mr patrick gladding - gp cme north/fri_room11_1630... · 80 year old woman seen in clinic....
TRANSCRIPT
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Mr Patrick GladdingSpecialist
General Cardiology and Internal Medicine
Auckland
16:30 - 17:25 WS #60: Individualising Hypertension Treatment - Intensive or Not?
17:35 - 18:30 WS #72: Individualising Hypertension Treatment - Intensive or Not?
(Repeated)
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Individualising Hypertension Treatment: Intensive or not?
Dr. Patrick Gladding, MBChB, FRACP, PhDAscot Cardiology
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Hypertension update
• New Guidelines
• Definitions and treatment thresholds
• Global risk, investigations (Pulse wave velocity) and monitoring (mHealth)
• Targets – SPRINT trial
• Lifestyle interventions (Functional Foods)
• Genomics and Personalised Care
Outline
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Secondary causes of Hypertension
Cushings syndrome
Aortic coarctation
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• Office BP• White coat hypertension
• Ambulatory 24-hr BP (ABPM)• Masked hypertension
• Home blood pressure monitoring• Increased granularity
• White coat hypertension
• Feedback
• Dietary/Lifestyle and drug n=1 trials
• Adherence
• Personal control
JAMA. 2014;312(8):799-808
• 552 patients• 9mmHg SBP reduction with self-Mx
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• 2 emerging techniques in echo to improve detection of end-organ damage:
1) LV strain; Deformation of the LV vs EF
2) LV mass
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• 76 yr old man –Supine HTN orthostatic hypotension (~50mmHg)
• Arterial stiffness indicates lower central BP
14
Hypertension update
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• JNC 8• Goal for people > 60 yrs should be a SBP < 150, DBP < 90
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• For fit elderly patients, a high DBP (>90 mm Hg) was associated with a 50% increase in mortality
• By contrast, for frail elderly patients, a low DBP was associated with a 50% increased risk of dying during 15 year follow-up period
1466 older men and women
“The ultimate goal is personalized treatment so that we can avoid overtreatment of the frail, and undertreatment of the fit.”
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• 9361 patients (age, ≥50) with SBP of 130 to 180 mm Hg and high cardiovascular (CV) risk
• One or more: CV disease, CKD EGFR 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75
• Patients with diabetes and stroke were excluded. • Patients were randomized to either intensive or standard treatment (systolic
BP targets, 120 or 140 mm Hg, respectively)• The trial was terminated early after median follow-up of 3.3 years• The primary composite outcome (MACE) occurred in 5.2% of intensive-
treatment patients and 6.8% of standard-treatment patients (P<0.001)
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• “First, the results should not be considered a mandate for people to run out and get treated so their blood pressures are below 120.
• Second, the potential benefits of lowering blood pressure must be weighed against harms.
• Third, we need more information about the balance of risks and benefits for each person so that the choice can be personalized.”
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“The ideal blood pressure for most people is likely to be below 120 mmHg systolic and 75 mmHg diastolic.”
“The 2017 AHA/ACC guideline’s recommended treatment goal is to reach office BP levels of less than 130mmHg (systolic) and less than 80 mmHg (diastolic) if pharmacotherapy is commenced.”
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80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations.
Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od.She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/L.
Creatinine 82 umol/L, caucasian, nonsmoker.
• Is she well treated?• Should treatment be intensified?• Is the SPRINT trial relevant?
Is there an app for that????
Personalised Hypertension Management
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Insert title of presentation here
ABPM shows average BP 135/80 with a precipitous drop
at around 1400 (see attached) to BP 105/66, when she
often feels unwell.
Diastolic BP <65mmHg is BAD
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80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations.
Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od.She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/L.
Creatinine 82 umol/L, caucasian, nonsmoker.
• Is she well treated? – NO. She is overtreated.• Should treatment be intensified? – NO• Is the SPRINT trial relevant? – YES and NO
SPRINT score calculator NNT 267, NNH 30.
Personalised Hypertension Management
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80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations.
Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od.She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/L.
Creatinine 82 umol/L, caucasian, nonsmoker.
• Inhibace + is halved
“I’m a different person!”
Personalised Hypertension Management
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iOS Android
https://itunes.apple.com/ru/app/blood-pressure-calculation/id1270845450?l=en&mt=8
https://play.google.com/store/apps/details?id=com.blood.lukas.myapplication
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Guidelines – take with a grain of salt
• Increased risk of CV events with very low salt intake
• Guidelines based on averaging population
28
N Engl J Med 2014
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Renal denervation therapy
• SYMPLICITY-3:• Renal denervation therapy
doesn’t work, for unselected patients with HTN
• Renal artery stenosis
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Age directed vs Renin directed Rx
Individualise Rx based on other comorbidities
Spironolactone for Resistant HTN
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J Clin Pharmacol 1994;34:1173-1176
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Gladding et al. Personalized Medicine Journal. June 2015 ,Vol. 12, No. 3, Pages 297-311
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Personalised Medicine in practice
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Era of Mobile Health
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Advanced ECG
• WiFi based ECG
• Ultraportable, $3,500
• Deconvolutes ECG components
• Advanced pattern recognition, artificial intelligence
• ECG biological age
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Advanced ECG for general practice
• Sensitive, high sampling frequency, accurate.
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Case
• 43 year old man with dyspnoea, BP 220/140
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Case
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41
British Journal of General Practice 2007; 57: 191–195
BMJ 1996;312:222
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• A-ECG LVSD Sensitivity 93-95%, Specificity 95%
• Southern X reimbursed
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Conclusion
• Hypertension is common, often called the “Silent Killer”
• Requires personalised Care taking into account • Global risk• Age and comordities• Guidelines not always applicable to the individual patient
• Emerging technologies for investigation of end-organ disease
• Lifestyle, diet, prevention paramount• Functional foods• Feedback, mHealth, Internet of Things (IoT)
• Limited new drug treatments, or procedures though these will be targeted
• Emerging role of genomics (not yet fully advocated)
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Interactive Session: Hypertension and Personalised Care
Dr. Patrick Gladding, MBChB, FRACP, PhD
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Case: 26 year old with HTN on home BP monitor
• Checked BP on friend’s mother’s home BP machine
• Measurement “high”
• ABPM 169/101
• No other PMHx
• Maternal Grandparents had HTN, Gfather had ESRF and HD
• Normal diet, no illicit drugs
• Mother did not have pre-eclampsia
• Normal FBC, Cr, TSH.
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Ubiquitous home BP monitoring
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Case: 26 year old with HTN on home BP monitor
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What investigations would you order?
1. Urinalysis – sediment, microalbumin/Cr ratio2. Renin/Aldosterone levels3. Echocardiogram4. Renal artery USS5. All of the above
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Case: 26 year old with HTN on home BP monitor
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What investigations would you order?
1. Urinalysis – sediment, microalbumin/Cr ratio2. Renin/Aldosterone levels3. Echocardiogram4. Renal artery USS5. All of the above
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Case: 26 year old with HTN on home BP monitor
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Differential diagnosis for his age
•Secondary hypertension much more likely from structural reasons e.g. coarctation, PCKD, but acute renal injury, nephritis but also endocrine (hyperaldosteronism)•FHx – PCKD? Hereditary HTN
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Case: Value of ubiquitous home BP monitoring
• Checked BP on friend’s mother’s home BP machine
• Measurement “high”
• ABPM 169/101
• USS – right renal hydronephrosis
• ACEi - ?nephrectomy
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Case: 56 year old man with longstanding hypertension
• 56 year old man with longstanding hypertension
• GORD, dyslipidaemia, TIA 2014?, abnormal LFTs - 3-4L beer/day
• Palmar desquamation reaction to indapamide
• ABPM average BP 145/87, whilst on Candesartan 16mg od
• Renal USS – no renal artery stenosis, post void residual 80mls
• Echocardiogram: Mild basal septal hypertrophy
• Renin 744 (4 – 46), Aldosterone 134 (60 – 1,000) on ARB
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Case: 56 year old man with longstanding hypertension
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Case: 56 year old man
53
How would you manage him?
1. Renin directed Rx - Bb2. Add bendrofluazide3. Add amlodipine4. Counsel regarding EtOH5. 1 or 3, and 4
Spironolactone for Resistant HTN
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Case: 56 year old man
54Spironolactone for Resistant HTN
How would you manage him?
1. Renin directed Rx - Bb2. Add bendrofluazide3. Add amlodipine4. Counsel regarding EtOH5. 1 or 3, and 4
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• Renin is a red herring, cannot be relied upon whilst taking antiHTN meds, especially RAAS blockers• Renin is also elevated in chronic EtOH
• Indapamide is a “thiazide-like diuretic”, as is bendrofluazide ?Class effect with desquamation
• Age on the cusp of the NICE guidelines so could get ACEi (<55yrs) or CCHB (>55yrs) however the big problem is in the ABPM
Case: 56 year old man with longstanding hypertension
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Case: Value of 24hr ABPM and diurnal measures
Focus on alcohol
Worrying diastolic nadir 40mmHg
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Case: 56 year old man abstaining from alcohol
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Case: 61 year old GP
• 61 year old GP, Hx of HTN on Rx
• 12L ECG “normal” AECG abnormal/CAD and biological age
• Coronary angiogram mild-moderate CAD58
Journal of Hypertension 2014, 32:1229–1236
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What are the red arrows pointing to?
1.Acute coffee intake2.Conn syndrome3.Work stress4.Normal diurnal variation5.Phaeochromocytoma
Case – 61 year old GP
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What are the red arrows pointing to?
1.Acute coffee intake2.Conn syndrome3.Work stress4.Normal diurnal variation5.Phaeochromocytoma
Case: 61 year old GP
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Case – 61 year old GP
• Work stress is associated with HTN
• Concurrent CAD Rx to lower target?
• Manage causes of stress, mindfulness61
Journal of Hypertension 2014, 32:1229–1236
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Case: 56 year old wife of GP
• ABPM BP 166/97
(Grade II HTN)
• Was on Amlodipine 5mg
• Drug withheld 2 weeks:• Renin 22, Aldo N
• Green mussel extract, celery extract
Emotional stress
Journal of Hypertension 2014, 32:1222–1228J Clin Hypertens (Greenwich). 2014 Jan; 16(1): 54–62.
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What is the next course of action?
1.Increase dose of CCHB2.Bb3.ACEi or ARB4.Diuretic5.Spirinolactone
Case: 56 year old wife of GP
63Spironolactone for Resistant HTN
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What is the next course of action?
1.Increase dose of CCHB2.Bb3.ACEi or ARB4.Diuretic5.Spirinolactone
Case: 56 year old wife of GP
64Spironolactone for Resistant HTN
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Case – 56 year old wife of GP
• Was on Amlodipine 5mg
• ABPM BP 166/97
• Renin 22, Aldo N
• Green mussel extract, celery extract
• Px Chlorthalidone12.5mg od
• Pranayama
Emotional stress
Journal of Hypertension 2014, 32:1222–1228
Pranayama
J Clin Hypertens (Greenwich). 2014 Jan; 16(1): 54–62.
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Case: 48 year old woman
• 48 year old woman with depression on Venlafaxine 225mg
• Mild dyslipidaemia
• Prior Hx of right sided breast cancer, partial mastectomy
• FHx of premature stroke
• Office BP 145/99
• Normal Cr, ECG, renin/aldosterone ratio
66
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How would you better define risk in view of BP?
•Advanced lipids Lp(a)
•CIMT
•CAC
•ETT
•CTCA67
Case: 48 year old woman
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How would you better define risk in view of BP?
•Advanced lipids Lp(a)
•CIMT
•CAC
•ETT
•CTCA68
Case: 48 year old woman
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What is the cause of her mild hypertension?
69
Case: 48 year old woman
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Case: Drug induced HTN
• 48 year old woman with depression started Venlafaxine, BP 145/99
• Genomics indicated ADE
• WiFi BP max 133/95
70
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Case:29 year old woman
•29 year old woman, otherwise well, father adopted
•Normal weight, no EtOH
•No added salt, good sleep quality
•Office BP 140/90 on OCP71
Journal of Hypertension 2009, 27:1594–1601
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What would you do next?
1. Stop the OCP, alternative Rx and retest her BP
2. 24-hr ABPM
3. Renin/Aldosterone
4. Renal USS
5. Renal denervation therapy
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What would you do next?
1. Stop the OCP, alternative Rx and retest her BP
2. 24-hr ABPM
3. Renin/Aldosterone
4. Renal USS
5. Renal denervation therapy
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Case: Incidental genomics
• 29 year old woman, otherwise well, father adopted
• Office BP 140/90 on OCP
• ABPM 132/85
74
• 3-4 cups of coffee per day associated with increased risk of MI and HTN in poor metabolisers
Journal of Hypertension 2009, 27:1594–1601
deltaF508 carrier
Genetic counselling
Prenatal screening
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Case 54 year old man
• 54 year old man presents with MI
• HTN with known hypertensive retinopathy, mild-mod LVH on Echo• BP 217/119 in 2014, started on Felodipine 10mg od
• Smoker
• Occasional methaphetamine user
• BP 170/90 on chlorthalidone 12.5mg od
• Moderate CAD on coronary angiography
• ASA/Ticagrelor/Statin/Bb/Chlorthalidone
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Case 54 year old man - Potassium
Losartan + Thiazide
MI
Atypical CP, dyspnoeaAdmitted to hospital
TnI <15
Felodipine 10mg odAtypical CP, dyspnoeaAdmitted to hospital
Dx GORD
Took P went to ED
F/up clinicChlorthalidone
stopped
3.5
3.42.9
Renin <2 (4 – 46), Aldosterone 600 (60 – 1,000)
K supp
Spironolactone
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What is the diagnosis?
1.Acute coffee intake2.Surreptitious thiazide use3.Conn syndrome4.Methaphetamine related hypokalaemia5.Phaeochromocytoma
Case: 54 year old man
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What is the diagnosis?
1.Acute coffee intake2.Surreptitious thiazide use3.Conn syndrome4.Methaphetamine related hypokalaemia5.Phaeochromocytoma
Case: Conn Syndrome
Saline suppression testRenal vein sampling
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Thank you