Title

ASCVD Risk and Effect of HypertensionLauren HolroydFHD Intersession #1 PresentationAugust 25, 2016

Case Mrs. P is a 63 y/o AA femaleBegan care at Vanderbilt in 2010, seen in 2016PMH: HTN, Diastolic CHF, T2DMSH: No stable living situationPrior smokerFH:Mother: HTN, T2DM, CAD, ESRDFather: HTN, T2DM

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CaseMedications: 15 total medications4 antihypertensivesPE: BP: 180/100, HR: 70, RR: 12, BMI: 39.9CV: RRR, normal S1 & S2, no S3 or S4, 3/6 holosystolic murmur best heard at apex, JVD approximately 11cmRespirarory: no crackles, rales or rhonchi, CTAB, normal work of breathing Labs: Total Cholesterol: 167HDL: 37

glimepiride 4 mg BID (dispensed as 2mg pills) (dispensed for 90 days on 1/5/16)carvedilol 50mg BID after eating (dispensed as 25 mg pills for 90 days on 1/5/16)aspirin 81mg qd (dispensed for 90 days on 1/5/16)ferrous sulfate 325 mg BID (dispensed for 90 days on 1/5/16)lisinopril 20 mg bid (dispensed for 90 days on 1/5/16)acetaminophen 325mg; take up to two tablets q6h PRN (dispensed for 90 days on 09/08/15)ranitidine HCl 150mg qd (dispensed for 90 days on 1/5/16)test strips for DM (dispensed for 90 days on 1/5/16)nifedipine ER 30mg BID before eating (dispensed for 90 days on 1/5/16)isosorbide mononitrate 30 mg ER QD (dispensed for 90 days on 1/5/16)hydrochlorothiazide 12.5 mg BID (dispensed for 90 days on 1/5/16)Flonase nasal spray 2 sprays per nostril QD (dispensed for 90 days on 09/08/15)atorvastatin 40mg QHS (dispensed for 90 days on 1/5/16)NPH insulin human recomb 7 units bid (dispensed for 142 days on 1/5/16)furosemide 20mg Qam (dispensed for 90 days on 1/5/16)

Total Chol 167 Trigs 167 HDL 37, Y diabetes, Y HTN, N Smoker10 yr risk 38.7%3

ASCVD Risk CalculationInformation available from 2016Criteria: Total Cholesterol: 167HDL: 37SBP: 180 Diabetes, treatment for hypertensionNot smoking at this time10 year risk was 38.7%Lifetime risk could not be calculated due to ageIf BP was 130, 10 year risk would be calculated as 18.7%

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Community ResourcesHealth Literacy in a Free Clinic SettingWhile not available currently at Shade Tree Clinic could be implementedWorks with patients to document a discussed changeUse of health notebooksMrs. P previously has talked about having issues keeping up with proposed health improvementsCelebrating successes Implementation of this project would be relatively low costImportant for this patient population

http://www.healthynashville.org/index.php?module=promisepractice&controller=index&action=view&pid=300497

Community ResourcesText4DietWe know weight reduction reduces burden of diabetes and hypertensionLosing weight can be challengingParticipants receive 2-5 text messages per dayHave the ability to customizeTexts contain tips, positive reinforcement, encouragement require user replyRCT showed those who used the service had significantly more weight loss- average 6 poundsGood for patient populations without stable living situation

http://www.healthynashville.org/index.php?module=promisepractice&controller=index&action=view&pid=34908

Aggregate Panel DataSex (M/F)Age (years)Race HDL cholesterol (mg/DL)Total Cholesterol (mg/dL)Triglycerides (mg/dL)BMI (kg/m2)DiabetesTreatment for HypertensionSystolic Blood Pressure (last read)Active Tobacco UseASCVD 10 year risk scoreASCVD Lifetime Risk ScoreF59African American4119518641.8YY135N19.8%50.0%F64White2813024431YY154N19.0%N/AF41White3913514430.3NN116N0.4%8.0%F60Asian2513014929.4YN124N7.2%N/AM41White3314211745.5NY108N0.9%50.0%F50Hispanic561986429.3NY150N2.2%39.0%M51Hispanic5014510029.2NY124N3.8%50.0%F70White5820410932.9NY122N11.5%N/AF65White5019519934.3NY136Y15.5%N/AF79Hispanic5715112336.4NY128N31.8%N/AF53Hispanic3121415529.5YN124N5.9%39/0%M45Asian3121465726.5NN118Y9.4%50.0%M62White4014714026.6YY124N18.5%N/AF54White8224213641.4NY132N2.1%50.0%F63White561314723.6NY158Y13.2%N/AF63African American3716716739.9YY180N38.7%N/AM58Hispanic2913215851.5YN119N12.2%50.0%M52African American462298028.2NY143Y20.6%69.0%M55White271836121NY150Y23.5%69.0%M46African American4623625731.6YY156N20.1%69.0%

Patients being treated for HTN

Grant Project- PopulationTarget Population: Shade Tree ClinicWhere I saw my patientsMajority of patients at this site have multiple chronic health conditions that contribute to increased ASCVD riskSpecifically will target hypertension improvement

Grant Project- Intervention Use $5,000 to: Implement Health Literacy in Free Clinic project explained aboveUtilizing Shade Tree Patient Health Educators as main source of contactPurchasing home blood pressure cuffs for Shade Tree Patients to use at homeWould be given only to patients on 3 or more antihypertensives to startGet at core of blood pressure management Would be feasible within the Shade Tree model of care

Grant Project- Metrics1. Continued BP readings below 140mmHg systolic in clinic2. Consistent involvement in Health Literacy program3. Consistent home BP log entries

Grant Project- Time CourseBP readings at or below 140mmHg for at least 6 months and up to 1 yearWould be manually monitored using PHEs and clinical teamsProject implementation itself would not take more than 1 monthAt 1 year mark, run reporting technology available in Epic to see trends in BP measurements

Grant Project- DefenseMany patients have poorly controlled hypertension which contributed to their overall increased ASCVD riskBlood pressure changes rapidly from moment to moment so home BP readings provide more data points to determine trendsEngaging low resource populations using techniques to improve health literacy increase their ownership and sense of control over their healthThis intervention could be scalable to large populations and other free clinics throughout the country