1

Case Studies in Managing g gHypertension: Defining the Barriers

to Control

David Feldman, MD, PhD, FACC, FAHADirector of Heart Failure and CardiacDirector of Heart Failure and Cardiac

TransplantationThe Ohio State University

Learning ObjectivesAggressively screen for and manage hypertension, using evidence-based guidelines to help you and your patients set treatment goalsg

Target interventions (lifestyle changes and pharmacologic agents) to prevent disease progression and reduce morbidity and premature mortality

Recognize and remove important barriers to improving blood pressure control

Explore therapeutic combinations that can prevent disease progression and improve morbidity and mortality

Identify one change you can make to your practice that will support ongoing implementation of these lessons

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Significance of Hypertension•In the United States, hypertension affects approximately 50 million individuals, and accounts for 35 million office visits per year. Worldwide, about 1 billion people have hypertension.

•Only 33% of people who are receiving treatment for hypertension have their blood pressure under control.

•Relationship between blood pressure (BP) and risk of cardiovascular disease (CVD) is continuous, consistent, and independent of other risk factors.

•Individuals who are normotensive at 55 years of age have a 90% lifetime risk of developing HTN (Framingham).

•For those between 40 and 70 years of age whose BP is between 115/75 to 185/115, each increase of 20 mmHg in systolic BP or 10 mmHg in diastolic BP doubles the risk of CVD.

JNC 7

Men age 55 and woman age 65 have a 90% risk of developing hypertension.

2004 direct costs = $55.5 billion

If co-morbidities are added (end-stage renal disease, coronary artery disease, congestive heart failure diabetes mellitus cerebrovascularheart failure, diabetes mellitus, cerebrovascular accident), cost is $108 billion.

3

JNC 7: Are You Surprised?

30% of adults do not know they have hypertensionhypertension.

40% of those who are hypertensive are not being treated.

66% of those who are being treated have a blood pressure greater than 140/90 mmHg.

Benefits of Lowering Blood Pressure

Anti-hypertensive therapy associated with:

• 35% – 40% mean decrease in stroke• 20% – 25% decrease in MI• More than 50% decrease in heart failure

Patients who have stage 1 hypertension/additional risk factors:

• Achieving a sustained 12 mmHg decrease in systolic BP for 10 years will prevent 1 death for every 11 pts treated

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JNC 7: Treatment Algorithm for HypertensionLifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

Without compelling indications

Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg)Thiazide-type diuretic for most.May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 hypertension(SBP ≥160 or DBP ≥100 mm Hg)Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

With compelling indications

Drugs for compelling indicationsOther antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=β-blocker; CCB=calcium channel blocker

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report. National Heart, Lung and Blood Institute. Bethesda, 2004.

Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.

Not at goal blood pressure

JNC 7: The Fine Print

Cracking open the door beyond diuretics for first line in a patient without co-morbid conditionsp− Along with promoting a thiazide diuretic for Stage 1

HTN, the committee added this surprising sentence: “May consider ACE-I, ARB, BB, CCB.”

The ‘Compelling Indication’ Category - JNC put emphasis on evidence showing benefits with specific antihypertensive agents for certain medical conditions. Again, taking a small sidestep from the NHLBI dictum of diuretics first.

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Case Presentation #1

Vicki Struthers

36 y/o white female

PMH− Recently returned to work

10 weeks after the birth of first child

− Total cholesterol: 160 mg/dL

/− HDL: 66 mg/dL − LDL: 120 mg/dL − Family history of diabetes− No history of smoking

*Hypothetical case based on a typical patient expected to present in clinical practice

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Vicki Struthers – by the numbersTests Ordered Before Your

Visit TodayECG lECG-normal

LabsCr: 0.9 mg/dL; Na: 135 mmol/L; glucose: 97 mg/dL; HCT: 35; TSH: 2.1; K: 4.2 mmol/L

Vit lVitalsHR: 88 bpm, BP: 138/89mm/Hg, BMI: 23No Rx, NKDA

Treatment Alternatives

What do you recommend now?

A. Diet and lifestyle modification

B. Begin drug therapy

C. Ask her to come back for a BP recheck in one week.

D. All of the above.

E. A & C

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Treatment Alternatives Correct Answer

What do you recommend now?

A. Diet and lifestyle modification

B. Begin drug therapy

C. Ask her to come back for a BP recheck in one week.

D. All of the above.

E. A & C

1-week Follow-up

Vicki returns in a week. She’s begun a daily exercise program and her BP on return is 138/88 H Wh t i th t di i ?138/88 mm Hg. What is the correct diagnosis?

A. Normal BPB. PrehypertensionC. Stage 1 hypertensionD. Not sure

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1-week Follow-upCorrect Answer

Vicki returns in a week. She’s begun a daily exercise program and her BP on return is 138/88 H Wh t i th t di i ?138/88 mm Hg. What is the correct diagnosis?

A. Normal BPB. PrehypertensionC. Stage 1 hypertensionD. Not sure

Treatment Alternatives

What is the best treatment for Vicki at this point?

A. Diet and lifestyle modification, and regular follow-up of her BP

B. Drug therapy

C. Both of the above

D. Have her fill out her “bucket list” and enjoy the last year of her life.

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Treatment AlternativesCorrect Answer

What is the best treatment for Vicki at this point?

A. Diet and lifestyle modification, and regular follow-up of her BP

B. Drug therapy

C. Both of the above

D. Have her fill out her “bucket list” and enjoy the last year of her life.

Vicki Struthers @ 1 & 12 Years Later

At 1 yr: “I take my medicine”, structured exercise programstructured exercise program

Low-salt, low-fat diet

At 12 yrs: Running 10Ks, daughter in middle school.

BP: 118/70

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Clinical Practice Recommendation

Exercise may be beneficial in lowering blood pressure and reducing cardiovascular risk.

Strength of Evidence:Three reviews of 50 observational studies found the risk of CV disease was lowered in those who were physically active. Conversely, a review of 43 epidemiological studies found that physical inactivity was associated with a doubling of cardiovascular disease.

Evidence Based Source:Bandolier

Website of Supporting Evidence:http://www.jr2.ox.ac.uk/bandolier/booth/hliving/ExcerCVDis.html

Initial Drug Therapy

BP SBP* DBP* Lif t lWithout

C lliWith

C lli

JNC 7: Classification and Management of Blood Pressure for Adults

BP Classification

SBP* (mm Hg)

DBP* (mm Hg)

Lifestyle Modification

Compelling Indications

Compelling Indications

Normal <120 and <80 EncourageNo antihypertensive drug indicated.

Drug(s) for compelling indications.Prehypertension 120–139 or 80–89 Yes

Stage 1 hypertension 140–159 or 90–99 Yes

Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination.

Drug(s) for compelling indications.

Other antihypertensive Stage 2

Two-drug combination for most (usually yp

drugs (diuretic, ACEI, ARB, BB, CCB) as needed.

Stage 2 hypertension ≥160 or ≥100 Yes thiazide-type diuretic

and ACEI or ARB or BB or CCB).

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report. National Heart, Lung and Blood Institute. Bethesda, 2004.

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Case Presentation #2

Nate Biddleson55 y/o African-American male presents for follow-up after an Executive Physical.

Past Medical History− Blood pressure on initial presentation

was 157/95, now 146/94− Non-smoker, no known CAD − Fasting glucose 140 mg/dL (repeated

f i i it h it 142from previous visit, when it was 142 mg/dL); A1C: 8.2%

− Initial therapy: Diet modification, increased exercise, took “some vacation”, and started 25 mg of HCTZ

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When the First Drug Doesn’t Work

JNC 7 advocates for rapid progression to combination therapy before fully exploring mono-therapy.

This approach is not an issue for those with Stage 2, but for Stage 1. Different mechanisms may cause HTN in different patients; and heterogeneous mechanisms from multiple class of agents may be necessary.

Alternative approach: if there is a partial response, then increase the dose or add a second agent. If there is no response at all, try an alternate class. The goal here being to find the simplest way to control blood pressure.

What Should We Do Next?

A. Continue dietary modification and exercise recommendationsrecommendations

B. Begin therapy with an ACEi, ARB, or CCB

C. Refer to dietitian for diet counseling

D. Begin metformin

E. All of the above

F. A & B only

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What Should We Do Next? Correct Answer

A. Continue dietary modification and exercise recommendationsrecommendations

B. Begin therapy with an ACEi, ARB, or CCB

C. Refer to dietitian for diet counseling

D. Begin metformin

E. All of the above

F. A & B only

2-Week Follow-Up

Mr. Biddleson returns, having visited with the dietitian and is trying to implement his recommendations. He has started y gwalking daily. His BP at this visit is 136/84; 2hr postprandial glucose is 126 mg/dL. What should we consider next?

A. Increase the dose of the ACEi/ARB or CCB

B. Consider additional up-titration or new medications for diabetes, High BP or cholesterol as needed.g

C. Initiate a dose of aspirin, if not already startedD. All of the above

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2-Week Follow-Up Correct Answer

Mr. Biddleson returns, having visited with the dietitian and is trying to implement his recommendations. He has started y gwalking daily. His BP at this visit is 136/84; 2hr postprandial glucose is 126 mg/dL. What should we consider next?

A. Increase the dose of the ACEi/ARB or CCB

B. Consider additional up-titration or new medications for diabetes, High BP or cholesterol as needed.g

C. Initiate a dose of aspirin, if not already startedD. All of the above

1-Month Follow-Up

Mr. Biddleson returns for follow-up. His BMI is 29; 2hr postprandial glucose is 92 mg/dL; HgA1c is 6.8% and his BP is 120/78.

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ABCD2 3 (132 mm Hg)

AASK1 (134 mm Hg)

High-Risk Hypertensive Patients Require Multiple Agents to Get to Goal

AchievedSystolic BP

ABCD2,3 (132 mm Hg)

ALLHAT4 (135 mm Hg)

RENAAL7 (140 mm Hg)

IDNT6 (140 mm Hg)

UKPDS2,8 (144 mm Hg)

HOT2,5 (141 mm Hg)

1 2 3 4

AASK=African-American Study of Kidney Disease and Hypertension; ABCD=Appropriate Blood Pressure Control in Diabetes; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trials; HOT=Hypertensive Optimal Treatment; IDNT=Irbesartan Diabetic Nephropathy Trial; RENAAL=Reduction of Endpoints in Non-Insulin Diabetes Mellitus with the Angiotensin II Antagonist Losartin; UKPDS=United Kingdom Prospective Diabetes Study.1Wright JT et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147. 3Estacio RO et al. N Engl J Med. 1998;338:645-652. 4The ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997. 5Hansson L et al. Lancet. 1998;351:1755-1762. 6Lewis EJ et al. N Engl J Med. 2001;345:851-860. 7Bakris GL et al. Arch Intern Med. 2003;163:1555-1565. 8UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.

Number of BP Medications

Compelling Indications for Consideration of One Drug Class vs. Another

Heart Failure: Thiazide/loop, BB, ACEi, ARB, Aldosterone antagonist

Post- MI: BB, ACE, Aldosterone antagonist

High CVD risk: Thiazide, BB, ACEi, ARB

DM: Thiazide, BB, ACEi, ARB, CCB

CRF:Cr > 1.5 in menCr > 1.3 in women

ACEi, ARB. For creatinine 2-3 try loop diuretic

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R f t

ACC/AHA Practice GuidelinesPyramid Approach to HF Stages

Structural Heart DiseaseP i MI

HF with Current or Prior SymptomsKnown structural heart diseaseShortness of breath and fatigue

Reduced exercise tolerance

Refractory End-Stage HF

Marked symptoms at restdespite maximal medical therapy*

B

CD

High Risk for Developing HFHypertension

CADDiabetes mellitus

Family history of cardiomyopathy

Previous MILV systolic dysfunction

Asymptomatic valvular disease

A

B

Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43

Case Presentation #3

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Clark Galloway

42 y/o white male

Past medical history• “borderline” hypertension• “…too busy to exercise”• Total cholesterol: 223 mg/dL • HDL: 24 mg/dL

P t d d l t d t• Parents deceased related to “some heart failure thing”

• +TOB (smoker)

*Hypothetical case based on a typical patient expected to present in clinical practice

Clark Galloway – by the numbers

Tests Ordered Before Visit TodayECG: normal sinus rhythm (NSR), No Q wave, an intra-

t i l d ti d l d lt / l ftventricular conduction delay and voltage c/w left ventricular hypertrophy.

Echo: next slide

LabsTotal cholesterol 223 mg/dL, HDL-C 24 mg/dL, SCr: 1.1mg/dL; Na: 140 mmol/L, fasting glucose: 140 mg/dL; HCT: 44; TSH: 1.1; fasting glucose taken on two separate days 128 mg/DL and 138 mg/DLseparate days 128 mg/DL and 138 mg/DL

VitalsHeart Rate: 82 bpm; BP: 142/86 mmHg; BMI: 26

No prescription medicine (Rx), NKDA

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Clark Galloway –Parasternal Long Axis Echo

What Do You Recommend?

A. Begin an ACEi or ARBB St l d di t d lif t lB. Strongly recommend dietary and lifestyle

modification, including low Na, low-fat diet and a daily exercise program

C. Begin a statin and aspirinD. Return visit in 2 weeks with recheck of fasting

blood glucose and blood pressure and considerblood glucose and blood pressure and consider a BB at this juncture as an additional medication.

E. All of the above

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What Do You Recommend?Correct Answer

A. Begin an ACEi or ARBB St l d di t d lif t lB. Strongly recommend dietary and lifestyle

modification, including low Na, low-fat diet and a daily exercise program

C. Begin a statin and aspirinD. Return visit in 2 weeks with recheck of fasting

blood glucose and blood pressure and considerblood glucose and blood pressure and consider a BB at this juncture as an additional medication.

E. All of the above

Clark Galloway 1 Year Later

At 1 yr: “I was too busy to exercise and I don’t like medicine… I felt fine”

BP is 156/98, HR93 bpm. His BMI is 26. His fasting blood glucose is 130blood glucose is 130 mg/dL. His total cholesterol is 240.

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What Are Appropriate Actions At This Visit?

A. Discuss the potential outcomes and risks of uncontrolled hypertension with other factors such as elevated blood l d d li id iglucose and dyslipidemia

B. Re-prescribe medications mentioned earlier

C. Cautiously add a prescription for metformin and a nonspecific-BB in a short period of time.

D. Admit to the hospital

E. Choices A and B

F. Choices A, B and C

What Are Appropriate Actions At This Visit? Correct Answer

A. Discuss the potential outcomes and risks of uncontrolled hypertension with other factors such as elevated blood l d d li id iglucose and dyslipidemia

B. Re-prescribe medications mentioned earlier

C. Cautiously add a prescription for metformin and a nonspecific-BB in a short period of time.

D. Admit to the hospital

E. Choices A and B

F. Choices A, B and C

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Clark Galloway 5 Years Later

In the past 5 years he has received a majorhas received a major promotion, gained 15lbs and joined a cigar club.

Today his BP is 162/100 He is angry162/100. He is angry and significantly short of breath at rest.

After leaving your office and rebuking your suggestions, Clark presents in the emergency room

after two additional hours of symptoms

Now with unremitting chest pain for 2 hours.

His EKG and cardiac enzymes confirm ACS.

At his heart cath, he is found to have 2-vessel disease, and two stents are placed in one artery.

Hi LEVF i 40 45% BP i 148/100 d hiHis LEVF is 40-45%, BP is 148/100 and his HbA1C is 12.0%.

22

Post-Discharge

He is discharged on several medications, including a beta-blocker, an ACE inhibitor, aspirin, clopidogrel, a , , p , p g ,statin and diabetic regimen (including low dose insulin and an oral agent(s).

He is advised to cease tobacco immediately.

He is scheduled to see a dietitian, a diabetes educator, d t t di h b (f k ft d/ ) H iand start cardiac rehab (four weeks after d/c). He is

instructed to return to your office in one week, and follow-up with the cardiologist that was established in the hospital.

What’s Your Advice To Clark Today?

A. If he does not follow his recommended regimen, his risk of recurrent MI is almost certain, only the exact timing is

t iuncertain.

B. Of all the actions that he can take to lower his risk, the most important are to control his blood pressure and take his clopidogrel/aspirin combination.

C. Dietary and lifestyle modification are important in preventing further cardiovascular diseasepreventing further cardiovascular disease

D. All of the above

E. A & C only

23

What’s Your Advice To Clark Today?Correct Answer

A. If he does not follow his recommended regimen, his risk of recurrent MI is almost certain, only the exact timing is

t iuncertain.

B. Of all the actions that he can take to lower his risk, the most important are to control his blood pressure and take his clopidogrel/aspirin combination.

C. Dietary and lifestyle modification are important in preventing further cardiovascular diseasepreventing further cardiovascular disease

D. All of the above

E. A & C only

Clark Galloway 12 Years LaterShortness of breath at rest and PND for the past 3 weeks.

Recurrent substernal chest pain 2-3 times daily with limited activity.

He has had a 9 kg. weight gain.

Significant jugular venous g j gdistension, bi-basilar rales, a prominent S3 and S4 and 3+ pitting lower extremity edema.

His BP is 105/50 and HR 95. LVEF is <20% and VO2 max 11.

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Your Best Action Would Be To:

A. Start an ACE inhibitor and low-dose beta-blocker

B. Admit to the hospital to start an ACE inhibitor AND low dose beta-blocker

C. Admit to the hospital to re-start an ACE inhibitor ASA/clopidogrel and low dose beta-blocker and obtain cardiology consultationobtain cardiology consultation

D. Send him to the ED ASAP

Your Best Action Would Be To: Correct Answer

A. Start an ACE inhibitor and low-dose beta-blocker

B. Admit to the hospital to start an ACE inhibitor AND low dose beta-blocker

C. Admit to the hospital to re-start an ACE inhibitor ASA/clopidogrel and low dose beta-blocker and obtain cardiology consultationblocker and obtain cardiology consultation

D. Send him to the ED ASAP

25

R f t

ACC/AHA Practice GuidelinesPyramid Approach to HF Stages

Structural Heart DiseaseP i MI

HF with Current or Prior SymptomsKnown structural heart diseaseShortness of breath and fatigue

Reduced exercise tolerance

Refractory End-Stage HF

Marked symptoms at restdespite maximal medical therapy*

B

CD

High Risk for Developing HFHypertension

CADDiabetes mellitus

Family history of cardiomyopathy

Previous MILV systolic dysfunction

Asymptomatic valvular disease

A

B

Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43

Hypertension in Patients With High-Risk Conditions

~3/4 of adults with diabetes have BP ≥130/80 mmHg or use prescription medications for HTN1mmHg or use prescription medications for HTN1

~2/3 of patients with HF have a past or current history of HTN2

More than 50%–75% of patients with chronic kidney disease have BP >140/90 mmHg3kidney disease have BP >140/90 mmHg3

1. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics. Bethesda, MD: US Department of Health and Human Services, NIH, 2005. Available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed Oct. 2006. 2. Hunt SA et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Available at http://www.acc.org/qualityandscience/clinical/guidelines/failure/update/index.pdf. Accessed Oct. 2006. 3. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Available at http://www.kidney.org/professionals/KDOQI/guidelines_bp/guide_1.htm. Accessed Oct. 2006.

26

Chronic Kidney Disease

Goals: 1) Slow deterioration of renal function2) Prevent CVD

Often need 3 or more drugs

Target < 130/80

Drugs: ACE inhibitors/ARBs—favorable effects on progression-- Increase in creatinine of 35% is acceptableIncrease in creatinine of 35% is acceptable

Advanced Renal Disease:•GFR < 30, CR 2.5 – 3.0 mg/dL•Increased dose of loop diuretics usually needed in combo with other drugs

Incidence of Coronary Heart Disease (CHD) Events in Patients With and Without Diabetes

5045.0

P<.001

Nondiabetics with no prior MINondiabetics with prior MI

10

20

30

40

Inci

denc

e D

urin

g 7-

Year

Fol

low

-up*

(%)

18.8

Diabetics with prior MI

20.2P<.001

p

Diabetics with no prior MI

Haffner SM et al. N Engl J Med. 1998;339:229-234.

Events per 100 Person-years

0n=69 n=1,304 n=169 n=890

3.0 0.5 7.8 3.2

3.5

*Among 1373 nondiabetic subjects and 1059 diabetic subjects, from a Finnish population-based study.

27

Causes of Death in Persons With Diabetes, Based on US Studies

Cardiac Disease

Pneumonia/Influenza

Malignant Neoplasms

Diabetes

CerebrovascularDisease

0 10 20 30 40 50 60

All Other

Pneumonia/Influenza

1990 US death certificates with mention of diabetes, all ages.1990 US death certificates with mention of diabetes, age at death ≥45 years.

Moss SE et al. Am J Public Health. 1991;81:1158-1162. Ochi JW et al. Diabetes Care. 1985;8:224-229. Kleinman JC et al. Am J Epidemiol.1998;128:389-401. Bender AP et al. Diabetes Care.1986;9:343-350.

Deaths (%)

The Diabetic Hypertensive Patient Is at Especially High Risk…

For cardiovascular disease (CVD)− “Two thirds to three fourths of people with diabetes

f f fmellitus die of some form of heart or blood vessel disease”1

For myocardial infarction (MI)− Patients with diabetes without a previous MI have

as high a risk of MI as patients without diabetes with a previous MI2

DIGAMI=Diabetes Insulin-Glucose Infusion in Acute MI.American Heart Association. Heart and Stroke Statistical—2004 Update. Dallas, TX: AHA; 2003; 2Haffner SM et al. N Engl J Med. 1998;339:229-234; 3Malmberg K et al. Eur Heart J. 1996;17:1337-1344.

p

For congestive heart failure (CHF)− In the DIGAMI trial, 66% of total mortality among

patients with diabetes was due to HF3

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UKPDS: Blood Pressure Control Study in Type 2 Diabetes Effect of Intensive BP Lowering on Micro-

and Macrovascular Complications Risk

AnyDiabetes-

relatedEndpoint

Diabetes-relatedDeath Retinopathy Stroke HF0 MI

RenalFailure

Vision Deterioration

Ris

k R

educ

tion

(%)

−24P=.0046

−32P=.019

−34P=.0038

44

-20

-10

-30

-40

−21P=.13

−42P 29

UKPDS Group. UKPDS 38. BMJ. 1998;317:703-713.

Benefits of 144/82 vs 154/87

−44P=.013

−56P=.0043

-70

-50

-60

P=.29−47

P=.0036

1,148 hypertensive patients with type 2 diabetes were allocated to tight (144/82 mm Hg, n=758) or less tight (154/87 mm Hg, n=390) and followed for a median of 8.4 years.

UKPDS: Benefits of Glycemic vs BP Control With ACEi’s or β-Blockers

20HF Stroke MI Diabetic Death

-9

+7

-12-8

-21

-32

0

-20

40

Ris

k of

Eve

nt (%

)

HF Stroke MI Diabetic Death

ACEi=Angiotensin-converting enzyme inhibitor. UKPDS Group. BMJ. 1998;317:703-713. Lancet. 1998;352:837-853.

-56

-44

-40

-60Glycemic control

ACEi or β-Blocker

29

Clinician Input

When we first encountered Clark, what are the things we could have done that would

have made a difference?

Clinical Practice Recommendation

Treating high blood pressure to JNC-7 GOALS with anti-hypertensive medications reduces the risk ofanti hypertensive medications reduces the risk of cardiovascular disease and death.

Strength of Evidence:A Recommendation; There is robust evidence to recommend a pattern of care.

Evidence Based Source:National Guideline Clearinghouse

Website of Supporting Evidence:http://www.guideline.gov/summary/summary.aspx?doc_id=5635&nbr=003796&string=hypertension#s23

30

Importance of Patient Education50% of patients discontinue their anti-hypertensive within one year of initiating t t ttreatment.

DASH diet for hypertension: − limit sodium− increase fruits and vegetables (8-10/day)

increase low fat dairy (3 4/day)− increase low fat dairy (3-4/day)

Focus on diet history for hypertensive patients

Key Diet History Questions for Patients with HTN

Do you use a salt shaker?

Do you taste your food before you add salt?

How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods?

Do you read labels for sodium content?

How many servings of fruits and vegetables do you eat everyday?

How often do you eat or drink dairy products? What kind?

How often do you eat out? What kinds of restaurants?

Do you like to drink alcohol? How much?

How often do you exercise, including walking?

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Lack of Adherence• Causes 125,000 deaths a year - twice the

mortality rate from MVAs

• Direct cause of 30% of hospital admissions for people over the age of 65

• Half of all prescriptions are taken incorrectly, contributing to prolonged or additional illnesses.

• Increases with the number of meds and doses per day; at 4 times a day, only 40% of patients get it right.

Selected Factors that Influence Dissemination and ImplementationSystems of Care

• Access to careCoverage

Patients• Beliefs about disease

Relationships with health• Coverage• Marketing influences

Providers• Limited visit time to

address a patient’s multiple issues (CVD, di b t ki )

• Relationships with health care providers and systems

• Preferences• Understanding of disease

(inextricably connected to beliefs)

diabetes, smoking)• Office design oriented

toward acute, rather than chronic care

• Innovation bias• Lack of knowledge

32

Differences Between More and Less Successful Providers

More Successful Less SuccessfulInvolved patients in decision making Referenced technical aspects of drugInvolved patients in decision-making.Used med changes to educate /

engage.Patient-maintained record card to

monitor compliance.Progressively introduce effective dose

and number of meds.Awareness of patient ability to afford /

Referenced technical aspects of drug benefits.Less information sharing – “only if

asked”.Felt time constraint did not permit

discussing adverse effects of meds.Felt knowledge of side effects would

hinder compliance.Awareness of patient ability to afford / role of formulary (e.g., VA)Least expensive appropriate med when

possible.Greater attention to gender,

comorbidities, age when prescribing.

p

Shared Traits of More and Less Successful Providers

Several BP readings to confirm hypertension, multiple visits.

− Unless BP very high or comorbidities present.

High awareness of national BP guidelines.

Concurrence on hypertension treatment goals, especially for comorbidities, e.g., diabetes, etc.

Likely to begin hypertension treatment with 2-3 months of lifestyle management.

− Not sufficient to attain desired BP

Difficulty / reluctance in treating older patients to JNC standards.

− Questioned value of aggressively treating older (80+ years) patients with other severe problems

Would look at any BP reduction as partial success

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Causes of Resistant HypertensionImproper MeasurementVolume Overload

Excess SodiumVolume retention from Renal DiseaseInadequate Diuretic Therapy

Drug-Induced/Other CausesNoncompliance LicoriceInadequate Doses EphedraInappropriate Combos ma haungNSAIDS; COX 2 inhibitors Bitter OrangeCocaine, amphetamines, other illicits ObesitySympathomimetics (decongestants etc.) EtOH Sleep ApneaOCPs SteroidsCyclosporine and tacrolimus Erythropoietin

Secondary CausesRenal Artery StenosisPhenyl Chromocytoma

Additional Challenge in Treatment of Hypertension: Medication Adherence

Adherence to a drug regimen is an important component of BP control

Approximately 50% of patients with poor BP control− Approximately 50% of patients with poor BP control have adherence problems (defined by taking <80% of medication)

Several drug-related factors can influence medication adherence, including:− Adverse events

• Frequency of adverse events has been inversely correlated with adherence rates

− Dosing frequency• Reduction in dose frequency can lead to improved

adherenceFeldman R et al. Can J Public Health. 1998;89:I-16–I-18.

34

In-hospital I iti ti 2 3

Increasing OutpatientACC/AHA HF

1

Strategies to Improve Management of Patients With Hypertension and Diabetes

• Implement evidence-based care and therapies

Initiation2,3 Outpatient Compliance2,3Guidelines1

• Improve quality of • Clinical trial evidence

I IIa IIb III

care and therapies• Majority of patients eligible

for treatment• Early benefit of therapy not

missed• Higher persistence rates

post discharge

care and outcomesevidence incorporated into recommendations for patient care

1. Hunt SA et al. Circulation. 2005;112:1825–1852. 2. Fonarow GC. Rev Cardiovasc Med. 2002;3:S2–S10. 3. Gattis W et al. J Am Coll Cardiol. 2004;43:1534–1541.

Improved Adherence Has Been Associated With Improved Outcomes

In the BHAT trial, patients who took ≤75% of their prescribed β-blocker regimen were 2.6 times more likely to die within the first year of follow-up compared withto die within the first year of follow-up, compared with more compliant patients1

In the COMPASS study, patients treated with oral nitrates had better efficacy with once-daily dosing2

− Mean weekly number of chest pain episodes: • 94% decrease in once-daily group • 30% decrease in twice-daily group (P<.0001 compared to

once-daily group)

Beta-Blocker Heart Attack Trial (BHAT): multicenter, randomized, double-blind trial comparing propranolol vs placebo in 3837 patients aged 30–69 years surviving acute MI. Patients 5–21 days post-MI were randomized to propranolol or placebo and were followed for an average of 25 months. Adherence data were available for 2175 patients (1081 randomized to propranolol).Compliance With Oral Mononitrates in Angina Pectoris Study (COMPASS): open, nonblinded, randomized, parallel-group study in 101 patients aged 40–75 years; compared patient compliance (using electronic measurement) and treatment effectiveness in patients with stable angina pectoris treated with oral nitrates administered once daily vs twice daily. 1. Horwitz R et al. Lancet. 1990;336:542–545. 2. Kardas P et al. Am J Cardiol. 2004;94:213–216.

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Summary

Every patient will be screened for hypertension.

Hypertension is a significant risk factor forHypertension is a significant risk factor for cardiovascular disease.

Every patient should be treated to goal to decrease the risk of premature death due to cardiovascular disease.

Treatment plans should always include helping patients adhere to lifestyle and medication changes.

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References• ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in

the Adult—Summary Article. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the A i C ll f Ch t Ph i i d th I t ti l S i t f H t d LAmerican College of Chest Physicians and the International Society for Heart and Lung Transplantation: Endorsed by the Heart Rhythm Society. Circulation 2005;112:1825-1852.

• American Academy of Family Physicians Home Study Self-assessment Program. Hypertension monograph #305. FP Essentials, 2004. AAFP; Kansas City, Mo.

• American Heart Association. Heart Disease and Stroke Statistics — 2004 Update. Dallas, Tex.: American Heart Association; 2003.

• Bakris GL, Weir MR, Shanifar S, Zhang Z, Douglas J, van Dijk DJ, Brenner BM; RENAAL Study Group. Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med 2003 Jul 14;163(13):1555-65.

• Bakris GL. Maximizing Cardiorenal Benefit in the Management of Hypertension: Achieve Blood Pressure Goals. J Clin Hypertens (Greenwich). 1999 Oct;1(2):141-147.

• Bender AP, Sprafka JM, Jagger HG, Muckala KH, Martin CP, Edwards TR. Incidence, prevalence, and mortality of diabetes mellitus in Wadena, Marshall, and Grand Rapids, Minnesota: the Three-and mortality of diabetes mellitus in Wadena, Marshall, and Grand Rapids, Minnesota: the ThreeCity Study. Diabetes Care 1986;9:343-350.

• Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72.

• Domenic A Sica MD (2007) Distinctions in Class: Considerations for the Use of β-Blockers in Cardiovascular Disease. J Clin Hypertens 2007;9 (s4);2-3.

• Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998 Mar 5;338(10):645-52.

• Feldman R, Bacher M, Campbell N, Drover A, Chockalingam A. Adherence to pharmacologic management of hypertension. Can J Pub Health 1998;89:I-16-I-18.

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References, cont.• Fonarow GC, Gawlinski A, Watson K. In-hospital Initiation of Cardiovascular Protective Therapies

to Improve Treatment Rates and Clinical Outcomes: The University of California-Los Angeles, Cardiovascular Hospitalization Atherosclerosis Management Program. Crit Path Cardiol 2003;2(2):61-703.H ff SM L ht S Rö T P ö älä K L k M M t lit f h t di i• Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998 Jul 23;339(4):229-34.

• Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998 Jul 23;339(4):229-34.

• Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 1998;351:1755-1762.

• Herzog E, Varley C, Kukin M. Pathway for the Management of Acute Heart Failure. Crit Path Cardiol 2005;4(1):37-42.

• Horwitz RI, Viscoli CM, Berkman L, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990;336:542–545.myocardial infarction. Lancet 1990;336:542 545.

• Hunt SA et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult—Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to update the 2001 guidelines for the evaluation and management of heart failure). J Am Coll Cardiol 2005 Sep 20; 46:1116-43.

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Pittsburgh School of Public Health; Pittsburgh, Penn. http://www.publichealth.pitt.edu/supercourse/SupercoursePPT/22011-23001/22501.ppt accessed April 13, 2008.Kl i JC D h RP H i MI Fi FF M d JH B k DB M t lit• Kleinman JC, Donahue RP, Harris MI, Finucane FF, Madans JH, Brock DB. Mortality among diabetics in a national sample Am J Epidemiol 1988.128: 389-401.

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• National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics. Bethesda, MD: US Department of Health and Human Services, NIH, 2005. Available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed April 13, 2008.http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed April 13, 2008.

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• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report. National Heart, Lung and Blood Institute. Bethesda, 2004.

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