1. 2014 Update on Hypertension
Focus on the Hispanic Patient
Aldo J. Peixoto, MD
Professor of Medicine (Nephrology)
Associate Chair for Ambulatory Services, Dept. of Medicine
Clinical Chief, Section of Nephrology

2. Educational Objectives
To review the burden of HTN in the US with a focus on the Hispanic population
To review the approach to treatment of hypertension in 2014

3. Hypertension Facts >1 billion people worldwide
30-45% of adults in developed countries
Responsible for 13.5% of overall world deaths
12.9% low-income countries
17.6% high-income countries
Responsible for 6% of overall world lost years due to disability from stroke or MI
ISH document prepared for the world bank.
Lawes et al. Lancet 2008

4. Each 20/10 mmHg increase in BP is associated with doubling of risk of death
X increased risk of death
ref
Meta-analysis of 61 observational studies
>1,000,000 subjects
12.7 million person-years
Lewington et al. Lancet 2002

5. Prevalence of HTN in the US according to age, sex and ethnicity
CDC, 2012 Report. MMWR 2012; 61: 703-9

6. There are differences in HTN rates among Hispanics according to country of origin
US-born Hispanics:
Mexicans: 19%
Puerto-Ricans: 16%
Cubans: 9%
Central & South American (pooled): 9%
Foreign-born Hispanics:
Mexicans: 13%
Puerto-Ricans: 32%
Cubans: 29%
Central & South American (pooled): 13%

7. Hypertension-related mortality (per 100,000) among different Hispanic subpopulations
From CDC. MMWR 2006; 55: 177

8. Awareness, Treatment and Control rates are lower among Hispanics in the US (NHANES 2003-2010)
Mexican Americans
Whites (NH)
Blacks (NH)
Awareness
69%
79%
81%
Treatment
59%
71%
72%
Control
36%
49%
43%
Stage 2 HTN
(BP >160/100)
19%
12%
18%
Non-Mexican Hispanics excluded from analysis.
From a syst review in Ethn Dis in 2007, the prevalance of obesity and hyperchol is similar among Hispanics and others. DM is more common in Blacks. Smoking is less common in Hispanics. Hispanics have the lowest rates of leisure physical activity.
CDC 2013 Report. MMWR 2013; 62: 351-5

9. Factors responsible for worse HTN control among Hispanics
Limited access to care
Communications barriers
Less leisure time physical activity
Dietary patterns
Leisure PA syst review: no activity in 17-30% whites vs 30-43% Mexican Americans
Perez. Clin Nurs Res 2011; 20: 347

10. Healthcare access and rates of awareness, treatment and control of HTN among Hispanics
Mexican Americans
Whites (NH)
Blacks (NH)
Health care coverage
65%
92%
83%
Routine place for health care
81%
95%
> 2 times receiving health care in the past year
67%
82%
Non-Mexican Hispanics excluded from analysis.
CDC 2013 Report. MMWR 2013; 62: 351-5

11. BP Control in women in INVEST:
Control is achievable when care is accessible Lessons from Hispanics in clinical trials
BP Control in ALLHAT:
72% Hispanic Whites
69% Hispanic Blacks
67% Non-Hispanic Whites
59% Non-Hispanic Blacks
BP Control in women in INVEST:
75% Hispanics (all)
68% Non-Hispanic Whites (P <0.001)
Hispanics (N ~8000) fared better than non-Hisp (~!4500) in INVEST (composite endpoint of death, NFMI and NFS)
Guzman. Am J Cardiovasc Drugs 2012; 12: 165

12. Factors responsible for worse HTN control among Hispanics
Limited access to care
Communications barriers
Patient teaching in Spanish improves health behaviors
Preference for direct management in PC rather than referrals
Less leisure time physical activity
Dietary patterns
6 week course resulted in improved health behaviors at 4 months and 1 year
Preference for PCP to have direct engagement in education and treatment rather than referrals. Not sure how disseminated this is (certainly not the case in Brazil and there may be different geographic variations, but the point is that one should discuss this with the individual pt).
Perez. Clin Nurs Res 2011; 20: 347

13. Factors responsible for worse HTN control among Hispanics
Limited access to care
Communications barriers
Less leisure time physical activity
Dietary patterns
Leisure PA syst review: no activity in 17-30% whites vs 30-43% Mexican Americans
Perez. Clin Nurs Res 2011; 20: 347

14. Factors responsible for worse HTN control among Hispanics
Limited access to care
Communications barriers
Less leisure time physical activity
Dietary patterns
Excess salt intake
“Salt titration”
Cultural issues related to food sharing
Salt intake and salt sensitivity are common
Salt titration refers to titration of salt intake according to time of day, a perception in some Hispanic groups
Cultural unacceptability to decline unhealthy foods. Importance of social gatherings and food in maintaining salt intake, high fat, wt gain, etc.
Perez. Clin Nurs Res 2011; 20: 347

15. Summary #1 HTN is less common among Hispanics than other groups
Treatment and control rates are lower in Hispanics
Limited access to care is a major issue
Modifiable social/cultural factors need attention – important role of Hispanic healthcare providers

16. Management of Hypertension
What’s new in 2014?

17. Basic Clinical Evaluation of HTN
Clinical history
Focused exam
Accurate BP
Focused laboratory testing:
Basic metabolic panel Ca
CBC
Urinalysis
EKG

18. Home BP Monitoring Identifies risk better than office BP
Improves treatment adherence
Improves BP control rates
Technique:
Twice a day (AM and PM)
Duplicate readings
7 days at a time
Target: <130/85
Niiranen. Hypertension 2013; 61: 27
ESH Practice Guidelines. J Hum Hypertens 2010; 24: 779

19. 2013 JNC8 Targets General Population
Age >60:
BP <150/90 mmHg (A)
Age <60:
Diastolic BP <90 mmHg (A for ages 30-59; E for ages )
Systolic BP <140 mmHg (E)
JNC8. JAMA 2013: epub ahead of print Dec 18

20. 2013 JNC8 Targets Special Groups
Diabetes
140/90 mmHg (E)
Chronic Kidney Disease
JNC8. JAMA 2013: epub ahead of print Dec 18

21. Lifestyle Modification
Approximate SBP reduction (range)
Weight reduction
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg

22. 2013 JNC8 Initial Drug Recommendations
Non-Black, including DM:
ACEi or ARB or Thiazide Diuretic or Calcium Channel Blocker (B)
Black, including DM:
Thiazide Diuretic or Calcium Channel Blocker (B for all, C for DM)
CKD, regardless of race or DM status:
ACEi or ARB (B)
JNC8. JAMA 2013: epub ahead of print Dec 18

23. Summary #2
Out-of-office BP is an essential part of the management of HTN
New BP targets are less strict, 140/90 mmHg for most, 150/90 mmHg acceptable for older patients
Lifestyle changes and drug treatment remain the cornerstones of therapy
Initial drug choices include ACEi, ARB, CCB and diuretics, not beta-blockers