Brian Rayner, Division of Hypertension, University …...HYPERTENSION (>18 years) Blood pressure, mm...
Transcript of Brian Rayner, Division of Hypertension, University …...HYPERTENSION (>18 years) Blood pressure, mm...
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Hypertension update – a practical guide
Brian Rayner,Division of Hypertension, University of Cape Town
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Overview
• Introduction and importance• Definitions and targets• BP measurement • Basic tests• Non pharmacological treatment• Pharmacological treatment• A few words on treatment resistant HT
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Historical Perspective
• The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it. J.H. Hay, 1931
• Hypertension may be an important compensatory mechanism which not be tampered with, even were it certain that we could control it – Paul Dudley White, 1937
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Unexpected
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VA Cooperative Study Group – Estimated Cumulative Incidence of All Morbid Events Over 5 Years
Veterans Administration Cooperative Study Group on antihypertensive agents JAMA 1970;213(7):1143-1152.
0
10
20
30
40
50
60
0 1 2 3 4 5Years
Estim
ated
Cum
ulat
ive
Inci
denc
e of
All
Mor
bid
Even
ts (%
) Control - Placebo
Active Treatment Groups -Diuretic-based regimen and hydralazine
Hypertension Treatment Significantly Reduced Mortality and Morbidity
DBP – 90 -114 mmHg
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Why talk about the Same Old Thing1,2
67% INCREASEIN HYPERTENSIONBetween 1990 and 2010
4 in 10PEOPLE GLOBALLY
HAVE HYPERTENSION
18%
40%
50%
18% of deaths overall arecaused by high BP
40% of deaths in peoplewith diabetes is causedby high BP
50% of heart disease,stroke and HF is causedby high BP
1. Adapted from The Journal of clinical hypertension. 2014.DOI:10.1111/jch.12372. 2. www.hypertension.org
#1Risk for Death in 2010
Estimated to causes
500, 000DEATHS
AND10 MILLIONYEARS OF LIFE LOST
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Bradshaw et al MRC and CDiA 2011
Scope of Problem in South Africa
Rise in Prevalence of Hypertension in SA menSimilar in females
Deaths attributable to high blood pressure in males, South Africa 2000
0
1000
2000
3000
4000
5000
6000
7000
30 - 44 45 - 49 60 - 69 70 - 79 80+
Stroke Hypertensive disease Ischaemic heart disease other cardiovascular
Norman et al. 2007 BOD at the MRC
Economically productive age
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HT in South Africa
100
48.7
23.1
5.813.5
8.9
0
20
40
60
80
100
120
Total HT Unscreened Screened,undiagnosed
Diagnosed,untreated
Treated,uncontrolled
Controlled
Perc
enta
ge
Berry KM, Parker WA, Mchiza ZJ, Sewpaul R, Labadarios D, Rosen S, Stokes A.Quantifying unmet need for hypertension care in South Africa through a carecascade: evidence from the SANHANES, 2011-2012. BMJ Glob Health. 2017
91.1% unmet need
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Why do we have guidelines?
Go et al, Effective approach to HT management, Hypertension 2014
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Effect of proper implementation of guidelines
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“ is particularly evident in people who reside in the Southeastern portion of the United States, which once had the highest mortality rates of stroke in the United States.”“The public awareness has increased dramatically”
“This dramatic decrease in strokes and heart disease has occurred despite the substantial increase in obesity and diabetes in the United States.”
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Kaiser Permanente Model
• Between 2001-2009 number of patients with HT increased from 349,937 to 652763
• Introduction of simplified guidelines• Target BP from 44% to 80%• In 2011 > 87% reached target
Go et al, Effective approach to HT management, Hypertension 2014
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Goals of treatment
Systolic DiastolicUncomplicated <140 <90
Diabetic <130 <80(or any high risk patient)
CKD with proteinuria <120 <70
Guidelines Subcommittee 2003
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Blood pressure and cardiovascular death
0
2
4
6
8
10
<120 120-139 140-159 >160
Systolic blood pressure
Card
iova
scul
ar d
eath
(%)
Diabetics n=3,305
death rate - 5.3%
Non-diabeticsn=88,257
death rate - 2.2%
Asia-Pacific Cohort Studies Collaboration. Diabetes Care. 2004;27:2836-2842
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J Hypertension 2009
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Reappraisal of ESH Guidelines, J Hypertens 2009
Diabetes mellitus – Systolic BP
133.5
119.3
130
BPΔBenefitPartial benefitNo Benefit
SBP (mmHg)170
160
150
140
130
120
110
100HOT SHEP UK MHope SEur ABCD IDNT REN PROG ADV ACCORD
HT NT IR AM
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Lewington et al. Lancet 2002;360:1903-1913.
Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increment in Systolic/Diastolic Blood Pressure*
CV mortality risk
0
2
4
8
115/75 135/85 155/95 175/105
6
Systolic BP/Diastolic BP (mmHg)
*Individuals aged 40–69 years
2X risk
4X risk
8X risk
1X risk
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Incidence of primary outcome (bar graphs) and HR (line graphs; adjusted for baseline conditions, without propensity score analysis) as a function of SBP and DBP in patients with
and without previous revascularization.
Denardo S J et al. Hypertension 2009;53:624-630Copyright © American Heart Association
INVEST Study
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Balancing harm vs good (BP)
Too high1. Stroke2. CCF3. CKD4. IHD5. PVD
Low target1. Dizziness, falls2. ? ↑ CV events3. Other adverse effects
Does it meet the pragmatic definition proposed by Geoffrey Rose decades ago should perhaps be considered—viz: “that level of BP above which investigation and management does more good than harm.”
Poulter NR, Prabhakaran D, Caulfield M. Seminars in Hypertension. Lancet. 2015;386:801–812
>140/90 <130/80 or lower
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Ruiz-Hurtado, G. et al. (2017) Has the SPRINT trial introduced a new blood-pressure goal in hypertension?Nat. Rev. Cardiol. doi:10.1038/nrcardio.2017.74
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The SPRINT Research Group. N Engl J Med 2015. DOI: 10.1056/NEJMoa1511939
Eligibility, Randomization, and Follow-up.
Clinical or sub-clinical cardiovascular diseaseexcluding stroke and diabetesORCKD - proteinuria <1 g/d, eGFR 20-59 mL/minOR†Estimated 10-year global cardiovascular risk ≥15%(Framingham) ORAge ≥ 75 years
SBP between 130 -180 mmHg
Age ≥ 50 years
Mean of 3 BPs unobserved
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Systolic Pressures (mean + 95% CI)
Average after 1st year: 133.5 Standard vs. 119.3 Intensive, Delta = 14.2
Mean # MedsIntensive: 3.2 3.4 3.5 3.4Standard: 1.9 2.1 2.2 2.3
Method of measurement not defined
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SPRINT Primary Outcome and its ComponentsEvent Rates and Hazard Ratios
Intensive Standard
No. of Events Rate, %/year No. of Events Rate, %/year HR (95% CI) P value
Primary Outcome 243 1.65 319 2.19 0.75 (0.64, 0.89) <0.001
All MI 97 0.65 116 0.78 0.83 (0.64, 1.09) 0.19
Non-MI ACS 40 0.27 40 0.27 1.00 (0.64, 1.55) 0.99
All Stroke 62 0.41 70 0.47 0.89 (0.63, 1.25) 0.50
All HF 62 0.41 100 0.67 0.62 (0.45, 0.84) 0.002
CVD Death 37 0.25 65 0.43 0.57 (0.38, 0.85) 0.005
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Serious Adverse Events* (SAE) During Follow-up
All SAE reports
Number (%) of ParticipantsIntensive Standard HR (P Value)
1793 (38.3) 1736 (37.1) 1.04 (0.25)
SAEs associated with Specific Conditions of Interest
Hypotension 110 (2.4) 66 (1.4) 1.67 (0.001)Syncope 107 (2.3) 80 (1.7) 1.33 (0.05)Injurious fall 105 (2.2) 110 (2.3) 0.95 (0.71)Bradycardia 87 (1.9) 73 (1.6) 1.19 (0.28)Electrolyte abnormality 144 (3.1) 107 (2.3) 1.35 (0.020)Acute kidney injury or acute renal failure 193 (4.1) 117 (2.5) 1.66 (<0.001)
*Fatal or life threatening event, resulting in significant or persistent disability,requiring or prolonging hospitalization, or judged important medical event.
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Categories of BP in Adults
BP Category* SBP DBPNormal <120 and <80Elevated 120-129 and <80
HypertensionStage 1 130-139 or 80-89Stage 2 ≥140 or ≥90
*Individuals with SBP and DBP in 2 categories should be designated to higher.BP in indicates BP based on ≥2 careful readings obtained on ≥2 occasions
Adapted AHA/ACC Hypertension Guidelines, 2017
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BP Goals
COR BP Goal for Patients with HypertensionI For adults with confirmed hypertension and
known CVD or ASCVD event risk > 10%# a BP target < 130/80 is recommended*
IIb For adults with confirmed hypertension without additional markers of increased CVD risk a BP
target < 130/80 maybe reasonable
Adapted AHA/ACC Hypertension Guidelines, 2017
*Including patients with diabetes, CKD# http://tools.acc.org/ASCVD-Risk-Estimator/Framingham risk 15% = +/- 6-7% ASCVD
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CLASSIFICATION OF HYPERTENSION (>18 years)
Blood pressure, mm Hg
Category Systolic Diastolic
Optimal <120 and <80Normal <130 and <85High-normal 130 - 139 or 85 - 89
Hypertension Stage 1 140 - 159 or 90 - 99Stage 2 160 - 179 or 100 - 109Stage 3 ≥ 180 or ≥ 110
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140 90
80120130140
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Balancing harm vs good (BP)
Too high1. Stroke2. CCF3. CKD4. IHD5. PVD
Low target1. Hypotension 2. Electrolyte abN3. AKI, no ↑ ESRD4. No increase in MI5. Benefit in certain high risk patients e.g.Sprint entry criteria
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BP ~ ‘KING’ OF PROGNOSTIC MARKERS
ESSENTIAL FOR DIAGNOSIS
ESSENTIAL FOR BP CONTROL
WHY SO MUCH ATTENTION TO ACCURATE BP MEASUREMENT?
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OBSERVER
TRAINING
BIAS
DIGIT PREFERENCE
INATTENTION
RAPPORT
HEARING & VISION
DISTANCE
CUFF/BLADDER
CUFF CONDITION
APPLICATION
BLADDER SIZE
BLADDER POSITION
RIGHT OR LEFT?
SPHYGMO
HEIGHT
POSITION & TILT
LEVEL OF HG
CLOGGED VENT
MAINTENANCE
STETHOSCOPE
SUBJECT
ANXIETY
RECENT EXERCISE
MEAL OR TOBACCO
OBESITY
ELDERLY
ARRHYTHMIA
POSTURE
ARM LEVEL
ARM SUPPORT
CLINIC
TEMPERATURE
HUMIDITY
NOISE
INACCURATE IN 0VER ONE-THIRD OF PATIENTS IF NOT DONE CORRECTLY
Subject to White Coating
CONVENTIONAL BP MEASUREMENT
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0. 0.1 0.2 0.3 0.4 0.5 0.6
OBP
HBPM
ABPM
Mulè G, et al. J Cardiovasc Risk 2002;9:123-9.
0. 0.1 0.2 0.3 0.4 0.5 0.6
OBPHBPMABPM
0. 0.1 0.2 0.3 0.4 0.5
0. 0.1 0.2 0.3 0.4 0.5
SBP
DBP
LVH Albumin excretion ratio
SBP
DBP
Indexes of hypertensive target organ damage Indexes of hypertensive target organ damage
Out-of-Office BP Measurements are More Highly Correlated With BP-Related Risk
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NICE GUIDELINES (UK) - DIAGNOSIS
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Hyvet Study
Initiation > 160Target < 150
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Automated Office (unattended, AOBP) Oscillometric (electronic)
Automated Office BP MeasurementPreferred
• Automated office blood pressure (AOBP) is the preferredmethod of performing in-office BP measurement
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Automated Office BP Measurement
• More closely approximates ABPM than routine office BPs (mitigates white coat effect)1-3
• Is more predictive of end organ damage (LVMI, proteinuria and cIMT), similar to ABPM4-6
1. Beckett L, et al. BMC Cardiovasc Disord 2005;5:18; 2. Myers MG, et al. J Hypertens 2009;27:280-6; 3. Myers MG, et al. BMJ 2011;342;d286;4. Campbell NRC, et al. J Hum Hypertens 2007;21:588-90;
5. Andreadis EA, et al. Am J Hypertens 2011;24:661-6; 6. Andreadis EA, et al. Am J Hypertens 2012;25:969-73.
ABPM = ambulatory blood pressure measurementLVMI = left ventricular mass indexcIMT = carotid intima media thickness
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Automated Office BP (AOBP)
• Automated and calibrated device• BP taken in the normal way away from the physician• Avoids white coating• At least 3 readings at 1-2 min intervals, average 3 stable
readings• Cut off 135/85 mmHg• Used for diagnosis and follow up
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Increasing risk ofan event
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Approach
• History • Con meds – NSAIDs, Ritalin, Tik, OC, etc• Risk factors and prior events• Level of BP• Examination – TOD (fundi, apex) , secondary causes (pulses,
bruits, striae, etc), waist and BMI• Basic investigations
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Investigation TOD Secondary cause Risk stratification
Dipsticks urine Yes, usually 1+ protein
only in hypertensive
nephrosclerosis
2+ or more proteinuria and/or
haematuria suggests kidney
disease
Yes
ECG LVH (see ECG criteria) No Yes
Creatinine/eGFR Yes Yes Yes
Echocardiogram# LVH No Yes
K+ No Low K+ may suggest primary
aldosteronism/excess diuretic
No
Fasting glucose No No Yes
Fasting lipogram No No Yes
Urine albumin/creatinine
ratio*
Yes Yes, if markedly elevated Yes
*mandatory in diabetics, first voided urine specimen, < 3mg – normal, 3-30 microalbuminuria,> 30 macroalbuminuria (spot urines tend to overestimate ratio),
# - only if readily available
Mandatory Investigations
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>35 – Sokolow-Lyon)
Cornel – (S in V3 + R in aVL + 6 in females) x QRS duration > 2440
Harbinger of death
R in AvL > 11
ECG Criteria for LVH
Repolarisation changes– harbinger of death
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Risk stratification guides treatment
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TREATMENT
• Lifestyle• Antihypertensive therapy• Treatment of all risk factors – LDL and diabetes as per LASSA and
SEMDSA guidelines• Statins should be considered in every patient• Aspirin for secondary prevention and only for very high risk for
primary prevention• BP must be controlled (at least < 160 mmHg) to avoid cerebral Hx
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PATIENT REPORTED HE WALKED THE DOG REGULARLY
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CHO free
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SUGAR
0
10
20
30
40
50
60
70
80
1700 1800 1900 2000 2015
Sugar intake (kg)
Sugar intake (kg)
Sugar – 50% glucose/50% fructose, high fructose corn syrup 45% glucose/55% fructoseHoney = sugar from bees
It is important to recognise sugar causes HT through mechanisms other than obesity
Johnson et al, Am J Nutrit, 2007
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View of Table Mountain from Khayelitsha
How do we realistically institute life style changes?
Exercise? Fresh fruit and veg? Salt for preservation of foodstuffs?Alcohol reduction? Access?
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Avoid refined CHO or sugar
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NICE/SA/JNC/ISHIB GUIDELINES
Thiazides/indapamide*/chlorthalidone*
ARB
CCB
ACEi
Diuretic/CCB preferred in black patients*Recommended by NICE
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Figure 6
The Lancet 2016 387, 957-967DOI: (10.1016/S0140-6736(15)01225-8) Copyright © 2016 Elsevier Ltd Terms and Conditionsβ-blockers no longer recommended unless compelling indications
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SAHS Practice Guidelines, CVJA,2014
BP > 180/110 – see severe hypertension
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South African GP Study
162.2158.2
141.6 138.7
93.9 92.284.6 82
73.7 76.1 79.3 78.4
60
80
100
120
140
160
180
Screening Baseline 6 weeks 12 weeksSBP DBP Pulse
P=0.08
P<0.00001 P=0.05
P=0.03
P<0.00001
P=0.55
Stage 1 HT – lercanidipine Stage 2 HT – lercanidipine/enalapril
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Red
uctio
n in
blo
od p
ress
ure
(mm
Hg)
–11
–21
15 days
–41.9
–23.2
60 days
–63
–29
Stage 3 hypertension(SBP>180 mm Hg)
–29
–16
30 days
–10
0
–20
–30
–40
–50
–60
–70SBP DBP
n=161
13. Adapted from STRONG. Bahl VK, et al. Am J Cardiovasc Drugs 2009;9:135-142.
BP lowering Efficacy of perindopril and amlodipine combination
n=1 250
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Amlodipine/Valsartan: Superior Systolic BP-lowering Efficacy Versus Amlodipine Monotherapy in Black Patients with Stage 2
Hypertension
–26.6
–33.3
LSM
cha
nge
from
bas
elin
e in
M
SS
BP
(mm
Hg)
at W
eek
8
Amlodipine/Valsartan Amlodipine
p<0.0001
0
–5
–10
–15
–20
–25
–30
–35
–40MSSBP = mean sitting systolic BPBaseline MSSBP = 170 mmHgLSM=least square mean
N=277 N=278
Flack et al. J Hum Hypertens 2009 (E-pub ahead of print)
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Dose Dependent Efficacy1
Perindopril 5 mg & Indapamide 1,25 mg
Perindopril 10 mg & Indapamide 2,5 mg
n = 397; Duration = 6 months*SBP = Systolic blood pressure; *DBP = Diastolic blood pressure1.Netchessova TA, Shepelkevich AP, Gorbat TV. High Blood Press Cardiovasc Prev 2014; 21(1): 63-69.
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Effects of switching from free combinations to the corresponding single-pill combinations (SPCs) on medication adherence in the whole study population (A) and patients categorized
according to the number of concurrent antihypertensive drugs (B). *P values are for between-group medication possession ratio differences by using the 1-way ANOVA, followed by post hoc
Bonferroni analyses.
Wang T et al. Hypertension. 2014;63:958-967
Copyright © American Heart Association, Inc. All rights reserved.
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Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind,
crossover trial
Prof Bryan Williams, FRCP, Prof Thomas M MacDonald, FRCP, Steve Morant, PhD, Prof David J Webb, FMedSci, Prof Peter Sever, FRCP, Prof Gordon McInnes, FRCP, Prof Ian Ford, PhD, Prof J Kennedy Cruickshank, FRCP, Prof Mark J Caulfield, FMedSci, Prof
Jackie Salsbury, RGN, Isla Mackenzie, FRCP, Sandosh Padmanabhan, FRCP, Prof Morris J Brown, FMedSci
The LancetVolume 386, Issue 10008, Pages 2059-2068 (November 2015)
DOI: 10.1016/S0140-6736(15)00257-3
Copyright © 2015 Williams et al. Open Access article distributed under the terms of CC BY Terms and Conditions
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Figure 1
The Lancet 2015 386, 2059-2068DOI: (10.1016/S0140-6736(15)00257-3) Copyright © 2015 Williams et al. Open Access article distributed under the terms of CC BY Terms and Conditions
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Figure 2
The Lancet 2015 386, 2059-2068DOI: (10.1016/S0140-6736(15)00257-3) Copyright © 2015 Williams et al. Open Access article distributed under the terms of CC BY Terms and Conditions
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KEY MESSAGES• Hypertension is major world wide epidemic• There are substantial differences in awareness, prevalence
and control rates, and CV outcomes especially in S. Africa• The SA Hypertension Guideline can make substantial impact
even in low resource settings• It provides a basis for developing minimum standards for care
essential for holding health authorities to account• These guidelines could be adapted to the economic
considerations of each country but the cost of untreated and poorly treated hypertension needs to be considered
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GUIDELINE CONSENSUS• Broad consensus for BP thresholds for intervention (140/90)• ACC/AHA has recommended a new target of < 130/80 mmHg in most at risk
patients, but S Africa is not ready for this and this recommendation is also controversial in low risk patients
• Importance of accurate BP measurement within and out of office• Much closer agreement on optimal drug treatment (ACE or ARB, CCB, diuretic
or all 3)• Recognition for the wider use of single pill drug combinations for optimal BP
control, and earlier initial use of combinations in high risk e.g. > 160/100• Spironolactone low dose for resistant hypertension, caution if eGFR < 45,
monitor K+• Routine use of statins
73