evidence-based decisions for improving hypertension management youssef moussa

Low incidence of adverse events

Thanks For Your Attention

Practice Essentials

2017 Guideline for High Blood Pressure in Adults

• Hypertension is 1 of the most common chronic conditions seen in primary care offices, and it is frequently comorbid with smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea..
• it is a major risk factor for:

Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, and ARBs inhibitors or ACE, CCBs.

Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target.

Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components.

• Stroke,
• Myocardial Infarction,
• Vascular Disease,
• Chronic Kidney Disease.

A Recommendation to Monitor Orthostatic Blood Pressure

American Diabetes Association (ADA)

Autonomic Neuropathy

Volume Depletion,

Orthostatic blood pressure should be measured at initial visits for hypertension and then periodically.

This includes checking a second blood pressure within 3 minutes of standing from a sitting or supine position.

This can help monitor for:

which can get worse with high blood pressure medications.

It's important because orthostatic hypotension is linked to an increased risk for heart failure and death.

The evidence is overwhelming. Reaching blood pressure goals with our patients reduces cardiovascular events and microvascular complications.

Diabetes Care. Published online August 22, 2017.

Hypertension 2017

What’s new?

Single pill combinations as a first line treatment

(regardless of the extent of BP elevation)

Properties of an Ideal Hypertensive medication

CHANCE Study

Duration of Action > 24 hours coverage

Results : % of Patients with Normalized BP

Vascular Health and Risk Management 2006:2(3) 317–323

JNC 8 Recommendations BP Treatment Targets

Automated Office BP Measurement Preferred

What’s new?

Automated office blood pressure (AOBP) is the preferred method of performing in-office BP measurement

Automated Office (unattended, AOBP)

Oscillometric (electronic)

JNC 8 Recommendations BP Treatment Targets

Hypertension 2017

What’s still important?

• The diagnosis of hypertension should be based on out-of-office measurements; in the office, use automated office BP monitoring (AOBP)

• The threshold and target blood pressures are lower in those at greater risk

Automated Office BP Measurement

More closely approximates ABPM than routine office BPs (mitigates white coat effect)1-3

Is more predictive of end organ damage (LVMI, proteinuria and cIMT), similar to ABPM4-6

ABPM = ambulatory blood pressure measurement

LVMI = left ventricular mass index

cIMT = carotid intima media thickness

Beckett L, et al. BMC Cardiovasc Disord 2005;5:18; 2. Myers MG, et al. J Hypertens 2009;27:280-6;

3. Myers MG, et al. BMJ 2011;342;d286;4. Campbell NRC, et al. J Hum Hypertens 2007;21:588-90;

5. Andreadis EA, et al. Am J Hypertens 2011;24:661-6; 6. Andreadis EA, et al. Am J Hypertens 2012;25:969-73.

Properties of an ideal Hypertensive Medication

Hypertension 2017

• What device do you currently use in the office to measure BP?
• What do you tell patients about home BP assessment?
• Do you document BP targets on the patient's chart/EMR?
• How do you communicate BP targets to your patient?

Properties of an Ideal Hypertensive medication

End Organ Protection

Properties of an Ideal Hypertensive medication

• Efficacy & Potency

• Duration of action >(24 hours coverage)

• End Organ Protection

• Low incidence of adverse events

Properties of an Ideal Hypertensive medication

Efficacy & Potency

1- Left Ventricular Hypertrophy

2- Renal

3- Stroke