Why the New Hypertension Guidelines Matter

Why the New Hypertension Guidelines Matter

Putting Them Into Practice

Topics in the Tropics 2018

07 December 2018

Robert Jay Amrien, PA-C

Founding Program Director & Clinical Associate Professor Bryant University School of Health Sciences

Clinical Physician Assistant

Massachusetts General Hospital

Disclosure

American Heart Association Council on Hypertension

Organizational Reviewer, 2017 AHA/ACC Guideline for High Blood Pressure in Adults

Board, AHA Southern New England

American College of Cardiology

Cardiovascular Team Member

Legal Consultant

Fair Winds & Following Seas

Dr. Martin J. Nemiroff, M.D. USPHS 16 December 1940 - 28 November 2018

President George H.W. Bush

12 June 1924 – 30 November 2018

In memory of 2403 lives lost in Pearl Harbor on this day 77 years ago

Objectives

Discuss hypertension as a critical disease in the US Understand how the new guidelines came into place, and why they are necessary Understand the role of every provider in recognizing and treating hypertension

This talk brought to you courtesy of:

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How many of you are familiar with the 2017 AHA/ACC Hypertension

Guidelines?

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Which beta blocker should be used to treat hypertension?

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You have newly diagnosed a patient with hypertension. What is the first

line medication you should prescribe?

Definition A progressive cardiovascular syndrome with many causes that results in both functional and structural changes to the heart and vascular system.

http://www.ash-us.org/about_hypertension/index.htm




"A man's health can be judged by which he takes two at a time - pills or stairs." -Joan Welsh

Epidemiology 2018

Centers for Disease Control

•Prevalence: •46% if the population •Increased from 31% under new guidelines

•80% know they have hypertension •Improved from 70%

•73% are prescribed medication •Improved from 60%

•47% are controlled on medication (US Only) •Includes non-compliance •Improved, especially in ACO model v. Fee for Service

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Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†

SBP/DBP ≥130/80 mm Hg or

Self-Reported

Antihypertensive Medication†

SBP/DBP ≥140/90 mm Hg or Self-

Reported Antihypertensive

Medication‡

Overall, crude 46% 32%

Men

(n=4717)

Women

(n=4906)

Men

(n=4717)

Women

(n=4906)

Overall, age-sex

adjusted

48% 43% 31% 32%

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 cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition 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.

Epidemiology


•Prevalence confounders: •Increased prevalence

•Black Americans: 34% •Decreased control

•Mexican Americans •Men •Elderly (>65) •Lack of PCM

•Better control •Insurance •PCM with continuity of care (medical home!)

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History

ESH Guidelines 2018 *AHA/ACC Guidelines 2017* JNC 8: Published 2013 JNC7: published 2003 (ALLHAT) JNC6: published 1997 JNC 5: published 1992 JNC 4: published 1988 JNC 3: published 1984 JNC 2: published 1980 JNC 1: published 1976 (NHANES)

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Epidemiology


•Other facts to consider: •Up to 5% of children and adolescents have primary hypertension •Hypertension is the most common cause for an office visit in non-pregnant adults

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Etiology

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Why we treat?

LVH Heart Failure

Ischemic Stroke Intracerebral Hemorrhage

Ischemic Heart Disease Chronic Kidney Disease

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Classification

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Normal: Less than 120/80 mm Hg; Elevated: Systolic between 120-129 and diastolic less than 80 Stage 1: Systolic between 130-139 or diastolic between 80-89 Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg Hypertensive crisis: Systolic over 180 and/or diastolic over 120

Classification

Pediatrics: HTN: >95th percentile value for age, height & gender

Pre-HTN: >90th percentile value for age, height & gender

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“…the risk of cardiovascular disease doubles with every 20mmHg increase in systolic blood

pressure…”

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Secondary Hypertension

Renal • RAS (atherosclerosis, FMD) • RPD (DM, Renal Cystic Disease)

Adrenal • Cushing’s • Pheochromocytoma • Hyperaldosteronism

Medications • NSAIDS, OCPs, Ephedrine, MAOI

Others: • Pregnancy, Coarctation of the aorta, OSA, Thyroid disease

ETOH, Drugs

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White Coat Hypertension

“Legitimate” diagnosis ICD9: 796.2 (no ICD 10)

Definition: clinic BP >140/90 on 3 occasions, less than 140/90 on 2 non-clinic visits Increased risk of progression to hypertension No proven increased risk in cardiovascular mortality or stroke Increased lifestyle modifications, yearly follow up No medications! 24

Masked Hypertension

No ICD 10

Definition: Normal clinic BP with elevated ambulatory BP Up to 10% of general population Usually diagnosed after high home BP Increased EOD, CV mortality, Stroke

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Ambulatory Monitoring

• Required for dx in NICE guidelines • White coat hypertension • Masked Hypertension • Drug resistance • Hypotensive symptoms • Episodic dysfunction

May improve patient compliance This is a mainstay of the new guidelines

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Ambulatory Monitoring

A 24 hour mean of 125/75 A daytime (awake) mean of 130/80 A nighttime (asleep) mean of 110/65

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Self Monitoring ”Giving the patient power over their disease process is likely

to have better results.”

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Home BP Testing

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Screening

• USPSTF

• Screen all adults aged 18 and over • Annual for normal readings • Semi-annual for high risk or elevated BP

• AAP:

• Screen children over 3 annually in conjunction with routine health care

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Diagnosis

Diagnosis: • Elevated blood pressure on at least two separate

occasions (unless EOD) • Ideal settings • Multiple readings

• Consider secondary causes

• Document: • Elevated blood pressure without diagnosis of

hypertension (ICD10 R03.0) • Pre-Hypertension • Compelling indications

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Diagnosis

Elevated: What should we do? • 120-129 systolic

• MISSED OPPORTUNITY ALERT

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Diagnosis

Diagnosis: • BP repeated:

• Manual cuff • Baumanometer • Both arms (on the first visit) • Consider lower extremity • Ambulatory BP monitoring

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Risk Factors Hypertension

• Genetics

• Family History

• Environment: • Inactivity

• Stress

• Obesity

• Tobacco

• Age

• Menopausal meds

• High NA Diet

• ETOH

Evaluation

Work up: • Complete history & focused physical examination

• Concentrate on end-organ-damage • Risk factors • Secondary causes • Erectile dysfunction

• Labs: CBC, BMP, Lipid Panel, UA • Other labs for secondary causes (TSH) • 12 lead ECG • 10 year ASCVD risk score

• Always ask:

• OTC Medications (NSAIDS) • OCP • ETOH/Drugs

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Evaluation

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http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/

http://tools.acc.org/ASCVD-Risk-Estimator-Plus/







Evaluation Work up:

http://ecg.bidmc.harvard.edu/maven/dispcase.asp?rownum=49&ans=1&caseid=240

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Evaluation

Work up:

• Other considerations • Urine microalbumin • Urine albumin to creatinine ratio • Lab: TSH, HgA1C, secondary causes • CXR • Echocardiogram • Ambulatory BP Monitoring • Fundoscopic exam

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Evaluation

Work up:

The ideal blood pressure reading: • Patient seated for 5 minutes

• Feet flat on floor • Arm supported at heart level

• Appropriate sized cuff for patient • At least two readings • Ideally ½ hour after eating, drinking or tobacco • Empty bladder

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Evaluation

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Management

ACC/AHA

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Management

Lifestyle Modifications • No trials on hard outcomes (just numbers)

• Dose and time dependent • Everyone should be encouraged despite numbers

• Evidence suggests

• Delayed onset of hypertension • Cost effective • Good for overall cardiovascular health

• Individual results may vary

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Management

Lifestyle Modifications

Weight Reduction: 5-20 mm Hg per 10kg • Goal BMI <25 kg/m2

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DASH Eating Plan: 8-14 mm Hg • 8 weeks • 8-10 servings per day • Low fat dairy • Reduced fat & cholesterol

Management


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Management


Cal: 4210 Fat: 228 Na: 6545 1930 mg

3000 mg

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Management


Dietary Sodium Reduction: 2-8 mm Hg • Conflicting evidence • Risk reduction in non-hypertensive patients • Less than 1.5 gm per day (Na)

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Management


Physical Activity: 4-9 mm Hg • 30 minutes a day most days of the week

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Management


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Management Lifestyle Modifications

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The Push away plan!

National Cholesterol Education Program (Adult Treatment Panel III Guidelines)

Management


Moderate Alcohol Consumption: 2-4 mm Hg • <2 drinks per day for males • <1 drink per day for females

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Management

Other Lifestyle Modifications

• Smoking cessation • Patient education • Relaxation/Meditation

Lifestyle modifications!

Stop all the bad stuff & start all the

good stuff!!!

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Management


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Management


Actigraphy

Management

Renal Denervation: • Simplicity 3 no long term benefit

• SPYRAL HTN-ON MED underway

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Management

Stretch Break!

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Management


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Management

Other Lifestyle Modifications Avoid NSAIDS Consider stopping OCP Avoid cough and cold medication, especially long term

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Current Management

Pharmacology

Compelling indications are no longer a consideration. Treat hypertension as hypertension & confounding diseases as their own entity

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Current Management

Pharmacology

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*Management*

Pharmacology

Stage I: Lifestyle Modifications and/or Pharmacologic Monotherapy Lifestyle modifications are the mainstay of treating Stage 1 HTN Consider pharmacologic therapy for Stage 1 HTN if: • Established cardiovascular disease • Type II Diabetes Mellitus • Patients over 65 years old • *An estimate 10 year risk of ASCVD of at least 10%*

Caution in patients over 75 or CVD risk over 10% but no CVD Withhold in the very frail or end of life

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Management

Pharmacology

Stage I: Pharmacologic Monotherapy Low doses of • ARB • ACE • DHP CCB • Diuretic

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Management

Pharmacology

Stage I: Monotherapy • Diuretic/ACE/ARB

• <55 yo • Non-black

• CCB • >55 • Black

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Management

Pharmacology

Stage II: Dual Therapy • Diuretic (chlorthalidone) + DHP CCB (amlodipine) • ACE1/ARB + DHP CCB (amlodipine) • ACE1/ARB + diuretic (chlorthalidone) Treatment failures on two drug therapy

• ACE1/ARB + DHP CCB + Diuretic

NO ACE1/ARB/Aliskiren combinations 69

Management

Pharmacology

Resistant or Difficult to Treat Hypertension • Add aldosterone antagonist (spironolactone or eplerenone) Then consider direct vasodilator

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Management

Pharmacology

Others: • Direct Vasodilators • Aldosterone Antagonists • Non Dihydropyridine CCB (bradycardia) • Alpha Blockers (syncope) • Centrally acting medications (clonidine) • Direct Renin Inhibitor • Loop diuretics • Methyldopa (pregnant)

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Management

Pharmacology

Combination pills improve tolerance

• Sequential monotherapy: • Start one medicine @ low dose • Consider only one dose increase • If treatment failure, stop medication and

switch class • Try ACE1, ARB, amlodipine, chlorthalidone

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Management

Pharmacology

Goals: <130/80 Consider <140/90 if hypotensive, symptomatic, or complications Consider <150/90 if frail elderly or over 80

• Accept higher systolic to maintain diastolic*

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Management

Pharmacology

• Focus on BP reduction! • All first line drugs confer the same

outcomes • Evidence based • Specific drug effect! • Compelling indications in line with BP

reduction

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Management

Pharmacology

• Drugs trump lifestyle modifications • Lifestyle modifications still imperative • Medications confer: • 35-40% stroke reduction • 20-25% MI reduction

• NNT: 100 patients for 5 years to prevent 2 CV mortalities

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Management

Pharmacology

• “2 or 3 medications at lower doses have better hypertension reduction with less side effects”

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Management

Pharmacology

• Consider using 1 antihypertensive at night. Especially in patients who are on 3 or more medications.

• Dippers vs. Non-Dippers

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Follow up

Patients should be followed monthly until BP is at goal. Once goal is met, patients should be followed quarterly to semiannually. One lifestyle modification should be discussed at each visit. Motivational interviewing

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Children & Adolescents

No clear guidance from AAP, AHA FOCUS ON LSM Consider secondary causes in all! Refer (most do well on ACE1 and CCB)

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• Childhood obesity and hypertension are on the rise.

• All children over three years of age who present for medical care should have their blood pressure checked using an appropriately sized cuff. • Measurement is also appropriate in certain younger

children.


• Hypertension is diagnosed based on repeat measurements (on three or more separate occasions) that are at the 95th percentile or higher for age, height, and sex.

• Children are considered pre-hypertensive if their blood pressure reached the 90th percentile, and in adolescents, blood pressure over 120/80 mm Hg is considered prehypertension no matter what percentile he or she reaches


• LIFESTYLE MODIFICATIONS!

• Prevention is the key factor.

• Weight loss • Smoking cessation • Increased fruits, vegetables, fiber, and low-fat dairy in

the diet • Limited salt.

• These recommendations are family-centered and apply

to prevention as well as treatment


• ACE Inhibitors • Angiotensin Receptor Blockers • Calcium Channel Blockers • Diuretics

Take Home Messages

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Take Home Messages

1. Focus on recognizing patients with hypertension 2. Make the diagnosis! 3. Don’t hesitate to order an echocardiogram for LVH

• Look for all End Organ Damage 4. Get your patient to goal!

• <130/80 • Focus more on the numbers • ACE1, DHP CCB, Thiazide, ARB

5. Avoid BB and most Non-DHP CCB

6. Don’t miss an opportunity!

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Take Home Messages

!!!Getting your patient to goal is the standard of care!!!

Your reimbursement will be tied to success

Patients want to comply & are more willing to do so with an invested provider! Education is imperative! HTN does not hurt (until it becomes substernal crushing chest pain, the worst headache of their life, or when the left side of the body becomes numb!

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Take Home Messages

“LIFE STYLE MODIFICATIONS are a must for children. Eliminating Hypertension in the future should based on the elimination of risk factors and early application of life style

modifications”

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Thank you for your attention & thank you for all of the hard work you put forth in taking the best care of your patients!

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Documents

Why the New Hypertension Guidelines Matter