Hypertension Management for Primary Care: Current Recommendations Ashwani Bhatia M.D. 05-14-2009

OBJECTIVES Participants will be able to… Discuss the basics of HTN management Define resistant HTN and treatment options Identify strategies to improve compliance Able to state Aurora’s goals for 2009

Trends Updated estimates put the prevalence of hypertension at 72 million in 2004.(AHA) Net and age adjusted prevalence of HTN in adult population in united states has increased (NHANES) Over 45,000 AHC patients with Hypertension (14,400 not in control as of Feb 2009 data) Hypertension affects approximately 50 million individuals in the United States and approximately 1 billion worldwide. As the population ages, the prevalence of hypertension will increase even further unless broad and effective preventive measures are implemented. Recent data from the Framingham Heart Study suggest that individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension.7

Disease Awareness Table I. Trends in Awareness, Treatment, and Control of Hypertension in the US Adult Population From 1976 to 20041 NHANES II (1976–1980) NHANES III Phase 1 (1988–1991) NHANES III Phase 2 (1991–1994) NHANES (1999–2000) NHANES (2003–2004) Awareness 51 73 68 70 76 Treatment 31 55 52 59 65 Control 10 29 23 37 Control among those treated 32 44 53 57 The proportion of adults who are aware of their disease,receive HTN treatment and have a BP level of <140/90 has improved from 1976 to 2004

Just the Facts 32% of the non-institutionalized adult population over 20 years has hypertension Beginning at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg Individuals who are normotensive at age 55 have a 90% lifetime risk for developing hypertension In persons older than 50 years, SBP >140mmhg is a much more important CVD risk factor than diastolic blood pressure

An Accurate Measurement is the Key to Diagnosis Patient should be relaxed and seated quietly for at least 5 minutes before the measurement. Auscultatory method of blood pressure measurement should be used with appropriate sized cuff and the patient positioned correctly.

Patient Evaluation A diagnosis of HTN should be made on the basis of average of two or more readings taken in two or more office visits Assessment of life style and cardiovascular risk factors affecting management and prognosis Identifying secondary causes of HTN Evaluate for target organ damage through history, physical exam and lab data

Ambulatory BP Provides information about BP during daily activities Warranted for evaluation of “white-coat” hypertension in the absence of target organ injury. To assess patients with apparent drug resistance, Hypotensive symptoms with antihypertensive medications, episodic hypertension, and autonomic dysfunction. To assess the overall BP load, and the extent of BP reduction during sleep. The level of BP measurement by using ABPM correlates better than office measurements with target organ injury. In most individuals, BP decreases by 10 to 20 percent during the night; those in whom such reductions are not present are at increased risk for cardiovascular events.

Goals for Treatment <140/90 in benign essential HTN <130/80 in presence of diabetes, heart failure, and kidney disease Ultimate goal of reducing cardiovascular and renal morbidity and mortality in the community

2009 AMG Goal for HTN 70% or more are in control

2009 AMG Goals for DM and HF BP control Goal for DM and HF <130/80  48% of diabetics in control  58% of HF in control

Classification

Hypertension Management

Management

Life Style Modifications

Treatment Strategies Use a step wise approach Keep it simple for the patient and provider alike Include patient in decision-making Promote life style modifications Look for special considerations

Special Considerations

Pharmacologic Management Key Points Thiazide diuretics were the mainstay of management (ALLHAT trial) Patients whose BP is 20/10 mm hg above the goal BP should be started on combination therapy Addition of a second class of drug is recommended when use of single agent in adequate doses does not control BP Generic/combination drugs are preferred for better compliance and reduction of cost

LOOKING INTO THE FUTURE Combination therapy is here to stay Recent data from ACCOMPLISH trial indicates that a strategy of starting with fixed-dose combination BP-lowering therapy yields a higher percentage of BP control earlier Role of Direct Renin Inhibitors CCB-ACE combination vs. HCTZ-ACE as first line therapy Beta blockers as initial therapy JNC VIII Recommendations 2009

To enter CM Hypertension Website, click here  Aurora’s Statement for HTN “Based on JNC 7 and additional HTN trials, the goal of all providers is to get hypertensive patients controlled as soon as feasibly possible within a 3 month period, but preferably within 6 weeks of diagnosis.  Follow up should be scheduled accordingly.” To enter CM Hypertension Website, click here 

BP Follow-up Guidelines System-wide standard for scheduling F/U for hypertensive patients based on JNC VIII Use of guideline is strongly recommended Rationale: establish a routine for ensuring minimum guideline for timely follow-up of HTN Ultimate decision for follow-up per provider on case by case basis

BP Guideline Settings Clinic setting guidelines Provider is immediately available for consult Primary care and specialty clinics Specialty clinics can choose to manage or refer to primary care Community setting guidelines Providers is not always immediately available for consult May apply to settings such as community BP events, Total Health, Employee Health, Occupational Health, Quick Care, and Home Care.

Clinic Guidelines

Community Guidelines

Resistant Hypertension … The failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.

Resistant HTN Prevalence The prevalence of resistant HTN has never been examined properly. Limited patient adherence related to side effects, complicated dosing schedules,memory deficits or high cost of medication is the biggest contributing factor. Physician Inertia Issue A previous survey of a national sample of primary care physicians showed that at a time when JNC VI guidelines clearly recommended treatment of BP levels ≥140/90 mm Hg, 43 for middle-aged patients with uncomplicated hypertension 43% of physicians would start treatment only if SBP was >160 mm Hg and 33% if DBP was >95 mm Hg. In patients without complications who were receiving treatment, 33% of physicians would not intensify therapy for a persistent SBP of 158 mm Hg and 25% for a DBP of 94 mm Hg. Of note, 41% of the physicians were not familiar with JNC guidelines. a study in a large Midwestern health system, primary care physicians on average reported that 150 mm Hg was the lowest SBP level at which they would recommend pharmacologic treatment. 45 At 93% of patient visits, SBP values were ≥140 mm Hg, but pharmacologic therapy was initiated or changed at only 38% of visits. The most cited reasons for this related to the fact that physicians were satisfied with the patients’ BP levels Prevalence varies from 5% to 50 % depending upon general versus specialty practices

Possible Causes of Resistant HTN Improper blood pressure measurement Inappropriate combinations Patient non-adherence Drug-induced Costs of medication Inadequate doses Inconvenient dosing schedules Inadequate patient education Memory or psychiatric problems Licorice (including some chewing tobacco) Physician inertia (failure to change or increase dose regimens Related to antihypertensive medication when not at goal) Pseudo resistance Associated conditions Sleep apnea Diabetes Obesity Excess alcohol intake Adverse effects of medication Cocaine, amphetamines, other illicit drugs Nonsteroidal anti-inflammatory drugs; cyclooxygenase-2 inhibitors Sympathomimetics (decongestants, anorectics Oral contraceptive hormones Cyclosporine and tacrolimus Adrenal steroid hormones Erythropoietin Selected over-the-counter dietary supplements and medicines (eg, ma haung, bitter orange) Identifiable causes of hypertension Excess sodium intake Volume overload Volume retention from kidney disease Chronic kidney disease  Inadequate diuretic therapy Possible Causes of Resistant HTN

Treatment approach

Treat HTN aggressively with optimal doses of antihypertensive medications according to patient characteristics and recommended goals. Follow up with the patient effectively to evaluate BP control. Perform appropriate adjustments and/or changes of the antihypertensive medication. Key Provider Actions

Key Provider Actions Educate the patient on the risks of uncontrolled hypertension, the value of lifestyle modifications, and the benefits of drug treatment. Monitor the patient’s adherence to the treatment regimens and problem solve if issues. Motivate the patient toward an appropriate BP goal.

Key Provider Actions Evaluate the possibility of resistant or hard to control hypertension; Identify and correct remediable causes. Intervene early in pre-hypertensive patients by promoting lifestyle modifications. Become familiar with and adhere to the most recent hypertension guidelines.

NHANES, National Health and Nutrition Examination Survey NHANES, National Health and Nutrition Examination Survey. Combined data from Burt et al,3 Hajjar and Kotchen,4 and Ong et al.5 Numbers represent percentages of patients among all adults aged 18–74 years with hypertension, defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg or use of antihypertensive medication. JNC VII Guidelines U. S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Instite National High Blood pressure Education Program NIH Publication No. 03-5233, December 2003 http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf Kaplan NM. Resistant hypertension. J Hypertens. 2005;23(8):1441–1444 Moser M, Setaro JF. Clinical practice. Resistant or difficult-to-control hypertension. N Engl J Med. 2006;355(4):385–392. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981–2997 State of Hypertension Management in the United States: Confluence of Risk Factors and the Prevalence of Resistant Hypertension Pantelis A. Sarafidis, MD, PhD; George L. Bakris, MD- J Clin Hypertens. 2008 Feb;10(2):130-139  Health United States 2008. National Center for Health Statistics Health, United States, 2008 With Chartbook Hyattsville, MD: 2009 US Department of Health and Human Services. Retrieved on April 8, 2009 from http://www.cdc.gov/nchs/data/hus/hus08.pdf#071 References