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The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

ACOFP / AOA’s 122nd Annual Osteopathic Medical Conference & Exposition

OCTOBER 7 - 10PHILADELPHIA, PENNSYLVANIA29.5 Category 1-A CME credits anticipated

OMED 17®

ACOFP - The Heart of the Matter - An Evidence Based Approach to Common Cardiovascular Concerns:

Primary Care Approach to Hypertension - Sorting Out the Latest Treatment Guideline

Michael Levin, DO

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The Management of Hypertension

in 2017

Targets and Therapies

Michael Levin, D.O., FA.C.O.I.

Chair: Division of Nephrology

Philadelphia College of Osteopathic Medicine

Metropolitan Nephrology Associates

www.metroneph.com

@MetroNephro

Objectives

Review recent evidence affecting the diagnosis and

management of patients with elevated blood pressure

Discuss the therapeutics of various antihypertensive

agents used in managing patients with hypertension

Compare and contrast BP targets and first-line therapy

options from various clinical practice hypertension

guidelines ( e.g., JNC , ADA)

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The Renal Continuum of Care

Nephrologist

Primary Care Physician

ESRDCKD

At Risk

Population

Diabetes

Hypertension

Obesity

CVD

26,000,000+ People500,000+ People

~375,000 Dialysis

~125,000 Transplant

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Patient Background

60 y/o African American Male evaluated for challenging to control blood pressure issues

Diagnosed during routine examination in Primary Care office 4 years prior and has been a challenge for the Medical team to control

PMHx: HTN, CAD with stent, CKD stage 3, Obesity, DM x 4 years

PSH: Cardiac PTCA with DES Circumflex

Medications: Lisinopril 40 mg Daily, Coreg 25 mg Twice per day, Hydrochlorthiazide 25 mg per day

FamHx: Father; deceased, MI at 50

SocHx: Smoker, 15 pack years; quit 10 years ago. Factory worker.

Physical Exam

BP: 168/94 HR: 84 BMI: 44

Neck: supple, no goiter, but circumference > 18 inches

Heart: 84 per minute, no gallop or rub

Lungs: clear

Extremities: reduced pinprick b/l, no peripheral edema

Eyes: dilated exam background retinopathy changes

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Labs at Evaluation

Hgb 14.8 Hct 36%

Hgb A1C: 8.6%

Na: 140 K: 5.5 Cl: 104 CO2: 26

BUN: 31 Cr: 2.2 eGFR: 36 cc/min

UA: 1+ protein, no RBC’s

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Hypertension:

A Brief Snapshot

Most common modifiable CVD/Renal risk

factor

Contributed to > 50 % of adverse CVD outcomes

BP Control

Reduces Heart Failure by 50%; CVA by 40%; MI

25%

33 % of adults will be affected

60 % increase by 2025

US Renal Data System: Annual Data Report, US Department of Public Health and Human

Services, NIH 2007

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Hypertension:

A Brief Snapshot

The Big Question remains: What is the Goal

Blood Pressure, and what is Optimum

NHANES 2010

81.5 % aware of Diagnosis

74.9 % on current treatment

52.5 % “ Controlled”

47.5 % “ Uncontrolled”

Heart and Stroke Statistics- 2014 Update AHA. Circulation 14;129;e28-e292

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www.nhlbi.nih.gov

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Ambulatory Blood Pressure Monitoring

(ABPM)

Possibly more useful than clinic BP measurements

436 Italian CKD patients mean eGFR 43 ml/min

Elevated BP, non dippers, reverse dippers had increase

risk for composite endpoints of death or ESRD

Prognostic role of ABPM in patients with nondialysis CKD. Arch

Int Med 171: 1090-1098, 2011.

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Choice of Antihypertensive

Agents

Primary Prevention of CV complications

Lowering BP to “goal” is more important than the

choice of drug- assuming you achieve the “goal”

Secondary CV Protection with underlying comorbid

illnesses

Not all agents provide the same benefit

Assumption is that for the most part there are class

effects: Ace-I, ARB’s

Less noted class effects perhaps for choice in CCB’s,

Thiazide Types, β Blockers

Circulation 15;131: e435-e70

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Thiazide (Type/Like) Diuretic

Class

HCTZ vs. Chlorthalidone(CTD)

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Beta Blockade as Initial Therapy

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Major Hypertension Trials

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Lifestyle modifications

www.nhlbi.nih.gov

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Systolic Blood Pressure Intervention

Trial (SPRINT)

Compare SBP <120 vs. 140mmHg in delaying CKD

progression in HTN patients over age 50

SPRINT

9361 hypertensives with CV risk factor assigned to

intensive vs standard BP (SBP 120 vs 140)

At least 50 y/o; excluded DM, CVA, EF < 35%, >1gm

proteinuria

Trial stopped 3.5 into 5 years

Intensive arm: significantly lower primary

composite outcome (MI, ACS, cva, CHF, or death

from CV cause)

Intensive arm: significantly lower all cause mortality

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SPRINT CKD

Subgroup of 2646 CKD patients Again, no DM, no >1gm proteinuria

No difference in eGFR decrease ≥50% or ESRD. Too few events (15 in intensive group, 16 in standard group)

↓GFR statistically significantly higher in intensive group But not clinically significant

↑Risk of AKI in intensive group (HR 1.65) But most were stage 1 AKI, volume depletion, ≥90% recovered

Risk of primary outcome (MI, ACS, cva, CHF, or death from CV cause) reduced but not statistically significant (HR 0.81)

Risk of all cause mortality reduced, statistically significant (HR 0.72)

Bottom line…

Guidelines say <140/90

There is evidence of benefit with tighter BP

goals in proteinurics

Tighter BP control won’t slow CKD

progression, but will improve mortality and

prevent cardiovascular outcomes

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Risk Factors for CKD Progression

HTN

Proteinuric CKD (>300 mg/d)

RAAS inhibition superior to other antihypertensive

agents

Systematic review 85 RCTs (nearly 22,000 patients)

showed no benefit of combination of ACEI and

ARB

No benefit in preventing ESRD, progression of

proteinuria (micromacro)

Maione A, et al. ACEI ARB and combined therapy in patients

with micro- and macroalbuminuria and other CV risk factors:

systematic review of RCTs. Nephrol Dial Trans 26: 2827-2847.

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Effects of Intensive BP lowering on CV and Renal Outcomes

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