Controlling Hypertension in Primary Care: Hitting a moving target?

David J. Hyman, MD,MPHProfessor of Medicine andFamily & Community MedicineChief, Section General MedicineBaylor College of Medicine

No Conflicts of Interest

Controlling Hypertension in Primary Care: Hitting a moving target?

Objectives

• Review why hypertension is the most important topic in medicine and the great job that primary care is doing

• Be familiar with the shifting and conflicting guidelines: JNC 7, “JNC 8“ now AHA/ACC 2017 vs AAFP/ACP 2017 vs. other international groups vs NCQA (clinical quality) metrics

• Appreciate the critical role of how the blood pressure is measured in interpreting the guidelines

• Be relieved by the lack of controversy in drug regimens

• Recognize and intervene on resistant hypertension

Hypertension is the most important topic in medicine.

Prevalence of Hypertensionin the United States*

6%

16%

31%

48%

65%

78%

0%

20%

40%

60%

80%

100%

18-34 35-44 45-54 55-64 65-74 75+

†

*Based on NHANES 19992000 data. Hypertension is defined asblood pressure 140/90 mmHg or antihypertensive treatment.

†Low reliability due to large relative error.

Fields et al. Hypertension. 2004:44;398-404.

Hyp

erte

nsio

nP

revale

nce

Age

Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Global Disability Adjusted Life Years (DAYLs) Attributable to the 25 Leading Risk Factors

2010

Risk Factor 2010

Rank DALYs (95% UI)

in thousands

High blood pressure 1 173,556 (155.939-189.025

Tobacco smoking, including exposure to second-

hand smoke 2

156,838 (136,543-

173.057)

Household air pollution from solid fuels 3 108,084 (84,891-132,983)

Diet low in fruit 4 104,095 (81,833-124,169)

Alcohol use 5 97,237 (87,087-107.658)

High body-mass index 6 93,609 (77,107-110,600)

High fasting plasma glucose level 7 89,012 (77,743-101,390)

Childhood underweight 8 77,316 (64,497-91,943)

Expo sure to amblent particulate-matter pollution 9 76,163 (68,086-85,171)

Physical inactivity or low level of activity 10 69,318 (58,646-80,182)

Murray, Christopher J, et. al, New England Journal of Medicine, 2013

Diabetes: Tight Glucose vs Tight BP Control and CV Outcomes in UKPDS

Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.Reprinted by permission, Harcourt Inc.

StrokeAny Diabetic

EndpointDM

DeathsMicrovascularComplications

-50

-40

-30

-20

-10

0

%R

edu

ctio

n In

Rel

ativ

e R

isk

Tight Glucose Control(Goal <6.0 mmol/l or 108 mg/dL)

Tight BP Control(Average 144/82 mmHg)

32%

37%

10%

32%

12%

24%

5%

44%

*

*

*

**P <0.05 compared to tight glucose control

www.hypertensiononline.org

Hypertension Control

Horrible-Isn’t it?

“Less than ½ of persons with hypertension are controlled……”

“70% of people who start BP drugs stop within 5 years…..”

Chobanian, N Engl J Med 2009;361:878-87.

Blood Pressure Control Over Time

The percentages are shown (mean and 95% confidence intervals) for hypertension prevalence, awareness, treatment, control, and proportion of treated patients controlled (control/treated)

among adults ≥18 years of age in NHANES 1999 to 2012 at 2-year increments.

Egan B M et al. Circulation. 2014;130:1692-1699

Copyright © American Heart Association, Inc. All rights reserved.

Another database showing Hypertensives are mostly adherent

625,000 patients with prescription refill records available from insurer

Adherent (>80%) 74.6%Moderate (60-79%) 15.3%Poor (<60%) 9.9%

Pittman DG, et al Am J Managed Care 2010

Harris Health October 2018

Controlling Hypertension in Primary Care: Hitting a moving target?

- Be familiar with the shifting and conflicting guidelines:

JNC 7, “JNC 8“ now AHA/ACC 2017 vs AAFP/ACP 2017 vs. other international groups vs NCQA (clinical quality) metrics

0

2

4

6

8

10

12

In

cid

en

ce o

f card

iovascu

lar

dis

ease

120

Hypertension Treatment Effect Mirrors Observational Data

140 160 180 200 220

Systolic blood pressure (mmHg)

www.hypertensiononline.org

U.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

The Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure (JNC 7)

National Heart, Lung, and Blood Institute

National High Blood Pressure Education Program

80859095

100105110115120125130

JNC I JNC II JNC III JNC IV JNC V JNC VI

Considertherapy

Hyper-tensive

Mild Mild MildStage 1 Stage 1

Moderate Moderate Moderate

Stage 2

Severe Severe SevereStage 3 Stage 3

Stage 2

Stage 4

High-normal

High-normal

High-normal

High-normal

Normal Normal Normal Normal

Optimal

DBP(mm Hg)

Optimal

JNC 7

Stage 1

Stage 2

Prehyper-tension

Normal

JNC I. JAMA. 1977;237:255-261.JNC II. Arch Intern Med. 1980;140:1280-1285.JNC III. Arch Intern Med. 1984;144:1045-1057.

JNC IV. Arch Intern Med. 1988;148:1023-1038.JNC V. Arch Intern Med. 1993;153:154-183.JNC VI. Arch Intern Med. 1997;157:2413-2446.Chobanian AV et al. JAMA. 2003;289:2560-2572.

JNC BP Classifications: DBP

Hypertension. 1999;34:386-387

JNC V

Optimal110120130140150160170180190200210220

JNC I. JAMA. 1977;237:255-261.JNC II. Arch Intern Med. 1980;140:1280-1285.JNC III. Arch Intern Med. 1984;144:1045-1057.

JNC IV. Arch Intern Med. 1988;148:1023-1038.JNC V. Arch Intern Med. 1993;153:154-183.JNC VI. Arch Intern Med. 1997;157:2413-2446.Chobanian AV et al. JAMA. 2003;289:2560-2572.

JNC I JNC II JNC III JNC IV JNC VI

Border- line

ISH

Stage 1 Stage 1

Stage 2

Stage 3

High-normal

High-normal

Normal Normal

Optimal

SBP(mm Hg)

Normal

Border- line

ISH

Stage 4

No recommendations for SBP in JNC I

or JNC II

JNC 7

Stage 1

Stage 2

Prehyper-tension

Normal

Stage 3

Stage 2

JNC BP Classifications: SBP

JNC 8 majority report:

over age 60: 150/90 mm/HG

DM, cad, Ckd 140/90 mm/HG

JNC 8 minority report:

over age 60: 140/90 mm/Hg

Goals of Therapy – 2013.

2010 Accord BP Diabetics 120mmHg vs. 140mmHg Negative

2013 SPS3 Post subcortical <130 mmHG vs < 140 mmHG Negativestroke

2015 SPRINT high risk 120mmHG vs. 140mmHG Stopped early!!not DM or CVA Benefit

Sprint Trial

Major inclusion criteriaAge > 50 SBP 130-180 (tx or un tx)At least one of :

Clinical CVD except CVA CKD eGFR 20-50Framingham 10yr CVD risk > 15% Age >75

Major exclusion criteriaStroke DM CHF(sx or EF<35%) proteinuria >1 g/d CKD eGFR <20

ADHERENCE CONCERNS

SBP achieved: 121.5 mmHG

NNT event 61 NNT to Prevent one death 90

AHA/ACC 2017 vs everyone else

AHA 2017

Changes in BP Categories from JNC 7 to the 2017 ACC/AHA HTN Guideline

SBP DBP JNC7 2017 ACC/AHA

<120 and <80 Normal BP Normal BP

120–129 and <80 Prehypertension Elevated BP

130–139 or 80–89 Prehypertension Stage 1 hypertension

140–159 or 90-99 Stage 1 hypertension Stage 2 hypertension

≥160 or ≥100 Stage 2 hypertension Stage 2 hypertension

The 2017 ACC/AHA guideline definition of hypertension:SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg

If same patient was 60WF 10 yr risk 4.8% If 40 WM 10 yr risk 1.8%If 40 BM 10 yr risk 10.0%If 60 WM ,BM,BF 10 yr risk >10%

You have to use the calculator, “ guesstimates” difficult

Prevalence of Hypertension –2017 ACC/AHA and JNC 7 Guidelines

Prevalence of hypertension, % Number of US adults with hypertension, millions

Muntner et. al., Journal of the American College of Cardiology 2017, Nov 6Muntner, et. al., Circulation 2017 Nov 13

13.7% 31.1, M

“JNC 8” AHA/ACC 2017 ESC/ESH 2018 ACP/AAFP 2017

Threshold for starting by age

>60 150/90 < 60 140/90

all ages 140/90130/80High risk

< 80 140/90 >80 160/90

>60 150/no rec strong>60 CVA/TIA consider 140 (weak)>60 high risk consider 140 (weak

Target for on treatment BP

>60 150/90 <60 140/90

<130/80 18-65 to 130 but not <120 >65 130-140

>60 < 150>60 CVA/TIA consider 140mmHG (weak)>60 High risk consider 140 mmHG (weak)

Hitting the target…

How do you measure the BP you are acting on?

BP Measurement Techniques

Method Brief Description

In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring Indicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

Self-measurement

In Office automated unobserved

May help improve adherence to therapy and evaluate “white-coat” HTN.

Pt alone in room

If mean office visit SBP 140mmHG “control” about 50%

-3 -2 -1 mean +1 +2 +3

120 130 140 150 160

Number of standard deviations either side of mean

freq

uenc

y

99.7%

68%

95%

AHA 2017

Sprint Maybe much ado about nothing?

1) Sprint used unobserved Automated Office BP (AOBP) - pt seated alone in room for 5 minutes- only after 5 minutes of rest, would take 3 measurement 1 minute apart

unobserved AOBP averages SBP 16mmHG lower than regular office BPoften similar to day ABPM

2) Intervention achieved SBP 121.5 mmHG121.5 + 16= 137.5 about current 140

3) Control group had target of 140mmHG, could have baseline medications reduced to get thereactual SBP controls 134.6 mmHG

134.6 + 16 = 151.1if individual at 140, 140 +16 = 166

Kjeldsen & Mancia European Heart J 2016

What BPs are we being graded on?

Definition of Hypertension Control in Clinical Practice

NCQA/ HEDIS

Enrolled for 1 year or more

Have a hypertension code in 1st 6 months of year

Age 45-84

BP at last visit in chart used

Control: < 140 and < 90 mmHG at sampled visit

Sennett C, Managed Care 2000

NCQA HEDIS 2019

< 140/90 on last visit in evaluation period or remote BP devices electronically submitted

HEDIS 2015- 201818-59 140/9060-85 w dm 140/9060-84 w/o dm 150/90

BP Drugs now the easy part

- It will likely take more than one drug, tell patients this right from start

- If it is really high start 2 drugs

- Multidrug combination pills maybe good

- If the blood pressure is high on subsequent visits- titrate the medication!!!!

Clinical Inertia: not lack of access or non-adherence is biggest reason for lack of control

1st (Ace or ARB) or CCB or Diuretic For DM (Ace or ARB ) For African Origin no DM: CCB or Diuretic

2nd (Ace or ARB) and CCB or (ACE or ARB) and Diuretic

3rd (Ace or ARB) and CCB and Diuretic

4th spironolactone

Only then, the other classes

Sometimes other classes needed for other conditions or contraindications

Order of BP medication use:

NO ENALAPRIL Use Lisinopril

Few B blockers NO Atenolol

The REAL Dose of HCTZ is 50mg

Chlorthalidone may be coming to Harris Health

What if the patient’s Blood Pressure does not respond?

RESISTANT HYPERTENSION

Definitions

Resistant Hypertension: office blood pressure that remains elevated despite optimal doses of 3 classes of medication including diuretic if tolerated or controlled on 4 medicines

Pseudo-resistant Hypertension: seems to meet definition but on further evaluation pt is

-Non-adherent - Controlled on 24 hour ABPM- not really on optimal medications, - only uncontrolled on poor office measurement

True resistant: not pseudo- resistant

Apparent Resistant Hypertension: seems to meet definition but pseudo-resistant not ruled out

Persell NHANES 2003-8 Any diuretic 86%2011 Study BP, drug names loop 30%

not dosage thiazide like 59%(HCTZ 93%)539 patients uncontrolled > 3 aldo antagonists 3.0%or controlled > 4 drugs

Hanselin Drug insurance data base 2008-9 Any diuretic 93%2011 drug names, dose, No BPs loop 19%

140,000/5million hypertensives on thiazide like 80% (HCTZ 94%)> 4 drugs Chlorthalidone 3%,

aldo antagonist 5.9%HCTZ mean dose 21.1 mg

Fontil National Ambulatory Medical Care Survey Any diuretic 77%2013 2006-10 drug names, no dosages, office BP loop 23 %

1567 pts w uncontrolled > 3 or controlled thiazide like 56% (HCTZ 96%)> 4 drugs Chlorthalidone 1.2%

aldo antagonists 3.9%

Grigoryan Primary care patients 2006-7 uncontrolled Any Diuretic 91%2013 > 3 drugs, n=34 loop 15%

Drug names, doses, ABPM, thiazide like 84% (HCTZ electronic adherence monitor Chlorthalidone 0%

aldo antagonists 0% > ½ max dose ace/arb/ccbHCTZ 24/26 at 25mg QD

Apparent Resistant Hypertension

Drilling down on the medical regimen:

Source Result

Resistant Hypertension Uncommon if Appropriate Drugs used

In a network of 200 practices across the Southeastwith 468,000 treated hypertensives thoseuncontrolled on 3 or more drugs at acceptable dose:

4.7%

Egan B, Zhao Y , Li J et al

Houston TXOn a very detailed drill down using ABPM and electronic bottle cap monitoring:

of Apparent resistant hypertenvsives (N=69)22% normal ABPM29% non adherent

Essentially no one optimally treated,” mostly HCTZ 25,no Chlorthalidone, no spironolactone

Grigoryan L, Pavlik VN, Hyman DJ J Am Soc Hypertens 2013

Patients with severe BP elevations referred to resistant hypertension clinics or for device therapy have very high levels of non-adherence when measured by blood or urine samples

Diuretics are the key to controlling difficult to control hypertension

The dose of HCTZ is 50mg !!!!!!

Chlorthalidone if you can get it- 25 mg

Spironolactone 25 to 50 mg is 4th drug

Eplerenone is alternative

What is “real” prevalence of resistant hypertension?

A network of 200 practices across the Southeast468,000 treated hypertensives - uncontrolled on 3 or more drugs at acceptable dose

Semi Apparent Resistant Hypertension 4.7%

Egan B, Zhao Y , Li J et al

Diuretics are the key to controlling difficult to controlhypertension

The dose of HCTZ is 50mg !!!!!!

Chlorthalidone if you can get it- 25 mg

Spironolactone 25 to 50 mg is 4th drug

Eplerenone is alternative

Conclusions

• Hypertension is the most important topic in Medicine!

• You don’t have to accept the 2017 AHA/ACC guideline

• A well measured in office 140/90 is good criteria for starting 130/80 maybe indicated is some high risk patients 130/80 maybe reasonable target if well tolerated It is very fair that we will still “be graded” on 140/90

• If someone actually fits SPRINT criteria, and wants to do it- go for it! but remember it is an average SBP 121mm, not always less than 120mmHG

Conclusions continued..

• Measurement counts- follow the literature -follow your office practice-the closer to Automated Office BP method the better

• Do drugs ! ACE(ARB) CCB diuretics Hctz 50 aldactone 4th

• Resistant hypertension: check adherence. Rare referral for 2nd

hypertension

Hypertension is the most important topic in medicine!!!

Please do not let any differences in guidelines lead us to nihilism and inaction!!!