HypertensionThe basics…

Prof. Yehonatan Sharabi, MD, FAHADirector, Hypertension Unit

Deputy Chief of Medicine

Sheba Medical Center, Tel Hashomer

Executive Board, Israeli Society of Hypertension

Sackler Faculty of Medicine, Tel Aviv University

34 y/o black female 56 y/o Caucasian male

Lets follow Ms. X and Mr. Y

Ms. X

• 34 years old

• Executive job

• Healthy life style

Mr. Y

• 56 years old

• Works at a gas station

• Unhealthy life style

• Managed to beat anorexia…

Question: Ideal screening screening for hypertension

1. Self measurement every year

2. Depending on subject’s age

3. Depending on subject’s blood pressure last time they took it

4. Each time they see a doctor’s

Some facts…

• 40% undiagnosed means – they simply do not take their blood pressure

• At the time of diagnosis – about third had their BP measured last time more than 5 years ago

• Nurse led

• Barber shop…

Hypertension, 2007

Hypertension, 2007

ESH GUIDLINES

Screening

• Ms. X• Does annual checkups

• Recent check up -- BP was 143/88, HR 64

• Comes to your office

• Mr. Y• Never takes his blood pressure

• During ER visit for minor trauma BP was measured 212/114, HR 84

• His wife sends him to your office

Question: How would you make the diagnosis of hypertension

1. Blood pressure is greater than 140/90 therefore diagnosis is confirmed

2. A week of home blood pressure measurements

3. A 24-hour blood pressure monitoring4. Repeat a weekly office blood pressure

measurements over a period of 3 weeks

Young people, particularly <55 y/o - ABPM

• ~ 15% WCH

• ~ 15% masked HTN

• Cost benefit:“Compared with clinic BP measurement, ABPM was associated with cost-savings ranging from $77 (women 80 years of age) to $5013 (women 21 years of age)” Hypertension 2019

• Cost effectiveness – at all age groups:“We estimated that with ABPM total medical expenses can be reduced by 23% (157.500 euros) with a strategy based on ABPM for 1000 patients followed for 2 years” BMC Cardiovascular, 2013

HBPM – a good alternative

• Must be done right!!

• 7 consecutive days

• Twice in the morning, twice in the evening

• Record the second measurement in each pair

• Average the last 12 measurements of the last 6 days

Diagnostic thresholds (not targets!)

•Office: 140/90

•HBPM: 135/85

•ABPM either:•24H – 130/80•Day -- 135/85•Night 120/70

Diagnosis

Ms. X

• ABPM results showed 24H average of 151/96, HR 68

• 22% SBP dipping

• HBPM average on several occasions: 138/85, HR 62

Mr. Y

• Came twice to your office. Average BP was 176/110 HR 88

• Single BP measurement at the pharmacy with BP 210/110. Reported regular cuff

Question: what if the different methods disagree?

1. Doctor’s measurements matter

2. HBPM reflects different days and is reproducible thus – more important

3. ABPM overrules other methods

4. The method that results with the higher blood pressure

Clinical evaluation of newly diagnosed hypertension – a simple checklist: ❑Blood pressure profile

❑Symptoms of secondary hypertension

❑Drug induced medication

❑Contributing factors❑Job strain

❑Stress

❑Dietary factors

❑Sedentary lifestyle

❑Other risk factors

❑Known TOD

❑Known subclinical TOD

❑Other conditions

Clinical profile

Ms. X

• No relevant symptoms

• Job strain

Mr. Y

• Headaches

• Snores, daytime somnolence

• Smokes cigarettes

• Unhealthy lifestyle

Physical examination of newly diagnosed hypertension – a simple checklist: ❑BMI (wrist circumference)

❑Blood pressure on both hands

❑Supine and upright –particularly diabetics and elderlies

❑Sitting leg BP measurement in young / adolescent or with typical upper body part. Should be ~ 60 mmHg higher than arm

❑Focus on❑Cervical and renal bruits

❑Edema

❑Heart and lung

46 y/o surfer, gym addict…

Initial lab work

• Glucose, Urea, Creatinine, Na, K, Uric acid, Ca, P, LDH, GOT, GPT, Alk-Phos, CPK

• .CBC (for Hb & HCT)

• TSH, Lipid Profile

• Urine sample for urinalysis and Albumin : Creatinine ratio

• HbA1C (30% have both diabetes and HTN)

Diagnosis

Ms. X

• Normal lab results

• AHA risk score 2.3%

Mr. Y

• Low HDL, High LDL cholesterol

• HbA1C 6.6 mg%

• UACR 42 mg/g

• AHA risk score 13.7%

Question: should we refer the patients to the following tests?

1. ECG – yes? No?

2. Fundoscopy – Yes? No?

3. Abdominal ultrasonography – Yes? No?

4. Echocardiography – Yes? No?

5. Carotid doppler – Yes? No?

Assessment

•Grade of HTN

•Overall risk

• Framingham / AHA / ESC risk score

10 year Probability of CAD in relation to risk factors

3

68

13

23

42

6

9

13

19

25

44

0 %

10 %

20 %

30 %

40 %

50 %

Women

Men

Kannel WB, EH J 1992; 13:34-42

SBP (150-160) + + + + + +

HDL (33-35) - + + + + +

Chol (240-262) - - + + + +

Smoking - - - + + +

Diabetes - - - - + +

LVH - - - - - +

Management:Primary goal – reduce risk. Numbers are just surrogate markers

Treatment: patient education

The most important part of the initial evaluation

Treatment – appropriate lifestyle

•Set realistic goals•Weight•Diet•Physical activity•Coaching and stress management

Question: should we start drug treatment immidiately?

1. Ms. X no, Mr. Y yes

2. Both deserve a 3-month of non-pharmacological treatment

3. Ms. X – yes, Mr. Y should loose weight and avoid drug-treatment

4. Both should start drug-treatment immediately

Treatment – antihypertensive medications

Rule of thumb: one medication at standard dose = -10/5 mmHg ESH guidelines:”…overall, major cardiovascular outcomes and mortality were similar with treatment based on initial therapy with all five major classes of treatment”

Label Choose Response

Trial and Error

Label Test Choose Response

Predictable response

Choosing wisely – biomarkers?

• Pharmacogenomics• Age• Gender• Race• Weight• Isolated systolic• Isolated diastolic• Heart rate• Dipping• Variability

• Diabetes• Renal Failure• LVH• Proteinuria• Plasma renin• K• …• …

Individualizing hypertension treatment with impedance cardiography: a meta-analysis of published trials

Therapeutic Advances in Cardiovascular Disease 2010

John Laragh: It’s all about renin

HTN

V tension

Diur

CCb

R tension

RAASb

BB

Renin?

British Guidelines: it’s all about age

Brown M J BMJ 2011

Specific recommendations / suggestions

• Under 55 – ARBs

• Over 55 – CCB/Diur

• Obese – HCTZ

• HR>80 – BB

• Proteinuria - RAASb

• IHD – BB, ACEI

• CHF – Diur

Question: choose wisely?

Ms. X1. RAASb?2. BB?3. Diur?4. CCB?5. Combination?6. Flip a coin?

Mr. Y yes1. RAASb?2. BB?3. Diur?4. CCB?5. Combination?6. Flip a coin?

0

20

40

60

80

100

120

% c

on

tin

uo

us u

se

rs

Years after 1st prescription

Men

Women

Medication Persistence:

Van Wijk BL et al. J Hypertens. 2005; 23: 2101-2107

39% used anti-hypertensive medications continuously over 10-years

39% discontinued permanently

22% discontinued temporarily

Shared decision

Compliance decreases as the number of medications increases

Charman RH, et al Arch Intern Med 2005; 165: 1147-52

Unadjusted odds ratio for compliance (>80%) to both antihypertensive therapy and LLT (95%) Cl; p value)

No. of pre-existing

Rx medications

Decreasedcompliance

Increased compliance

ESH guidelines encourage single pill combination

BP targets -- <130/80:

So far

• We’ve walked with Ms. X and Ms. Y from before the diagnosis of hypertension was made, through the workup and the initiation of treatment

• The journey has just began. Next we’ll learn --• How to track and keep their BP controlled over the many years ahead

• How to engage them with the goals that were set

• How to manage the complexity their overall treatment

Thanks you and enjoy the rest of the meeting!