strategies in treating resistant hypertension · 8/20/2017 6 study yr n criteria result conclusion...

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Cindy Weston, DNP, RN, CCRN, CNS‐CC, FNP‐BCAssistant ProfessorTexas A&M University College of [email protected]

Review background and definitions of hypertension with appropriate ICD‐10

Discuss evidence for diagnosis and treatment of resistant hypertension

Describe classifications of pharmacologic treatment of resistant hypertension

Apply evidence based guidelines to the treatment of resistant

No Conflicts

“I struggled with everything cardiac in nursing school.”

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• 34% US adults > 18 year old

• 6% undiagnosed

• 77% people with 1st stroke BP > 140/90

• 76% of those diagnosed are on pharmacotherapy

• 46.5% are NOT controlled

• Health disparity‐ black women• Overall Death rate: 18.8 per 1000 per year

• Cost = $46.4 Billion$274 billion

Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28‐e292. http://circ.ahajournals.org/content/early/2013/12/18/01.cir .0000441139.02102.80. http://dx.doi.org/10.1161/01.cir.0000441139.02102.80.Benjamin et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association [published online ahead of print January 25, 2017]. Circulation. doi: 10.1161/CIR.0000000000000485

HDS‐4 Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high (GOAL = 92.6%....2014= 91.8%)

HDS‐5 Reduce the proportion of persons in the population with hypertension

HDS‐9 Increase the proportion of adults with prehypertension who meet the recommended guidelines

HDS‐10 Increase the proportion of adults with hypertension who meet the recommended guidelines

HDS‐11 Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure

HDS‐12 Increase the proportion of adults with hypertension whose blood pressure is under control (GOAL = 61.2%) 43.7%50.3%

https://www.healthypeople.gov/2020/topics‐objectives/topic/heart‐disease‐and‐stroke/objectives

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HDS‐4 Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high (GOAL = 92.6%....2014= 91.8%)

HDS‐5 Reduce the proportion of persons in the population with hypertension

HDS‐9 Increase the proportion of adults with prehypertension who meet the recommended guidelines

HDS‐10 Increase the proportion of adults with hypertension who meet the recommended guidelines

HDS‐11 Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure

HDS‐12 Increase the proportion of adults with hypertension whose blood pressure is under control (GOAL = 61.2%) 43.7%50.3%

HDS‐25 Increase the proportion of patients with hypertension in clinical health systems whose blood pressure is under control (58.3%64.3%)

https://www.healthypeople.gov/2020/topics‐objectives/topic/heart‐disease‐and‐stroke/objectives

Measure Population NCQA CMS/AHIPACO/PCMH

CPC+ HEDIS

Controlling High Blood Pressure

Adult

https://www.cms.gov/regulations‐and‐guidance/legislation/ehrincentiveprograms/ecqm_library.html

CMS165v6 Percentage of patients 18‐85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period (exclusions: ESRD, renal transplant, pregnancy, hospice.) Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period

CMS65v7 Percentage of patients aged 18‐85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement periodPatients whose follow‐up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.

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Cuff too small = False high BP

Cuff too big = maybe ok but maybe False low

BP 10‐20 mmHg higher in legs than arms

Right Arm = standard

Bladder Width > 40% arm circumference Bladder length 80‐100% arm circumference

No caffeine or Tobacco 30 minutes before measurement

Empty bladder

Seated, Back supported, Feet flat on floor for 5 minutes before measurement

Arm at heart level resting on support‐ 2 readings 1 minute apart & average (repeat other arm)

If variation‐ always use arm with higher readings

Useful to take standing measurement to check postural effects (older adults)

If high on automated machine‐ should be repeated by

auscultation 1‐2 minutes.

Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G….Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32: 3‐15. https://www.nhlbi.nih.gov/health/health‐topics/topics/hbp/diagnosis

BP > 140‐90 on 2 separate visitsIf 1 elevated BP reading bring patient back in 1‐4 weeks for a repeat BP

BP > 180/100 at any single visit

Be mindful of “white coat hypertension” phenomenon

Home BP readings/log (5‐7 days minimum)

Ambulatory Blood Pressure Monitoring

Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G….Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32: 3‐15.

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Cardiovascular Events

Stroke/TIA (vascular dementia)

CAD‐MI, angina, prior stents/CABG

Heart FailureLeft Ventricular Systolic function

Chronic Kidney Disease

Peripheral Arterial Disease

Diabetes Mellitus

OSA

I Cardiac codesHTN Heart

DiseaseHeart Failure

KidneyDisease

ICD‐10 codes

Description

YES No No No I10 Essential (Primary) Hypertension

YES YES No No I11.9 Hypertensive Heart Disease without Heart Failure

YES YES YES* No I11.0 Hypertensive Heart Disease with Heart Failure

YES No No Yes** I12.9 Hypertensive Chronic Kidney Disease stages 1‐4

YES No No Yes** I12.0 Hypertensive Chronic Kidney Disease Stage 5 or end‐stage Renal Disease

YES YES No Yes** I13.10 Hypertensive Heart Disease without Heart FailureWITH Chronic Kidney Disease stages 1‐4

YES YES No Yes** I13.11 Hypertensive Heart Disease without Heart FailureWITH Chronic Kidney Disease stage 5 or end‐stageRenal Disease

YES YES Yes* Yes** I13.0 Hypertensive Heart Disease with Heart Failure and Chronic Kidney Disease stages 1‐4

YES YES Yes* Yes** I13.2 Hypertensive Heart Disease with Heart Failure and Chronic Kidney Disease stage 5 or end‐stage Renal Disease

* Requires type of Heart Failure ICD‐10 code ** Requires type of Renal Disease ICD‐10 code

Adapted from: Family Practice Management, Coding Hypertensive Diseases under ICD‐10. http://www.aafp.org/fpm/2014/0300/fpm20140300p5‐rt1.pdf

CMP

Fasting Lipids

UA‐microalbuminuria

ECG

?H/H

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Study Yr n Criteria Result Conclusion

HOTHypertension Optimization Treatment Study

1998 18,790Age 50‐80HTN‐ DBP 100‐115

3 groups:DBP < 80DBP <85 DBP < 90All received Felodipine +

Lowest CV event DBP = 82.6 mmHg, Lowest mortality DBP = 86.5 mmHg

DBP < 90 mmHg

ALLHATAntihypertensive and Lipid‐lowering Treatment to Prevent Heart Attack Trial

2002 33,357HTN + 1 risk factor (1/3 DM)

4 groups:ChlorthalidoneLisinoprilAmlodipineDoxazosin **stopped CHF/Stroke

No difference in primary outcome or mortality

No difference in CV event or stroke

ACCOMPLISHAvoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension

2008 11,000HTN, High CV risk

2 groups:Benazepril + AmlodipineBenazepril + HCTZ

Less CV events (9.6 % vs 11.8%) with ACEI/CCB combo

ACEI/CCB combo in thin, high risk

HYVETHypertension in the Very Elderly Trial

2008 3,84580+ years old

2 groupsIndapamide SRPlacebo

Lower BP associated with risk reduction

ACCORDAction to Control Cardiovascular Risk in Diabetes

2010 4,73360 year oldDM II x 10 yrs with CAD or 2+ RF

2 groupsGoal SBP < 140 mmHgGoal SBP < 120 mmHg

No difference in CV events

Small decrease in stroke with intensive control group

AASKAfrican American Study of Kidney Disease and Hypertension Trial

2010 1,094Black, HTN, nephrosclerosis, NO DM

3 groupsMetoprololRamiprilAmlodipine

No difference in GFR BUT ACEI more effective in slowing decline of GFR than BB or CCB

ACEI best, Lower BP may be benefit with proteinuria

• 1977 – JNC 1 • 1980 – JNC 2 • 1984 – JNC 3 • 1988 – JNC 4 • 1993 – JNC 5 • 1997 – JNC 6 • 2003 – JNC 7 (delayed wait for ALLHAT) • 2014 – JNC 8

• AHA/ACC/CDC advisory algorithm 2013

• ASH/ISH 2013• Canadian 2011 • British 2012 • European 2013

Chopra, . & Nanda, N. (2013). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers.

BP Goal JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013

Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90

Age 60‐79 <140/90 <150/90 <140/90 <140/90 <140/90

Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90

Diabetes <130/80 <140/90 <140/90 <140/85 <130/80

CKD <130/80 <140/90 <140/90 <130/90 <140/90

Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), 1242‐1248.

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Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), 1882‐1888.

0%

5%

10%

15%

20%

25%

30%

35%

Coronary heartdisease

Stroke

Xie, X. et al. (2016). Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta‐analysis. Lancet, 387(10017), 435‐433.

BP‐ 133/76

Comparison of expected and observed effects of a 7 mm Hg systolic blood pressure decrease on coronary heart disease and stroke outcomes

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Blood Pressure Lipids

Mediterranean(low evidence)

If DM or 3 risk factors < 6‐7/2‐3 mmHgHealthy < 2‐3/1‐2 mmHg

No change

DASH(high evidence)

< 5‐6/3 mmHg < LDL 11mg/dL< HDL 4 mg/dLNo change TG

Reduce dietarySodium(high evidence)

Lowers BP

1150mg/d < 3‐4/1‐2 mmHg

No change

Exercise < 2‐5/1‐4 mmHg(high evidence)

< LDL 2.5 mg/dL< non‐HDL 6 mg/dLNo change TGNo change HDL(moderate evidence)

EXERCISE: at least 12 weeks duration, 3 to 4 sessions per week, lasting on average 40 minutes per session, and involving moderate‐ to vigorous intensity physical activity. Strength of evidence: High

Eckel, R.H.. et al. (2013). 2013 AHA/ACC Guideline on lifestyle management to reduce cardiovascular risk. Circulation.

Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), 1882‐1888.

0%

5%

10%

15%

20%

25%

30%

35%

Coronary heartdisease

Stroke

Xie, X. et al. (2016). Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta‐analysis. Lancet, 387(10017), 435‐433.

BP‐ 133/76

Comparison of expected and observed effects of a 7 mm Hg systolic blood pressure decrease on coronary heart disease and stroke outcomes

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Diuretics

ACEI: Angiotensin Converting Enzyme Inhibitors

ARB: Angiotensin Receptor Blockers

Calcium Channel Blockers

Beta Blockers

Alpha Blockers

Central Acting

Vasodilators

Potassium Channel Activators

JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013

Non‐blackNo DM/CKD

Thiazide Thiazide, ACEI, ARB, CCB

< 60 ACEI, ARB> 60 CCB, Thiazide

Thiazide,ACEI, ARB, CCB, BB

Thiazide, ACEI, ARB (BB if < 60)

BlackNo DM/CKD

Thiazide ThiazideCCB

ThiazideCCB

Thiazide, ACEI, ARB, CCB, BB

Thiazide, ARB (BB if < 60)

DiabetesWithout CKDAll races

ACEI, ARB, CCB, BB, Thiazide

Thiazide,ACEI, ARB, CCB

ACEI, ARB, CCB, Thiazide

ACEI, ARB ACEI, ARB, CCB, Thiazide

CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB


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Diuretics

Drug Class Drug Dose Interval

Benzophenone Chlorthalidone(Hygroton)

12.5‐25mg Daily

Benzothiadiazine HCTZ 12.5‐50mg Daily

Indapamide(Lozol)

1.25‐2.5mg Daily

Quinazolinones Metolazone(Zaroxolyn)

2.5‐10mg Daily

JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013






BlackNo DM/CKD


ThiazideCCB



DiabetesWithout CKD


Thiazide, ACEI, ARB, CCB





ACEIs

ARBs

Aldosterone Antagonist

Renin Inhibitor

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Captopril (Capoten)

Lisinopril (Zestril, Prinivil)

Enalapril (Vasotec)

Ramipril (Altace)

Fosinopril (Monopril)

Benazepril (Lotensin)

Quinapril (Accupril)

Trandolapril (Mavik)

Perindopril (Aceon)

Losartan (Cozaar)

Candesartan (Atacand)

Valsartan (Diovan)

Telmisartan (Micardis)

Irbesartan (Avapro)

Omesartan (Benicar)

Eprosartan (Teveten)

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Aliskiren (Tekturna)

CYP3A4!

Avoid grapefruit juice, ‐azoles

JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013






BlackNo DM/CKD


ThiazideCCB



DiabetesWithout CKD







DihydropyridinesAmlodipine (Norvasc)

Felodipine (Plendil)

Isradipine (DynaCirc)

Nifedipine (Procardia XL, Adalat CC)

Nisoldipine (Sular)

Non‐dihydropyridinesVerapamil (Isoptin, Calan)

Diltiazem (Cardizem, Dilacor)

Avoid grapefruit juice

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JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013






BlackNo DM/CKD


ThiazideCCB



DiabetesWithout CKD







Beta Blocker TherapyPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease or heart failure seen within a 12

month period who also have a prior MI OR a

current or prior LVEF <40% who were prescribed beta‐blocker therapy

Metoprolol (Lopressor, Toprol)

Atenolol (Tenormin)

Bisoprolol (Zebeta)

Esmolol (Brevibloc)

Carvedilol (Coreg)

Propranolol (Inderal)

Labetalol (Trandate)

Nadolol (Corgard)

Nebivolol (Bystolic)

JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013






BlackNo DM/CKD


ThiazideCCB



DiabetesWithout CKD







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Terazosin (Hytrin)

Prazosin (Minipress)

Doxazosin (Cardura)

Phentolamine (Regitine)

JNC‐72004

JNC‐82014

ASH/ISH2013

ESC/ESH2013

CHEP2013






BlackNo DM/CKD


ThiazideCCB



DiabetesWithout CKD







Clonidine

Methyldopa

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Loop DiureticsFurosemide

Torsemide

Bumetanide

Ethacrynic Acid

Mineralcorticoid AntagonistSpironolactone

Eplerenone

Sodium Channel BlockerAmiloride

Hydralazine

Sodium Nitroprusside

Minoxidil (Loniten)

Diazoxide (Proglycem)

Uncontrolled blood pressure despite the use of three optimized antihypertensive medications, of which one is a diuretic.

D. A. Calhoun, D. Jones, S. Textor et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510–e526.

Prevalence is unknown(Estimated 10‐30%)

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Poor adherence

Provider inertia

Inadequate doses

Inappropriate combinations of meds

Excess alcohol intake

Obstructive Sleep Apnea

D. A. Calhoun, D. Jones, S. Textor et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510–e526.P. A. Sarafidis and G. L. Bakris, (2008). Resistant hypertension. An overview of evaluation and treatment. Journal of the American College of Cardiology, 52(22), 1749– 1757.

Thyroid Disease

OSA

Primary Hyperaldosteronism

Renal Artery Stenosis

Cushings Disease

Coarctation of the Aorta

Hyperparathyroidism

Pheochromocytoma

Faselis, C., Doumas, M. & Papademetriou, V. (2011). Common secondary causes of resistant hypertension and rational for treatment. International Journal of Hypertension,.

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Increase diuretic doseConsider a loop if GFR< 30mL/min/1.73m2

Add an alpha blocker

Use a combined alpha/beta blocker: carvedilol, labetalol

Add spironolactone, epleronone, OR amiloride

Add hydralazine, clonidine, guanfacine,

Consider using BOTH a nondihydropiradine CCB AND a dihydropiradine CCB

Consider minoxidil

REFER to A HYPERTENSION SPECIALIST:

Viera, A.J. 7 Hinderlier, A.L. (2009). Evaluation and management of the patient with difficult to control or resistant hypertension. American Family Physician, 79(10), 863‐869.

BP remains > 140/90

(>age 60 150‐90)

despite 3 antihypertensives

(1 being a diuretic)

Review Lifestyle Factors & Coach patient

‐Obesity, excess alcohol, high salt intake, DASH diet, physical

activity

SCREEN for SECONDARY causes of Hypertension

Stop or Minimize interfering substances

‐ NSAIDS, OCPs, Alcohol, Ephedra, etc.

Assess Adherence

Review Home BP log

Adjust Pharmacologic Treatment

Maximize Diuretic include Spironolactone

REFER to a SPECIALIST

Cardiology

Nephrology

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NSAID use

Belief System

Medication Adherence

Medication Affordability

Home Blood Pressure Monitoring

Self‐Titration

Patient Selection

BP Goals: < 140/90

Home BP monitoring

Patient Centered Care

Self Titration in select populations

Facilitate healthy lifestyle modification

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QUESTIONS??

[email protected]

• Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. (2008). Treatment of hypertension in patients 80 years of age or older. NEJM;358(18):1887‐189B.

• Benjamin et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association [published online ahead of print January 25, 2017]. Circulation. doi: 10.1161/CIR.0000000000000485

• Caboral‐Stevens, M. & Rosario‐Sim, M. (2014). Review of the Joint National Committee’s recommendations in the management of hypertension. JPN, 10(5), 325‐330.

• Calhoun, D. A. , Jones, D., Textor, S. et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510–e526.

• Chobanian AV. Bakris GL. Black HR, et al; (2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, 289(19), 2560‐2572.

• Chopra, . & Nanda, N. (2013). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers.

• Cushman WC, Evans GW, Byington RP, et al; (2010). ACCORD Study Group. Effects of intensive blood‐pressure control in type 2 diabetes mellitus. NEJM;362(17):1575‐1585.

• Eckel, RH, et al. (2013). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk, Circulation.

• Salvo, M. & White CM (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), 1242‐1248.

• Egan, B., Li, J., Hutchison, F. & Ferdinand, K. (2014). Hypertension in the United States 1999‐2012: Progress toward Healthy People 2020 Goals. Circulation.

• Faselis, C., Doumas, M. & Papademetriou, V. (2011). Common secondary causes of resistant hypertension and rational for treatment. International Journal of Hypertension.

• Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28‐e292.

• Healthy People 2020 – Heart Disease and Stroke. https://www.healthypeople.gov/2020/topics‐objectives/topic/heart‐disease‐and‐stroke/objectives. Accessed August 16, 2016.

• James, P. et al. (2014). 2014 Evidence‐based guideline management of high blood pressure in adults: Report from the panel members appointed to the eighth Joint National Committee (JNC8). JAMA, 311(5), 507‐520.

• Wright, JT, et al. (2015). A randomized trial of intensive versus standard blood‐pressure control. NEJM 373, 2103‐2116.

• Leung AA, et al. Hypertension Canada’s 2016 CHEP Guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention and treatment of hypertension. Can J Cardiol. 2016; 32:569–588.

• National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; (2003). National High Blood Pressure Education Program Coordinating Committee The JNC 7 report. JAMA. 289(19):256O‐2572.

• Sarafidis, P. A. and Bakris, G. L. (2008). Resistant hypertension. An overview of evaluation and treatment. Journal of the American College of Cardiology, 52(22), 1749– 1757.

• Viera, A.J. 7 Hinderlier, A.L. (2009). Evaluation and management of the patient with difficult to control or resistant hypertension. American Family Physician, 79(10), 863‐869.

• Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G….Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32: 3‐15.

• Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), 1882‐1888.

strategies in treating resistant hypertension · 8/20/2017 6 study yr n criteria result conclusion...

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