Paradigm Shifts in Paradigm Shifts in Hypertension ManagementHypertension Management

Dr. Sachin Verma MD, FICM, FCCS, ICFC

Fellowship in Intensive Care Medicine

Infection Control Fellows Course

Consultant Internal Medicine and Critical Care

Web:- http://www.medicinedoctorinchandigarh.com

Mob:- +91-7508677495

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Paradigm Shifts in Paradigm Shifts in Hypertension ManagementHypertension Management

1.1. Hypertension is an important global problem; Hypertension is an important global problem; Controlling it is challenging; All have room for Controlling it is challenging; All have room for improvement improvement

2.2. Focus on BP goal attainment– sooner rather than Focus on BP goal attainment– sooner rather than laterlater

3.3. Resort to combination therapy readilyResort to combination therapy readily

4.4. Prevent or reduce target organ damagePrevent or reduce target organ damage

Global Burden of HypertensionGlobal Burden of Hypertension2025 Projection2025 Projection

• 26.4% of world adult population had hypertension

• Total of 972 million adults

• Highest prevalence is in

established market economies (eg, North America, Europe)

• 29.2% of world adult population will have hypertension

• Total of 1.56 billion adults

(60% overall; 24% in

developed nations, 80% in developing nations)

• Highest prevalence will be in

economically developing continents (eg, Asia, Africa) – will account for 75% of world’s

hypertensive patients

Year 2000 Year 2025

Kearney PM et al. Lancet. 2005;365:217-223.

35%-40%

20%-25%

>50%

Average reduction in events

(%)

–60

–50

–40

–30

–20

–10

0Stroke

Myocardialinfarction Heart failure

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events

Consensus Target BP Levels Since JNC 7 in the Prevention and Management of

Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement

Area of Concern BP Target (mmHg)

General CAD prevention <140/90

High CAD risk* <130/80

Stable Angina <130/80

Unstable Angina/NSTEMI <130/80

STEMI <130/80

LV Dysfunction <120/80

*High CAD risk = diabetes mellitus, chronic kidney disease, known CAD, CAD equivalent (carotid artery disease, peripheral artery disease, abdominal aortic aneurysm), or 10-year Framingham risk score >10%

Rosendorff et al, Circulation,2007;115: 2761-2788

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Inadequate Control of HypertensionInadequate Control of Hypertension• New England VA Study New England VA Study

– 800 men; mean age, 66 years, many with comorbid conditions800 men; mean age, 66 years, many with comorbid conditions

– Mean duration of HTN = 12.6 years Mean duration of HTN = 12.6 years

– Index visit BP: 146/84 mmHgIndex visit BP: 146/84 mmHg

– Mean of 6.4 hypertension-related visits per yearMean of 6.4 hypertension-related visits per year

• Followed for two 2 yearsFollowed for two 2 years

25% reached goal BP 25% reached goal BP 140/140/90 mm Hg90 mm Hg

– 40% had BP 40% had BP 160/160/90 mm Hg90 mm Hg

• Percentage of visits where therapy was increased:Percentage of visits where therapy was increased:

– 11.2% overall 11.2% overall

– 22%, if DBP 22%, if DBP 90 mm Hg and SBP 90 mm Hg and SBP 165 mm Hg165 mm Hg

– 35% of time when DBP 35% of time when DBP >> 90 mmHg 90 mmHg

Berlowitz et al. N Engl J Med. 1998;339:1957-1963.

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• In 75% of visits documenting elevated blood pressure, In 75% of visits documenting elevated blood pressure, physicians failed to increase the dose of physicians failed to increase the dose of antihypertensive medications or to try new treatments.antihypertensive medications or to try new treatments.

• But clinicians But clinicians did not ignore patients with elevated did not ignore patients with elevated blood pressure.blood pressure. Follow-up visits occurred 2-3 weeks Follow-up visits occurred 2-3 weeks sooner for patients with poorly controlled sooner for patients with poorly controlled hypertension.hypertension.

• Thus, although physicians closely monitored elevated Thus, although physicians closely monitored elevated blood pressure, they repeatedly delayed making blood pressure, they repeatedly delayed making changes to a patient’s regimen. changes to a patient’s regimen.

Inadequate Control of HypertensionInadequate Control of HypertensionClinical InertiaClinical Inertia

Berlowitz et al. N Engl J Med. 1998;339:1957-1963.

Therapeutic (Clinical) Inertia?Therapeutic (Clinical) Inertia?

Satisfaction with current BP levelSatisfaction with current BP level

Elevated SBP more acceptableElevated SBP more acceptable

Use of “soft” reasons to avoid Use of “soft” reasons to avoid intensifying therapyintensifying therapy

Time constraints (15 min visits)Time constraints (15 min visits)

Reluctance to use Reluctance to use combination therapiescombination therapies

Competing prioritiesCompeting priorities

The failure of health care providers to initiate or intensify

therapy when indicated

Causes:

Phillips LS et al. Ann Intern Med. 2001;135:825–834.

“The trial gives new insights into the clinical importance of the rate of achieving BP control:

BP goals need to be reached within a relatively short time (weeks rather than months), at least in patients with hypertension who are at high cardiovascular risk.”

-VALUE Trial, 2004Julius S, et al. Lancet. 2004;363(9426):2022-2031.Julius S, et al. Lancet. 2004;363(9426):2022-2031.

Value: Early Onset of BP Effect

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BP Goal Attainment: JNC VII BP Goal Attainment: JNC VII Expert Roundtable ConclusionsExpert Roundtable Conclusions

“In addition to prescribing the right agent from the start, based on the individual needs of the patient, physicians need to be

more aggressive in bringing their patients to goal”-Michael A. Weber, MD; Founder & Past President of The

American Society of Hypertension

“We want them to attain BP goals while making sure they are adhering to the therapy. The problem is that physicians stop

evaluating the patient’s progress toward the targeted BP level”-Jan N. Basile, MD; Review Committee, JNC 7

Adapted from Weber et al., J Clin Hypertens 2004;6:699–705).

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The Practical Reality of Combination TherapyThe Practical Reality of Combination Therapy

Adding another drug provides greater blood Adding another drug provides greater blood pressure reduction than can be achieved by pressure reduction than can be achieved by titrating the current drug to a higher dosetitrating the current drug to a higher dose

Olmesartanmedoxomil dose

(mg/day)

Reduction in SeSBP(mmHg)

HCTZ dose (mg/day)

Olmesartan Medoxomil/HCTZReduction in SeSBP

4020

100

012.525

30

20

15

10

5

0

2523.0

27.126.8

20.620.1

17.4

9.6

3.3

10.7

15.5

16.0

17.1

HCTZ = hydrochlorothiazide; SeSBP = seated systolic blood pressureChrysant SG et al. Am J Hypertens 2004; 17(3):252-9.

Need for Combination TherapyNeed for Combination Therapy

Elliott WJ. Curr Hypertens Rep. 2002;4:278–285.

Ch

ang

e in

DB

P (

mm

Hg

)

-30

-25

-20

-15

-10

-5

0

0 0.5 1 1.5 2 2.5 3 3.5 4

HOPEProgress

STOP II-β

Syst-ChinaPROGRESS-Combo

TOMHS

Syst-EUR

NORDIL

SHEP

INSIGHT

HOT <90

STOP-βABCD

IDNTEWPHE

RENAAL

HOT <85

HOT <80

UKPDS

VA II

VA I

Number of Antihypertensive Agents

Lifestyle Modifications

Dietary modifications and exercise

Low calorie diets have modest effect on BP in overweight individuals (avg. 5-6 mm Hg).

Aerobic exercise (brisk walking, jogging, or cycling) for 30-60 min., 3-5 times/week, had small effect on BP (2-3 mm Hg).

Relaxation therapies

These activities (stress management, meditation, cognitive therapy, muscle relaxation) reduce by average of 3-4 mm Hg.

Limit alcohol consumption

Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health.Reducing alcohol can lower BP 3-4 mm Hg.

Limiting excessive consumption of coffee/caffeine

Limit dietary sodium intake< 6 g/day, modest reduction of 2-3 mm Hg.

Encourage smoking cessation

Initiating Treatment

Offer antihypertensive drug treatment to people aged under 80 years with Stage 1 hypertension who have one or more of the following:

Target organ damage

Established cardiovascular disease

Renal disease

Diabetes

10-year CV risk equivalent to 20% or greater.

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, CV disease, renal disease or diabetes

Consider specialist evaluation of secondary causes of hypertension and more detailed assessment of potential target organ damage.

Young subjects (<55 yr) Older subjects (>55 yr)

Step IA or B (if associated sympathetic hyperactivity)

A and/or C

Step 2 Add C or D or both Add D

Step 3 A or B, C and/or D, add EA and C, and/or D, add B or E

The ABCDE algorithm

What is New in Indian Guidelines on

Hypertension - 2013

Due to health related toxic effects

of mercury, mercury

sphygmomanometers

are being replaced by aneroid and

digital sphygmomanometers.

Use of beta-blockers as first line agents in hypertension has receded and these are now recommended as agents for use only in younghypertensives with specific indications.

For routine patients these are no longer recommended as first lineagents

Diuretics are now considered at par with of ACEI’s or ARB’s and calcium channel blockers and not as preferred agents as in previous guidelines.

Chlorthalidone is now available and shown to be better than Hydrochlorothiazide and its usage is tobe preferred.

When blood pressure is high by more than 20/10 mm of Hg systolic and diastolic it is now recommended to start with a combination of drugs.

Monotherapy is not going to be effective in achieving target bloodpressure.

Certain combinations have been shown to be betterthan others in recent trials.

Specially ACEI’s/ARB’s incombination with CCB’s forms a good combination.

J shaped curve exist specially for non revascularised coronary artery disease patients and caution has been advocated in trying to lower blood pressure to low target levels specially in these patients.

A new form of non pharmacological, interventional sympathetic denervation therapy has become recently available and is being evaluated.

JNC-8:

What Might Be Expected

Either a thiazide-type diuretic, CCB,ACEI/ARB will be recommended as initialdrug therapy for most patients.

Direct renin inhibitors will be recommended as an additive

• Chlorthalidone or indapamide should behighlighted as the evidence-based thiazide type diuretic of choice

Summary

It makes less difference which antihypertensive agent is used, unless the patient has a compelling

indication for a specific antihypertensive class

It matters more that BP is appropriately reduced to the chosen BP goal.

The current recommended BP goals in

those with Diabetes and CKD from the

ADA, NKF, and JNC 7 is

<130/80 mm Hg.

The initial drug chosen will be broadened to include

Thiazide-diuretic, ACEI/ARB, or CCB and may include non-atenolol BB’s.

Most patients will require 2 or more antihypertensive agents to get BPeffectively controlled which may bebest approached with initial combinationtherapy, either as a fixed-dose combination (FDC) or as 2 individual initial agents