Hypertension Update: Navigating the New Guidelines Shawna D. - PowerPoint PPT Presentation

“Hypertension Update: Navigating the New Guidelines” Shawna D. Nesbitt, MD, MS Professor of Medicine Associate Dean UT Southwestern Medical School

SPEAKER DISCLOSURE • Dr. Nesbitt has disclosed that she has received grant support from Quantum Genomics, she is a consultant for Relypsa, and she is on the advisory board for Quantum Genomics and Reylpsa.

EDUCATIONAL OBJECTIVES By completing this educational activity, the participant should be better able to: 1. Discuss the significance of early detection and effective treatment of hypertension. 2. Address barriers to care among patients with hypertension and assess treatment barriers in the elderly. 3. Discuss the recommendations of the JNC8. 4. Construct a management plan for patients with hypertension and discuss methods for treating for resistant hypertension.

BASELINE BP PREDICTS PROGRESSION TO HYPERTENSION 4 year Hypertension Incidence rates 60 60 Age 35-64 Age 65-94 49.5 4 Year Hypertension 50 50 Incidence % 37.3 40 40 25.5 30 30 17.6 16 20 20 10 10 5.3 0 0 Optimal Normal High Normal Optimal Normal High Normal Optimal = <120/80 mm Hg Normal = 120‐130/80‐85 mm Hg Adjusted for sex, age, BMI, and baseline BP High Normal = 130‐139/85‐89 mm Hg Vasan RS. Lancet. 2001;358:1682

KAPLAN‐MEIER CURVES OF CLINICAL HYPERTENSION IN THE TWO GROUPS 4 Years 1.0 RR ↓15.8 AR ↓ 9.6 0.9 Candesartan % Cumulative incidence 0.8 Placebo 0.7 0.6 0.5 0.4 2 Years 0.3 RR ↓ 66% 0.2 AR ↓ 26% 0.1 0 0 1 2 3 4 Years in study Candesartan 391 356 309 191 128 Placebo 381 269 184 118 85 Numbers under the graph refer to hypertension‐free individuals Julius S, Nesbitt SD, et al. NEJM. 2006;354

Risk of CAD and Stroke Mortality by SBP CORONARY ARTERY DISEASE MORTALITY STROKE MORTALITY Lewington S, et.al. Lancet. 2002;360:1903‐1913 Lancet, 2002; 360:1903‐1913

MORTALITY FROM HIGH BLOOD PRESSURE HIGHER IN AFRICAN AMERICANS Age‐adjusted Mortality Rates Attributable to Hypertension, 2014 60 50.1 Mortality Rate per 100,000 50 40 35.6 30 19.3 20 15.8 10 0 Men Women Men Women African American White Adapted from Benjamin EJ, et al. Circulation. 2017.

ADULT BLOOD PRESSURE CATEGORIES BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm and <80 mm Hg Hg Hypertension Stage 1 130–139 mm or 80–89 mm Hg Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg • *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. • BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure. Whelton PK, et.al. ACC/AHA/AAPA/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; Nov 13

PREVALENCE OF HYPERTENSION BASED ON 2 SBP/DBP THRESHOLDS*† SBP/DBP ≥130/80 mm Hg or SBP/DBP ≥140/90 mm Hg or Self- Self-Reported Reported Antihypertensive Antihypertensive Medication† Medication‡ Overall, crude 46% 32% Men Women Men Women (n=4717) (n=4906) (n=4717) (n=4906) Overall, age-sex 48% 43% 31% 32% adjusted Age group, y 20–44 30% 19% 11% 10% 45–54 50% 44% 33% 27% 55–64 70% 63% 53% 52% 65–74 77% 75% 64% 63% 75+ 79% 85% 71% 78% Race-ethnicity § Non-Hispanic White 47% 41% 31% 30% Non-Hispanic Black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32% • The prevalence estimates have been rounded to the nearest full percentage. • *130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014. • †BP cut points for defini�on of hypertension in the present guideline. • ‡BP cut points for defini�on of hypertension in JNC 7. • § Adjusted to the 2010 age‐sex distribution of the U.S. adult population. • BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure. Whelton PK, et al. Guideline for the prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; Nov 13

Prevalence of Hypertension Based on BP Thresholds (NHANES) 70% 60% 59% 56% 50% 47% 46% 40% 42% 41% 30% 31% 30% 20% 10% 0% Black men Black women White men White women JNC 7‐‐140/90 mmHg 2017 ACC/AHA‐‐130/80 mmHg Muntner, P et al. “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.” Circulation. 2017.

LANGUAGE AS A BARRIER TO HEALTHCARE “Triple Threat” 1. Language differences 2. Cultural differences associated with language 3. Low health literacy Schyve PM. J Gen Intern Med. 2007;22(suppl2);360

5 AREAS OF SOCIAL DETERMINANTS OF HEALTH (SDOH) Neighborhood and Built Environment • Access to foods that support healthy Eating Patterns • Quality of Housing • Crime and Violence • Environmental Conditions Economic Stability Health and Health Care • • Poverty Access to Health Care • • Employment Access to Primary Care Social • • Food Insecurity Health Literacy Determinants • • Housing Instability Provider Bias Of • Cultural Competency Health Education Social and Community Context • • High School Graduation Social Cohesion • • Enrollment in Higher Education Civic Participation • • Language and Literacy Discrimination • • Early Childhood Education and Development Incarceration Healthy People 2020; Healthy People.Gov

RECOMMENDATION FOR ACCURATE MEASUREMENT OF BP IN THE OFFICE Recommendation for COR LOE Accurate Measurement of BP in the Office For diagnosis and management of high BP, proper methods are recommended for accurate measurement I C‐EO and documentation of BP.

What’s wrong with this picture? Abbasi J. Medical Students Fall Short on Blood Pressure Check Challenge. JAMA 2017

OUT‐OF‐OFFICE AND SELF‐MONITORING OF BP Recommendation for Out‐of‐Office and Self‐ COR LOE Monitoring of BP Out‐of‐office BP measurements are recommended to confirm the diagnosis of A SR I hypertension and for titration of BP‐lowering medication

 Home BP monitoring  24 hr. ambulatory BP monitoring “The USPSTF recommends obtaining measurements outside of the clinical setting (Ambulatory or Home BP) for diagnostic confirmation before starting treatment. (Grade A)” Siu et al. Ann Intern Med . 2015;163:1‐10

White Coat Hypertension White Coat Hypertension 24 Hour Ambulatory BP Monitoring 250 Office visits 200 BP 150 mm Hg Sleep 100 50 0                                                   hr:min 16:00 24:00 16:00 15:00 24:00 White Coat Effect Normal

24 Hour Ambulatory BP Monitoring 24 Hour Ambulatory BP Monitoring Dow Jones Down Awake 180 Asleep Blood 140 Pressure 100 mm Hg 60 0 4 pm 4 pm midnight

Masked HTN and White Coat HTN in Dallas Heart Study Sustained Masked HTN 12% HTN 18% Population‐based probability sample (n =3,027 50% African Americans 49% female) WCH 3% Median follow up 9.5 years Tientcheu, et al. J Am Coll Cardiol . 201517;66(20):2159‐69.

Increased CV Complications in WCH and MH Sustained HTN Masked HTN White coat HTN Normotensives Tientcheu, et al. J Am Coll Cardiol . 2015 17;66(20):2159‐69

HOW ACCURATE ARE HOME BP MONITORS ? A CROSS‐SECTIONAL STUDY IN 210 PATIENTS Ruzicka, et al. PLOS ONE. June 2016

SPRINT TRIAL: Systolic Blood Pressure Intervention Trial A Randomized Trial of Intensive versus Standard Blood-Pressure Control • Patients at increased cardiovascular risk but without diabetes were assigned to intensive treatment of systolic BP (target, <120 mm hg) or standard treatment (target, <140 mm hg). • After a median of 3.26 years, the rate of cardiovascular events was significantly lower with intensive treatment. JT Wright, et al. A Randomized Trial of Intensive versus Standard Blood‐Pressure Control. N Engl J Med. Nov 26; 2015 373(22):2103‐2116

SPRINT TRIAL: Systolic Blood Pressure Trend The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT Trial: Primary Outcome and Death from Any Cause The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT Study Primary Outcome According to Subgroups The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL: Primary and Secondary Outcomes and Renal Outcomes. The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL: Primary and Secondary Outcomes and Renal Outcomes. The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116

SPRINT TRIAL CONCLUSION Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm hg, as compared with less than 140 mm hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive‐treatment group. The SPRINT Research Group. N Engl J Med. 2015;373:2103‐2116