 24-hour ambulatory BP monitoring (ABPM) may be used for further diagnostic evaluation3 Calhoun D, et al. Circulation. 2008;117;e510-e526. de la Sierra A, et al. Hypertension. 2011;57:898-902. Moser M, Setaro JF. N Engl J Med. 2006;355:385-392. Power Over Pressure www.poweroverpressure.com

  11. Automated BP measurement Automated office BP measurement has several advantages1: • Minimizes potential for user error • Enables efficient collection of multiple BP readings • Reduces patient anxiety and aids in detection of white-coat effect • Average of 5 BP readings taken 1 minute apart, while patient is alone in room, has been shown to approach average waking BP Home BP measurement is a useful tool: • Average of as few as 6 readings may achieve similar accuracy for measurement of true ambulatory BP as ABPM2 • May improve adherence to the treatment regimen3 • Affordable and accessible3,4 • Considerations: • Patients should be trained in proper BP measurement technique3,4 • Patients should utilize validated monitors to ensure accuracy (wrist or finger cuffs should be avoided)3,4 • Patients should bring new devices to clinic to confirm accuracy4 Myers M, et al. Hypertension. 2010;55:195-200. Chatellier G, et al. Am J Hypertens. 1996;9:644-652. 3. Parati G, et al. J Hypertens. 2008;26:1505-1526. 4. Pickering TG, White WB. J Am SocHypertens. 2008;2:119-124. Power Over Pressure www.poweroverpressure.com

  12. Treatment-resistant hypertension: a systematic approach to evaluation and management • Confirm Accuracy of BP Measurement • Utilize correct BP measurement technique • Rule out white-coat effect • Optimize Pharmacotherapy and Adherence • Regimen of 3 drugs of different classes, including a diuretic • Assess and improve adherence to the treatment regimen • Intensify pharmacologic therapy • Consider Referral to a Specialist • Treatment for secondary causes of hypertension • Hypertension specialist for intensive management of true treatment-resistant hypertension • Address Lifestyle Barriers to BP Control • Interfering substances • Dietary salt intake • Alcohol consumption • Obesity Power Over Pressure www.poweroverpressure.com • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392.

  13. Poor adherence is a common cause of pseudoresistance • Signs of nonadherence2 • Missed office visits • Lack of physiological evidence of therapy, such as • No change in BP • Absence of anticipated common side effects • Check for suspected nonadherence by • Discussing medication use with spouse or caregiver3 • Verifying prescription refills with the pharmacy • Reviewing factors causing nonadherence and counseling patients on importance of therapy4 39% Non-users 39% Continuous users 22% Restarters Percentage of patients utilizing antihypertensive agents at 10 years1 • Within just 1 year, >1 in 3 patients had already discontinued their medication1 • After 10 years, almost 2 in 3 patients did not take their antihypertensive medications continuously1 • Van Wijk BLG, et al. J Hypertens. 2005;23:2101-2107. • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392. • Calhoun DA, et al. Circulation. 2008;117:e510-e526. • Hill M, et al. J ClinHypertens. 2010;12:757-764. Power Over Pressure www.poweroverpressure.com

  14. Treatment-resistant hypertension: a systematic approach to evaluation and management • Confirm Accuracy of BP Measurement • Utilize correct BP measurement technique • Rule out white-coat effect • Optimize Pharmacotherapy and Adherence • Regimen of 3 drugs of different classes, including a diuretic • Assess and improve adherence to the treatment regimen • Intensify pharmacologic therapy • Consider Referral to a Specialist • Treatment for secondary causes of hypertension • Hypertension specialist for intensive management of true treatment-resistant hypertension • Address Lifestyle Barriers to BP Control • Interfering substances • Dietary salt intake • Alcohol consumption • Obesity Power Over Pressure www.poweroverpressure.com • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392.

  15. Interfering substances may contribute to treatment resistance Use of interfering substances • Certain medications or other drugs may cause elevated BP or inhibit the effects of antihypertensive medications • Nonsteroidalanti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors • Sympathomimeticdrugs (ephedra, phenylephrine, cocaine, amphetamines, etc) • Herbal supplements • Anabolic steroids • Appetite suppressants • Erythropoietin • Oral contraceptives • Question patients about the use of interfering substances • If possible, discontinue use of these agents; otherwise, consider modifying antihypertensive therapy • Calhoun DA, et al. Circulation. 2008;117:e510-e526. • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392. Power Over Pressure www.poweroverpressure.com

  16. Patient factors may contribute to treatment resistance Modifiable lifestyle factors • High sodium intake (urinary sodium excretion >150 mmol/day) may contribute to treatment-resistant hypertension both by increasing BP directly and by blunting the BP-lowering effect of antihypertensive drugs • Elderly patients, black patients, and patients with chronic kidney disease may be more sensitive to salt intake • Excessive alcohol intake of >3-4 drinks per day may also contribute to treatment-resistant hypertension • Obesity is associated with more severe hypertension, requirement for increased number of antihypertensive medications, and increased likelihood of never achieving BP control • It is estimated that >40% of patients with treatment-resistant hypertension are obese Excessive dietary salt ingestion Obesity Excessive alcohol ingestion Calhoun DA, et al. Circulation. 2008;117:e510-e526. Moser M, Setaro JF. N Engl J Med. 2006;355:385-392. Power Over Pressure www.poweroverpressure.com

  17. What to expect: lifestyle modification effects on BP *Combining 2 of these modifications may or may not have an additive effect on blood pressure reduction. SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension. Chobanian AV, et al. JAMA. 2003;289:2560-2572. Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958. Table courtesy of Hypertension Online. http://www.hypertensiononline.org/slides2/slide01.cfm?tk=24&dpg=5. Accessed April 27, 2012 Power Over Pressure www.poweroverpressure.com

  18. Treatment-resistant hypertension: a systematic approach to evaluation and management • Confirm Accuracy of BP Measurement • Utilize correct BP measurement technique • Rule out white-coat effect • Optimize Pharmacotherapy and Adherence • Regimen of 3 drugs of different classes, including a diuretic • Assess and improve adherence to the treatment regimen • Intensify pharmacologic therapy • Consider Referral to a Specialist • Treatment for secondary causes of hypertension • Hypertension specialist for intensive management of true treatment-resistant hypertension • Address Lifestyle Barriers to BP Control • Interfering substances • Dietary salt intake • Alcohol consumption • Obesity Power Over Pressure www.poweroverpressure.com • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392.

  19. Difficult-to-control hypertension may be due to underlying conditions • A number of medical conditions may contribute to hypertension • Patients should be screened for these disorders if suggestive findings are identified upon history taking, physical exam, or basic laboratory testing • Patients with treatment-resistant hypertension and a secondary cause will rarely achieve BP control until the underlying cause is treated* • Consider consultation with a hypertension specialist for evaluation of secondary causes of hypertension • *Many patients with renal artery stenosis or aldosteronism may achieve BP control without diagnosis of the underlying condition. • Calhoun DA, et al. Circulation. 2008;117:e510-e526. • Moser M, Setaro JF. N Engl J Med. 2006;355:385-392. • Kaplan NM, Victor R. Kaplan's Clinical Hypertension. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010. Power Over Pressure www.poweroverpressure.com

  20. Summary: diagnosis and management of treatment-resistant hypertension The diagnosis and management of true treatment-resistant hypertension is accomplished through a process of exclusion • Identify and reverse “pseudoresistance” • Confirm proper measurement technique • Exclude “white-coat” effect • Assess adherence to treatment regimen • Identify and reverse factors contributing to true resistance • Interfering substances • Modifiable lifestyle factors • Obesity • Excessive sodium intake • Excessive alcohol intake • Identify and, if possible, reverse causes of secondary hypertension • Consider consultation with a hypertension specialist for evaluation of secondary causes of hypertension Power Over Pressure www.poweroverpressure.com

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