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Hypertension: A Practical Approach

Jon Zlabek, MD, FACP. Gundersen Health System, La Crosse, WI.
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Jon Zlabek

on 22 April 2016

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Transcript of Hypertension: A Practical Approach

Hypertension:
A Practical Approach

Hypertension:
A Practical Approach

Jon Zlabek, MD, FACP
Vascular Medicine
Gundersen Health System
jazlabek@gundersenhealth.org

Last edited March 2016
Hypertension is my most common diagnosis in clinic, but I don't quite have a handle on it . . .
There are over 100 different blood pressure medications out there . . . which do I chose and in what order?
My patients don't
want to take a medication, let alone several, for a disease they can't even feel.

How can I convince them?
What do I do when my usual 3 medications don't get my patient to goal?
scottmccloud.com
I have no disclosures.
References
Convincing Your Patients

This is a life-long chronic disease, so patients need to understand and be regularly reminded of why they are taking pills for the rest of their life for something they can't feel

Over-educate patients about the severity of long term untreated hypertension
Aronow WS et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly. Circulation. 2011;123(21):2434-2506.
Bakris GL et al. RENAAL Study Group. Effects of blood pressure level on progression of diabetic nephropathy results from the RENAAL study. Archives of Internal Medicine. 2003;163:1555-65.
Beckett NS et al. Treatment of Hypertension in patients 80 years of age or older. New England Journal of Medicine. 2008;358:1887-98
Bravo E. Resistant Hypertension: Diagnostic Strategies and Management. Cleveland Clinic Journal of Medicine. 2013;80(2):91-6.
Calhoun DA et al. 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. 2008;51:1403-19.
Chobanian AV et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42:1206-1252.
Interesting . . . Why The Gap?

Nearly all individuals with uncontrolled hypertension have health insurance and visit their providers

Nearly half of patients with hypertension are still not at goal blood pressure levels

NHANES report of 13,375 hypertensive patients who were "treated but not controlled"
72% were on only 1-2 medications
What Causes Therapeutic Inertia?

We think we are better than we really are
"Positive Illusion"

Clinical uncertainty about the "true" blood pressure value

Distraction when other unrelated medical conditions are discussed during the visit
What Causes Therapeutic Inertia?

Lack of training/education

"Decision Paralysis" - we have about 100 medications to choose from and thousands of possible paths . . . so we don't act at all
Tips to Conquer Therapeutic Inertia

Be aware that we humans "drift" toward this

Some providers may need to be more "industrious" during clinic visits
It's much easier to "see you in 6 months" than to prescribe a medication

"Script the critical moves" - use the hypertension card
What To Tell Patients Over and Over

"Most patients will eventually need 3 medications to get to goal blood pressure levels"

"I will be seeing you for a brief visit every 2-4 weeks with lab tests until your blood pressure is controlled"
What To Tell Patients Over and Over

What To Tell Patients Over and Over

"Have I got a
DEALS

for you!"

D
iet
E
xercise
A
lcohol moderation
L
ose weight
S
alt reduction
"We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure"
Lifestyle Change Works

Lifestyle change can be a powerful motivator and tool for patient engagement

"We might be able to stop some medications as your lifestyle improves"
Your words should be so burned into their brain that
if they don't follow the plan, they shouldn't be surprised by their first event
Why Chlorthalidone over HCTZ?

About twice as potent with three to five times greater half-life

Outstanding benefit proven in several large trials and extended follow-up
HCTZ has a weaker resumé

Recommended to switch to it anyway if patient has resistant HTN
Why Chlorthalidone over HCTZ?

A retrospective observational cohort study of the MRFIT trial showed both were better than placebo, but Chlorthalidone was superior to HCTZ in reducing cardiovascular events

No head-to-head trial has been performed
ACE/ARB
Thiazide
CCB
Which Order?
First
Stop chasing low K's with unopposed thiazide
Second
ACE/ARB enhances the effect of thiazide
Third
ACE/ARB & thiazide decrease CCB-induced edema
Resistant Hypertension

Uncontrolled despite treatment with 3 or more medications or controlled on four or more medications
Up to 30% of patients have this
Incidence is increasing

Don't be fooled: Is your patient truly resistant or "pseudoresistant"?
"Pseudoresistance"

Non-optimized medication regimen
50-85% of uncontrolled patients are prescribed medications at suboptimal doses

Patient non-adherence to medications
Prevalence of ~40% in this population

White coat syndrome
Prevalence of 30% in this population

Inaccurate blood pressure measurement
Resistant Hypertension

1. Go back to the basics

Ensure proper measurement

Confirm adherence to medications

Lifestyle: "Have I got a
DEALS

for you!"

Maximize doses of current medications
3. Evaluate for Possible Secondary Causes

Ensure that "the basics" have been recently checked:
Creatinine for worsening CKD
If GFR <30, change to a loop diuretic

TSH for hyper or hypothyroidism

Calcium for hyperparathyroidism

Hemoglobin for polycythemia

My Assertion

We will save more lives using an easy-to-follow approach that is followed consistently than with a complex algorithm with multiple therapeutic pathways.
Dosing Strategy

International guidelines differ; JNC-8 recognizes this and suggests there is not a single evidence-based approach

Simple systems get things done more realiably than complex ones
Why Should I Treat Hypertension?
Treatment decreases risk of:

First stroke over 30%

CHF over 50%

MI by 20-25%

ESRD/death by 38%


Therapeutic Inertia


Healthcare providers' failure to increase therapy when treatment goals are unmet
Tips to Conquer Therapeutic Inertia

Remind patients (and yourself) that it may take 3 or more medicines to get to goal
Only 49% of patients in ALLHAT were controlled on 1 or 2 medications

Stress the importance of patient engagement
Have them get a good home monitor and involve them in treatment decisions
Tips to Conquer Therapeutic Inertia

"We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure"
Continually tell
yourself
and your patients
Compelling Indications for Initial Treatment

Diabetes with microalbuminuria
ACE-I/ARB

Chronic Kidney Disease
ACE-I/ARB

Black patients
Thiazide or CCB
Compelling Indications for Initial Treatment

CHF
ACE-I/ARB
Beta blocker
Aldosterone antagonists

Cerebrovascular disease
Thiazide
ACE-I/ARB
Dosing Strategy - Option 1

Titrate one drug to the maximum dose before starting another
Very linear - less therapeutic pathways from which to choose
Easy to put into practice
Most patients need ≥ 2 meds anyway, so you'll add on anyway
Synergistic effects delayed

Dosing Strategy - Option 2

Start one drug and then add a second drug before first drug is at maximal dose
Enjoy synergistic effects sooner
Dramatically adds to number of possible therapeutic pathways

Dosing Strategy - Option 3

Begin with two drugs at the same time
Recommended if blood pressure is more than 20/10 above goal
Lose dose combination pills may initially get patients to goal more rapidly
May add complexity as titrations occur
Tips to Conquer Therapeutic Inertia
"Picture your retirement . . . "
Insititute of Medicine Report - 2010

“Although hypertension is relatively easy to prevent, simple to diagnose, and relatively inexpensive to treat, it remains the second leading cause of death among Americans, and as such should rightly be called a neglected disease.”

The Big Picture

Hypertension is the most common diagnosis in the clinic
43.4 million visits per year

Affects 33% of US adults (78 million); men slightly more than women

Prevalence expected to be 41% by 2030

The Big Picture

Only 53% are controlled; women have better control than men

Control has significantly improved
It was 32% in 1999-2000
Why Care?

Are these organs important to you?

Brain - Stroke/TIA
Causes 60% of stroke

Heart - MI and CHF

Kidney - CKD and ESRD

Welcome to the Circus: JNC-8

Convened in 2008; many delays

In 2013 NHLBI stopped producing guidelines; JNC-8 decided to pursue publication independently
"Not an NHLBI sanctioned report and does not reflect the views of the NHLBI"
Welcome to the Circus: JNC-8

Was not endorsed by any federal agency or professional society prior to publication
Chose not to be a part of ACC/AHA or American Society for Hypertension (ASH)
High Controversy Recommendation

OK for those over 60 years old to drift up to <150/90 mm Hg
No other national or international guidelines have this
No solid evidence for, and a fair amount of evidence against this
High Controversy Recommendation

Studies at odds with this recommendation:
SHEP, HYVET, CARD-SIS, PROGRESS, FEVER, INVEST

Guidelines at odds with this recommendation:
European, Canadian, UK, ACC/AHA, ASH, International Society of HTN
SPRINT Trial

SPRINT compared 136/76 vs. < 121/69 mm Hg in patients age 55 or older without diabetes or stroke
2.8 vs 1.8 medications per person
Stopped early due to a 25% lower relative risk of major CV events
Guidelines likely to change due to this study

What To Do Until Then?

Consider the controversial recommendation in JNC-8 as disputed and at odds with the rest of the world

ACC/AHA is joining forces with ASH to produce a guideline in 2016 that will be adopted as the national standard
High Controversy Recommendation

Even some on the JNC-8 committee disagreed and published a rebuttal

There is concern that loosening the goal will partially undo the amazing decreases in stroke and heart disease mortality in this age group
JNC-8
Today's Goal
To equip you to confidently approach
and conquer this deadly disease
Is this what happens when you think about hypertension?
Back to the Basics - Proper Measurement

Patient preparation in the 30 minutes prior:
No caffeine
No smoking
No significant physical activity

Ensure bladder is empty

Arm cuffs are preferred; wrist and finger cuffs can be inaccurate
Back to the Basics - Proper Measurement

An excellent video on the proper method of blood pressuremeasurement from the
New England Journal of Medicine
http://www.nejm.org/doi/full/10.1056/NEJMvcm0800157

Back to the Basics - Proper Measurement

Seated for at least 5 minutes
Back supported
Legs uncrossed
Feet flat on floor
No talking

Bare arm resting comfortably at heart level

Cuff must be correctly sized
A cuff size too small can increase SBP by
5-15 mm Hg
Back to the Basics - Proper Measurement

The two step (pulse obliteration) method prevents mistakes from erroneously missing the first Korotkoff sound
The elderly can have a large ascultatory gap and give falsely low SBP

Beware rounding bias and digit preferences
Rounding up: 139 becomes 140
Some record 0s & 5s at the end: 14
0
, 14
5

Resistant Hypertension
Remember the Common Errors

Diuretic use - most are volume overloaded
Not using chlorthalidone
If furosemide is needed instead, not dosing at least twice a day

Not using spironolactone

Combining ACE-I and ARB
Medication regimens for 140,126 patients taking 4 or more antihypertensive agents
Lifestyle Change Works

May delay medication for 6-12 months if hypertension is mild and no end organ effects IF they are serious about lifestyle changes

BEWARE of the "talker"!
I only delay medications if he/she is truly a "doer"
Don't fall for the "I'll try harder" trap!
Lifestyle Change Works

"Have I got a
DEALS

for you!"

D
iet
DASH diet: 11 mm Hg reduction
http://dashdiet.org

E
xercise
Regular aerobic activity
4-7 mm Hg reduction
Lifestyle Change Works

"Have I got a
DEALS

for you!"

A
lcohol moderation
2-4 mm Hg reduction

L
ose weight
~3 mm Hg reduction/10 pounds lost

S
alt reduction
5-10 mm Hg reduction
ACE/ARB
Thiazide
CCB
Which Order?
First
Stop chasing low K's with unopposed thiazide
Second
ACE/ARB enhances the effect of thiazide
Third
ACE/ARB & thiazide decrease CCB-induced edema
Compelling Indications for Initial Treatment

Diabetes with microalbuminuria
ACE-I/ARB

Chronic Kidney Disease
ACE-I/ARB

Black patients
Thiazide or CCB
Compelling Indications for Initial Treatment

CHF
ACE-I/ARB
Beta blocker
Aldosterone antagonists

Cerebrovascular disease
Thiazide
ACE-I/ARB
Resistant Hypertension

4. Continue treatment . . .

Flip the card!
Electrolytes and Thiazides

Most of the Na and K changes occur within the first 2-3 weeks

Don't stop if K is low, just replace
HCTZ 0.2 - 0.4 mmol/L loss
Chlorthalidone 0.5 - 0.7 mmol/L loss

If Na drops below 130, stop and add to intolerance list - high recurrence rate
Diuresis is Critical

Treatment resistance is often related to occult volume overload - it may not be clinically obvious
Lack of, or underuse of diuresis is the most common cause of resistance
The Elderly

Unique considerations:
Predominantly systolic hypertension due to vascular stiffness
Reduced barorelex sensitivity increases blood pressure variability and vulnerability to hypotension when standing, after eating, and after medications
The Elderly

Despite this, there is a significant decrease in events with systolic blood pressure reductions to 135-150 mm Hg

There is a J shaped curve in regards to blood pressure reductions and adverse outcomes that differs in subpopulations of the elderly
Dorsch MP et al. Chlorthalidone reduces cardiovascular events compared with hydrochlorothiazide: a retrospective cohort analysis. Hypertension. 2011; 57: 689-694
Dunning D et al. Flawed Self-Assessment Implications for Health, Education, and the Workplace. Psychological Science in the Pulblic Interest. 2004;5(3):69-106.
Ernst ME et al. Use of diuretics in patients with hypertension. New England Journal of Medicine. 2009;361:2153-64.
Egan BM et al. Prevalence of optimal treatment regimens in patients with apparent treatment-resistant hypertension based on office blood pressure measurement in a community-based practice network. Hypertension. 2013:62(4):691-7.
Go AS et al. Heart disease and stroke statistics - 2014 update. Circulation. 2014;129:e28-e292.
Hanselin MR et al. Description of antihypertensive use in patients with resistant hypertension prescribed 4 or more agents. Hypertension. 2011;58:1008-13.
Heath C, et al. Switch: How to change things when change is hard. 2010. Crown Business.
James PA. 2014 Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA. 2014;311(5):507-520.
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hpertensive patients. Hypertension Research. 2008;12:2115-27.
Leaf DA, et al. A comparison of self-report and chart audit in studying resident physician assessment of cardiac risk factors. Journal of General Internal Medicine. 1995;10(4):194-8.
Liu L et al. The felodipine event reduction (FEVER) study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. Journal of Hypertension. 2005;23(12):2157-72.
Lipsitz LA. A 91-Year-Old Woman With Difficult-To-Control Hypertension. A Clinical Review. JAMA. 2013;310(12):1274-80.
Lozano L et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized controlled trial. Journal of Hypertension. 2010;28(10):2161-8.
Martinez-Garcia MA et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310(22):2407-15.
Masuo K. Changes in frequency of orthostatic hypotension in elderly hypertensive patients under medications. American Journal of Hypertension. 1996:9(3):263-8.
Ogihara T et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56(2):196-202.
Olin JW et al. Fibromuscular dysplasia: state of the science and critical unanswered questions. Circulation. 2014;129: 1048-1078.
Peterzan MA et al. Meta-analysis of dose-response relationships for hydrochlorothiazide, chlorthalidone, and bendroflumethiazide on blood pressure, serum potassium, and urate. Hypertension. 2012.59(6):1104-9.
Phillips LS et al. Clinical Inertia. Annals of Internal Medicine. 2001;135(9):825–34.
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-presure lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–1041.
SHEP authors. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Systolic Hypertension in the Elderly Program. JAMA. 1991;265(24):3255-64.
Strauch B et al. Precise assessment of noncompliance with the antihypertensive therapy in patients with resistant hypertension using toxicological serum analysis. Journal of Hypertension. 2013:31(12):2455-61.
Verdecchia P et al. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomized trial. Lancet. 2009;374:525-33.
Vongpatanasin W. Resistant hypertension. A review of diagnosis and management. JAMA 2014;311(21):2216-24.
Weber MA et al. 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. The Journal of Clinical Hypertension. 2014;32(1):3-15.
Weir MR et al. Pilot study to evaluate a water displacement technique to compare effects of diuretics and ACE inhibitors to alleviate lower extremity edema due to dihydropyridine calcium antagonists. American Journal of Hypertension. 2001. 14(9):963-968.
Wright BM, et al. Resistant hypertension: an approach to diagnosis and treatment. Consultant. 2013;January:9-16
Wright Jr JT. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: The minority view. Annals of Internal Medicine. 201;160(7):499-503.
Appendix
The Elderly

Because of these considerations, most guidelines give the option of allowing blood pressure to drift up to <150 mm Hg systolic in clinically appropriate patients aged 80 or older
TinyURL.com/LBT7a6u
High Controversy Recommendation

The two studies that influenced the panel toward this recommendation enrolled a Japenese population and were underpowered:
JATOS
VALISH
Resistant Hypertension


2. Determine your path:

Do nothing and rationalize why your patient is not at goal
OR
Consult a hypertension specialist for optimization and secondary evaluation
OR
Perform an appropriate secondary evaluation and continue treatment
The Big Picture

Increases with age; 71% prevalence in those ≥ 65 years old

Estimated direct & indirect costs:
2010: $46.4 billion
2030: $274 billion

Contributes to 1 in 6 deaths

What To Tell Patients Over and Over

"We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure"
"We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure"
Continually Tell Yourself and Your Patients
You Have Been Equipped!
Go forth to confidently approach
and conquer this deadly disease!
Take Home
Points
Lifestyle Change Works

"Have I got a
DEALS

for you!"

D
iet
E
xercise
A
lcohol moderation
L
ose weight
S
alt reduction
Determine Your Path for
Resistant Hypertension

Do nothing and rationalize why your patient is not at goal
OR
Consult a hypertension specialist for optimization and secondary evaluation
OR
Perform an appropriate secondary evaluation and continue treatment
Ways To Dose
The Elderly
HY
pertension in the
V
ery
E
lderly
T
rial

Enrolled 3845 patients 80 years or older with SPB of 160 mm Hg or more to indapamide-perindopril combination or placebo to goal BP of less than 150/80

Within 2 years there were large benefits in stroke, heart failure and all cause mortality

Fewer serious adverse effects in the treatment arm
A Big Contributor to "The Gap"
Resistant HTN Medication Recommendations

Use chlorthalidone as the thiazide diuretic

If you need a loop diuretic such as furosemide instead of a thiazide for volume overload (CHF/CKD), dose it twice daily

Use spironolactone as the 4th line medication after testing for hyperaldosteronism

Don't use an ACE-I + ARB together
3. Evaluate for Possible Secondary Causes

Primary hyperaldosteronism
Only 40% have a low potassium
Check morning aldosterone and renin
Positive screen is aldosterone/renin >20:1 (or 30:1) with aldosterone > 15
Must be off spironolactone and eplerenone 4-6 weeks prior to testing

If screen is positive, consult Endocrinology

3. Evaluate for Possible Secondary Causes

Renal artery stenosis - atherosclerotic
Screen with renal artery ultrasound
Indications for stenting atherosclerotic lesions are controverial since CORAL trial
High-grade bilateral stenosis
High-grade stenosis to solitary kidney
Especially with flash pulmonary edema, worsening CKD, creatinine rise with ACE-I/ARB, or recent worsening blood pressure control

3. Evaluate for Possible Secondary Causes

Renal artery fibromuscular dysplasia
Most common in females with onset of hypertension less than 50 years of age
Can see with renal artery ultrasound
Best test is CT angiogram

If renal artery imaging is abnormal, consult Nephrology for further discussion and evaluation

3. Evaluate for Possible Secondary Causes

Obstructive sleep apnea
Snoring, witnessed apnea, daytime hypersomnolence

If present, consult Sleep Center for evaluation and sleep study



3. Evaluate for Possible Secondary Causes

Coarctation of aorta
Onset of hypertension early in life, difference/delay between brachial and femoral pulses, murmur/bruit over posterior chest
Stress ABI, MR angiogram or CT angiogram

If abnormal, consult Cardiology to evaluate and coordinate treatment



3. Evaluate for Possible Secondary Causes

Cushing's syndrome
Significant weight gain, striae, moon facies, hyperglycemia; truncal, supraclavicular, or intrascapular obesity
24-hour urine cortisol, overnight dexamethasone suppression test, or late evening salivary cortisol

If abnormal, consult Endocrine



3. Evaluate for Possible Secondary Causes

Pheochromocytoma
Episodic hypertension, headaches, palpitation, sweating
24-hour urine for metanephrines and catecholamines or plasma fractioned metanephrines

If abnormal, consult Endocrinology



3. Evaluate for Possible Secondary Causes

Medications/Drugs
Estrogens
NSAIDS
Stimulants
Antidepressants
Corticosteroids
Herbal compounds
Full transcript