Learning & Action Network Session

Cardiac Health

Cardiac Session Disclosures

Speakers have no industry or other financial relationships to disclose.

Learning & Action Network Session

Cardiac Health

CONTROLLING LDL-CHOLESTEROL AND HYPERTENSION: WHAT TO DO WHILE WAITING FOR ATP-4 AND JNC-8?

Barry Stults, M.D. Division of General Medicine

University of Utah Medical Center Salt Lake City VAMC

OVERVIEW

• LDL-C and HTN: only pieces of puzzle – Assess total CVD risk – all RFs! – Rx all CVD RFs!

• How to estimate total CVD risk? • Improving LDL-D while awaiting ATP-4

– Autumn, 2012?

• Improving HTN control while awaiting JNC-8 – Autumn, 2012?

CARDIOVASCULAR MORTALITY: U.S. 80 million in U.S. have CVD ↓

CVD Deaths: 812,000/y – 33% of deaths

Men: 392,000/y Women: 420,000/y

Coronary disease 52%

Stroke 17%

Congestive heart failure 7%

Hypertension 6%

Peripheral artery disease 4%

Circulation 2012; 125:188 AHA Heart Disease and Stroke Statistics, 2012 Updated

LIFETIME RISK OF CVD IN U.S.

Free of CVD at Age 50y

Men Women

52% develop CVD 39% develop CVD

• 38% CHD • 21% CHD • 14% stroke • 18% stroke

Ann Int Med 2009; 150:405 Circulation 2006; 113:791 Arch Intern Med 2003; 163:2006

Average lifetime CVD risk is high!! Cost is enormous - $475 billion/y!

NATURAL HX OF ATHEROSCLEROTIC CVD

Lifestyle Factors Genetic Susceptibility

CVD Risk Factors • Smoking, HTN, Dyslipidemia, DM, Obesity

Subclinical Atherosclerosis • ↑ CAC, ↑ CIMT, ↓ ABI

Clinical CVD Event

Death Recurrence Event-free survival

Circulation 2009; 120:360

7 FACTORS FOR IDEAL CARDIOVASCULAR HEALTH: AMERICAN HEART ASSOCIATION, 2010

Goal Non-smoker BMI < 25 kg/m2

Physical activity > 150 min/wk • 33% say no physical activity Healthy diet (4-5 components) Total cholesterol < 200 mg % BP < 120/80 mm Hg Fasting glucose < 100 mg%

% Americans at Goal 73% 33% 45%

< 1% 45% 42% 58%

• < 50% have “ideal” LDL-C or BP

Circulation 2012; 125:188 Circulation 2010; 121:582

IDEAL CARDIOVASCULAR HEALTH: DOES IT MATTER? 20-Y CVD RISK ∝ # OF HEALTH METRICS

ARIC prospective cohort study: 1987 → 2007; 12,744 subjects

# of Ideal Metrics 20-Y CVD Risk 0 32% 1 22% 2 16% 3 12% 4 9% 5 6% 6 4% 7 0

• 20-y CVD risk < 10% if ≥ 4 ideal metrics

J Am Coll Card 2011; 57:1690

HEALTH BEHAVIORS = BP, CHOLESTEROL, GLUCOSE TO INCREASE CVD RISK

J Am Coll Card 2011; 57:1690

IDEAL CARDIOVASCULAR HEALTH: WE AREN’T DOING WELL!

No. of Ideal Health Metrics Present

7 6 5 4 3 2 1 0

NHANES 2005-2010 % of U.S. Population

1.2 7.5

16.6 22.4 25.5 18.0 7.3 1.4

• 52% of Americans have ≤ 3/7 ideal health metrics!

JAMA 2012; 307:1273

ASSESSMENT OF TOTAL CVD RISK = RECOMMENDED!

• ACCF/AHA 2009: Performance Measures for 1° Prevention

• ACCF/AHA 2010: For Asymptomatic Adults

• AHA/ASA 2011: For 1° Stroke Prevention

• USPSTF 2009: For 1° Prevention Aspirin Rx

• European Society of Cardiology 2012: CV Prevention Guideline

ASSESSMENT OF TOTAL CVD RISK: WHY?

Intensity of Risk Reduction Rx ∝ Person’s Absolute Risk

Clinicians more likely to correctly prescribe

Communicate CVD Risk to Patient:

• Comprehensible format

Patient makes informed decision:

Patient more likely to adhere

PATIENT ENGAGEMENT!

Gestalting CVD Risk Doesn’t Work!

Heart 2011; 97:173

ASSESSING CVD RISK IN 1° PREVENTION Gestalt often inaccurate

Multiple mild RFs

↓

Underestimate risk

↓

No Rx of 1/3 at high risk

Single moderate RF

↓

Overestimate risk

↓

Unnecessary Rx

Quantitative CHD/CVD risk scores superior to clinician estimates

Circulation 2010; 121:1768 JACC 2010; 55:1168 JAMA 2009; 302:2104

ASSESSMENT OF TOTAL CARDIOVASCULAR RISK: CORNERSTONE TO GUIDE LIPID RX

• Combinations of risk factors greatly impact CVD risk:

- A little of this, a little of that → ↑↑↑ CVD risk - Isolated ↑ LDL-C → little ↑ CVD risk

Sex

Age

Smoke

SBP

HDL-C

Fam. Hx

LDL-C

10y CVD*

NNT, 5y Simva 40 mg

M 55 No 120 55 Θ 90 4% 125 145 5% 100 190 6% 83

M 55 Yes 140 25 ⊕ 90 16% 31 145 22% 23 190 26% 19

*MI, stroke, revasc., death Circ Cardio Qual Outcomes 2012; 5:2

ASSESSMENT OF TOTAL CVD RISK: HOW?

Step 1: ID patients with obvious HIGH 10y CVD risk > 20%:

• Atherosclerotic CVD: ‒ Prior MI, stroke, PAD

• Diabetes ‒ Especially long duration, other RFs, complications

• Chronic kidney disease (CKD) ‒ eGFR < 45 (60) ml/min

(• Coronary artery calcium score > 100-300?) (‒ If measured)

ASSESSMENT OF TOTAL CVD RISK: HOW?

Step 2: Determine 10y CVD risk in all other patients

• Collect risk factors: Age Smoking Sex Diabetes Total cholesterol Systolic BP HDL-cholesterol ± HTN Rx

⊕ Family Hx of premature atherosclerotic CVD

• 1° relative (F, M, B, S) before age 60 • Doubles any calculated risk • Calculate 10y CVD risk: MI, stroke, PAD, HF

ASSESSMENT OF TOTAL CVD RISK: HOW?

• Calculate 10y Framingham CVD risk: advantages! – 10y risk: CHD ⊕ stroke ⊕ PAD ⊕ HF Stroke ≅ 50% of 1st CVD events in women

– May correct for ⊕ Fam Hx of premature ASCVD For individuals < age 60 with no CVD or DM Multiply by 1.5 (1, 1° relative) or 2.0 (≥ 2, 1° relatives)

– Provides patient communication tool: “Cardiovascular age” “You have the cardiovascular age and risk of a ___ yr-old” – www.zunis.org/FHS_CVD_Risk_Calc.2008htm paper chart: Am J Card 2009; 103:1174

Circulation 2008; 117:743 J Am Coll Card 2010; 55:1169

FRS 10-Y CVD vs CHD RISK SCORE 56 y-old woman: sister had ischemic stroke, age 54 - Obese (BMI = 31); sedentary; FBG = 109 mg%

Age 56y Sex Female

Smoking No TC 210

HDL-C 42 Sys BP 138

HTN Rx No 10y CHD risk 2% 10y CVD risk

Heart age 10% → 20% (Fam Hx) 73y (or higher!)

ASSESSMENT OF TOTAL CVD RISK: HOW?

Step 3: Estimate lifetime (30y) CVD risk IF: Non-smoking men ≤ age 50

• ≥ 1 RF in Women ≤ age 60

‒ Low 10y CVD risk, BUT ‒ ≥ 40% lifetime CVD risk (vs < 15% if optimal RFs)

• Formats to estimate lifetime (30y) risk: ‒ ≥ 1 “Major” CVD risk at age ≥ 50 TC ≥ 240 (≈ LDL-C ≥ 160), HTN, smoking, DM

www.circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.108.816694/DC1

Circulation 2009; 119:382 Circ Cardiovasc Qual Outcomes 2010; 3:8

YOUNGER PTS WITH RFs: LIFETIME (30Y) RISK

Age 56 42 Sex W M Smoking No No TC 248 242 HDL-C 42 34 Sys BP 138 138 HTN Rx No No 10y CHD 3% 5% 10y CVD 12% 11% 30y CVD 47% 41% - If optimal RFs: 17% 12%

Circulation 2009; 119:3078

IMPROVING LDL-CHOLESTEROL: WE NEED TO SIMPLIFY OUR APPROACH!

“HIGH” LDL-C: ATP-3, 2004 DEFINITION ∝ LEVEL OF 10-Y CHD RISK

10-Y CHD Risk “High” LDL-C (mg%) Very High: > 30% ≥ 70

• ACS in last year

• CHD ⊕ other CVD RF

• (CKD-eGFR < 30)

High: 21-30% ≥ 100

• CHD

• FRS > 20%

• DM, CKD with eGFR = 30-60 (?45)

Moderately High: 10-20% ≥ 100-130

• FRS = 10-20%

Moderate: < 10% ≥ 130

• FRS < 10% but ≥ 1 CVD RF

Low: < 10% ≥ 160

• FRS < 10% and 0 CVD RFs

• NOT EVIDENCE-BASED! Circulation 2004; 110:227

LDL-CHOLESTEROL IN U.S.: 2005-2008

“High” LDL-C All 34% • 20-39y 12% • 40-64y 41% • ≥ 65y 58%

71 million

Insured 75%

Treated 48%

Controlled 33%

• Even lower control rates: ‒ Hispanics (15%) vs AAs (26%), Whites (36%) ‒ Uninsured (15%)

• 32% (NHANES 2005-2010) have LDL-C ≥ 130 mg% • 14% (NHANES 2005-2010) have LDL-C ≥ 160 mg%

JAMA 2012; 307:1273 Circulation 2012; 125:188 MMWR 2011; 60:109

STATINS EFFECTIVELY REDUCE LDL-C Drug

Dose

% LDL-C Reduction (Mean)

Rosuvastatin 20, 40 mg > 50% Atorvastatin 80 mg > 50% Atorvastatin 20, 40 mg 40-50% Atorvastatin 10 mg 30-40% Simvastatin 20, 40 mg 30-40% Pravastatin 40, 80 mg 30-40% Lovastatin 40, 80 mg 30-40% Fluvastatin 80 mg 30-40%

J Clin Pharm Ther 2010; 35:139

STATINS REDUCE CARDIOVASCULAR EVENTS

CTT 2010 meta-analysis: 21 RCTs; 129,526 pts; 5y FU % Risk Reduction for

40 mg% ↓ LDL-C Total mortality 10% CAD mortality 20% CVD events 22% MI 27% Stroke 15%

• Same % relative risk reduction in 2°, 1° prevention - Less but important absolute risk reduction in 1° prevention • Benefits in year 1, increase over next 4y

Lancet 2010; 376:1670

STATIN EFFICACY: LOWER IS BETTER

CTT 2010 meta-analysis: 5 RCTs; 39,612 pts; 5y FU More intensive statin Rx (↓ LDL-C 20 mg%)

vs Less intensive statin Rx Major CVD events ↓ 15% Myocardial infarction ↓ 13% Stroke ↓ 16%

• Every 40 mg% ↓ in LDL-C will ↓ CVD events by 20-25% • Same relative benefit even if baseline LDL-C < 80mg% • ↓ LDL-C by 80-120 mg% may ↓ CVD by 40-50%!

Lancet 2010; 376:1670

WHY INADEQUATE LDL-C CONTROL?

• Therapeutic inertia – SIMPLIFY:

• Risk-Rx algorithm • LDL-C goals

• Select initial statin dose to ↓ LDL-C ≥ 30% AND get to goal

• Relax follow-up interval and NO LFT follow-up

• Reduce focus on HDL-C and TG

SS Martin, et al Am J Card 2012 – online 4/10/2012

Complex – not fully known

Clinician Factors Patient Factors System Factors

SIMPLIFY RISK/RX/LDL-C GOAL ALGORITHM!

• Focus on RISK, not baseline LDL-C!

SS Martin, et al Am J Card 2012 – online 4/10/2012

Atherosclerotic CVD Lifestyle Rx FRS 10y CVD risk ≥ 20% Statin Rx to: Diabetes (most) • ↓ LDL-C ≥ 50%, and CKD (eGFR < 45-60) • ↓ LDL-C to < 70 mg% (CAC > 100-300)

HIGH 10-YEAR

RISK

SIMPLIFY RISK/RX/LDL-C GOAL ALGORITHM!

SS Martin, et al Am J Card 2012 – online 4/10/2012

Lifetime (30y) risk ≥ 40% Lifestyle Rx Age ≥ 50y ⊕ “Major” RF Discuss Statin Rx: FRS 10y CVD risk = 10-19% • Refine risk (CAC)? (± CAC scan to refine risk) • Motivation to lifestyle

• Patient preference Statin Rx to: • ↓ LDL-C ≥ 30%, and • ↓ LDL-C to < 100 mg%

HIGH LIFETIME

RISK

FRS 10y CVD risk < 10% Lifestyle Rx

Lifetime (30y) risk < 40% LOW RISK

INITIAL STATIN DOSE: ↓ LDL-C ≥ 30% AND REACH GOAL

HIGH 10y risk: ↓ LDL-C ≥ 50% AND to < 70 mg% HIGH LIFETIME risk: ↓ LDL-C ≥ 30% AND to < 100 mg%

• Calculate statin/dose to accomplish above ‒ See slide 23[“Statins Effectively Reduce LDL-C”]

• Initiate Rx and LDL-C in 6-12 weeks • Prospective Rx trial in 1101 subjects:

‒ 86% to goal in 3 mo

Can J Card 2010; 26:80

RELAX LDL-C FU INTERVAL/NO LFT FU

LDL-C follow-up: • 6-16 weeks ∝ patient/clinician preference

Eliminate LFT monitoring: FDA statement 12/2011 • Not indicated/useful and may cause clinicians/patients

to DC statin and ↑ CVD risk • Significant liver damage “exceptionally rare” and “likely

idiosyncratic” • Communicate to patients!!

SIMPLIFIED FU → Lower cost, ↑ adherence?

SS Martin, Am J Card, online 4/10/2012 FDA Statement, 12/2011

REDUCE FOCUS ON HDL-C AND TRIGLYCERIDES

No data that Rx of ↓ HDL-C or ↑ TG will reduce CVD:

• AIM-HIGH: Statin ⊕ placebo vs statin ⊕ niacin ‒ No reduction in CVD events

• ACCORD: statin ⊕ placebo vs statin ⊕ fenofibrate

‒ No reduction in CVD events

Combo Rx adds complexity, expense, side effects • May add Rx to lower LDL-C if statin insufficient

WHY INADEQUATE LDL-C CONTROL?

Complex – not fully known

Clinician Factors Patient Factors System Factors • Low adherence

to statin Rx

NON-ADHERENCE TO STATIN RX: RAMPANT!

Study Level of Non-adherence Kripliani, 2010 43% Simons, 2011 43% DC’d statin after 6 mo Weigand, 2012 65% Pittman, 2011 33% Choudhry, 2011 50-65% Swindle, 2011 57-64%

• More common in younger, 1° prevention, women • ↓ statin benefit on CVD by 35-65% in real world • Costs healthcare system $3 billion/y

Patient Ed Counsel 2010; 81:177 Aust Fam Phys 2011; 40:319 NEJM 2011; 35:2088 Am J Managed Care 2012; 18:193 Am J Cardiol 2011; 107:1622

Am J Geriatric Pharmacother 2011; 9:471

WHY SUCH LOW ADHERENCE TO STATINS?

Complex, not fully known:

Barriers to Adherence Frequency Clinician Aware Concern about side effects* 18% 23% “Running out” of pills 13% 25% Concern about efficacy 8% 9% Cost/copayment Prescription refill management:

• Use of local pharmacy • 30 day supplies • Multiple pharmacies • Asynchronous refills

*”If the bomb doesn’t get you, the fall-out will!”

Patient Ed Counseling 2011; 85; 173 Arch Int Med 2011; 171:822 NEJM 2011; 365:2131

HOW TO IMPROVE STATIN ADHERENCE?

Intervention Comment • Detect non-adherence

‒ Ask the patient Often not done ‒ 4 item Morisky scale Detects statin non-adherence ‒ refills if available ---

• Provide “cardiovascular age” and expected 30-40% RRR

↑ LDL-C goal attainment by 26-29%

• Ask about side effect concerns and educate • Pharmacy issue: 1 pharmacy, 90 day supply, synchronous

medication refills, consider mail-order pharmacies

Can J Card 2011; 481 Arch Int Med 2011; 171:822 Clin Ther 2011; 33:1180

Complex, not fully known:

WHY INADEQUATE LDL-C CONTROL? Complex – not fully known

Clinician Factors Patient Factors System Factors • Registry of high LDL-C - EMR - Paper • Team care - Calculate “CV age” - Lifestyle Rx - Detect non-adherence - Address side effects - Arrange FU LDL-C testing - Follow-up phone calls for adherence

IMPROVING HYPERTENSION CONTROL WHILE AWAITING JNC-8

HTN AS A RISK FACTOR Increases RR by 2.0-4.0 fold for:

• CAD, stroke, HF, PAD • Renal failure, AF, dementia, ↓ cognition

Attributable risk for HTN: • Stroke 62% • MI 25% • CKD 56% • Premature death 24% • HF 49%

Aftermath:

• Shortens lifespan 5y • $93.5 billion/y in U.S.

Circulation 2012; 125:e12 J Hum Hypertension 2008; 22:63 Hypertension 2007; 50:1006

HYPERTENSION: EPIDEMIC CONTINUES

1988-1994 1999-2000 2008 Total in millions 50 65 76 % BP ≥ 140/90 or Rx 24% 28% 33.5% - Age ≥ 60y --- --- 66% - Age ≥ 60y, AA --- --- 81% - Age ≥ 90y --- --- > 90% - Age ≤ 17y --- --- ≥ 6%

Minnesota: 22% → W. Virginia: 38%

Hypertension 2009; 54:502 J Am Ger Soc 2007; 55: 1056 Hypertension 2004; 44:398 JAMA 2010; 303:2043 Circulation 2012; 125:e12 Hypertension 2007; 49:69

U.S. HTN CONTROL: 50% ≥ 140/90! 85% HAVE HEALTH INSURANCE

30% No Rx • Younger • Male • Hispanic • 0-1 visits/y

• Public education • Active screening • Improved access to care

20% Rx’d • Most on 1-2 meds • Men • AA, ↑ age, CKD, obese • ≥ 2 visits/y

• ↑ Therapeutic efficiency • ↓ Therapeutic inertia • ↑ adherence • Better BP assessment

Circulation 2011; 124:1046 MMWR 2011; 60:103

HOW TO IMPROVE HTN CONTROL?

• Measure office BP accurately • Detect/document “white-coat” HTN • Improve therapeutic efficiency:

– Initial low-dose, 2-drug Rx for many – Chlorthalidone as diuretic of choice for many – Optimal 2 and 3-drug regimens – Spironolactone at step 4 for many pts

• Drug titration every 2-4 wks (office or home BP) • Improve adherence • Improve office systems

IMPROVE HTN CONTROL: MEASURE BP ACCURATELY!

“Blood pressure reading does not seem to be done correctly in any clinic…It appears to be so simple that anyone can do it, but they can’t…”

JAMA 2008; 299:2842

• 8 studies with 8400 patients, 1995-2011: Routine clinical practice Research quality BP measurement BP measurement

– Accurate BP measurement ↓ BP ≈ 10/5 mm Hg!

Myers MG, Can J Card 2012, epub Hypertension 2010; 55:195

VS

BP MEASUREMENT: KEY TECHNIQUES BP (mm Hg) if not done

Rest ≥ 5 min, quiet ↑ 12/6 Seated, back supported ↑ 6/8 Cuff at midsternal level ↑ ↓ 2/inch Large enough cuff ↑ 6-18/4-13 Bladder center over artery ↑ 3-5/2-3 Deflate 2 mm Hg/sec ↓ SBP/↑ DBP No talking during measurement ↑ 17/13 If initial BP > goal BP: 1st reading higher 3 readings, 1 min apart • “Alerting response” Discard 1st, average last 2

• CAN WE TEACH/IMPLEMENT? DOUBTFUL! Hypertension 2005; 45:142 J Hypertens 2005; 23:697 Can J Card 2008; 24:455

A NEW APPROACH TO OFFICE BP MEASUREMENT: SERIAL AUTOMATED MEASUREMENTS ON

ISOLATED PATIENTS

• Equipment: BpTRU, Omron HEM-907, Microlife WATCH-BP – 3-6 automatic measurements at 1 min intervals

• Clinical use: – Patient to exam room – Health personnel/others leave room after 1st measurement – Next 2-5 measurements done in isolation

• Clinical utility: – Eliminates most technical errors – Reduces/eliminates white coat HTN?

Myers MG Can J Card 2012, epub J Hypertension 2010; 28:703 Hypertension 2010; 55:195

SEQUENTIAL BpTRU READINGS IN 284 PATIENTS IN PRIMARY CARE

Reading No. AOBP 1 (observer present) 147/82 2 (observer absent) 140/79

3 “ 136/78 4 “ 134/77 5 “ 132/76 6 “ 133/77 Mean 2-6 136/78

BMJ 2011; 342:d286

AOBP ON ISOLATED PATIENT IS LOWER THAN RESEARCH QUALITY ON OBSERVED PATIENT

Equivalent BPs: BP (mm/Hg) Research quality office BP 140/90 AOBP on isolated patient 135/85 Home BP, mean of 3-7 days 135/85 24 hour ABPM study: - Mean daytime awake 135/85 - Full 24 hour mean 130/80

Family Practice 2011; 28:110 Hypertension 2010; 28:703

IMPROVE HTN CONTROL: DETECT WHITE-COAT HTN = 20% OF OFFICE HTN

Minimize WCH in the office: • Trained, non-clinician staff measuring BP accurately • AOBP on isolated patients • Serial office visits

Out-of-office BP measurement:

• 24-hour ambulatory BP monitor study • Standardized home BP monitoring for 3-7d

HBPM MONITORS

• Must be validated: AAMI, BHS, and/or IP protocols – Omron (www.omronhealthcare.com) – A&D – Lifesource (www.andmedical.com) – MicroLife (www.microlife.com) – www.hypertension.ca/devices-endorsed-by-

hypertension-canada • Arm cuffs only (unless massive obesity) • Correct cuff size for mid-arm circumference

– < 33 cm regular cuff – 33-43 cm large adult or self-adjusting – > 43 cm wrist cuff (if wrist < 22 cm)

HBPM MONITORS

• Features ∝ cost: $50-$110 – Average last 3 readings $70.00 – 2-use mode $70.00 – Self-adjusting cuff $90.00 – Automatic 3 readings ⊕ average $100.00 – AM/PM 8 wk averages $100.00 – Software manager $110.00

HBPM: PRECISE PREPARATION/MEASUREMENT TECHNIQUE

Same careful preparation/technique as required in office: • Home BP technique video:

– www.hypertension.ca/hypertension-videos • Home BP technique written instructions:

– www.hypertension.ca/measuring-blood-pressure – www.hypertension.ca/chep-resources-and-downloads-dp1 – UUMC/VAMC Home BP Measurement handouts

• Check technique in the office!

HBPM MONITORING PROTOCOLS Designed to correlate with 24h ABPM, CVD outcomes:

• Optimal preparation (5 min rest, no talking or TV, etc) • Duplicate/triplicate trough readings 1 min apart 6-9 AM ⊕ 6-9 PM

– Average 2/2 or last 2/3 • For 3, preferably 7 days

– 12-28 readings required • Discard Day 1, average last 2-6 days

– Do not consider isolated readings for decisions • Communicate mean BP to team

– HBPM cuffs that take 3 readings, average them

J Hypertension 2010; 28:226, 259 Hypertension 2011; 57:1081 J Hum Hypertension 2010; 24:779

GOAL BP: HOW LOW TO GO IN 2012?

Initiate Rx Goal BP Lower risk HTN ≥ 140/90 < 140/90 CKD ≥ 130/80 < 130/80

vs vs ≥ 140/90 < 140/90

Diabetes ≥ 130/80 < 130/80

CHEP, on-line 2012 Circulation 2011; 123:2434

Age ≥ 80y ≥ 150 140-145 • ACC/AHA, 2011

IMPROVE HTN CONTROL: INITIAL LOW-DOSE 2-DRUG RX

• 75% of HTN patients need ≥ 2 drugs • Better BP reduction than high dose of 1 drug • 20% higher HTN control rates at 6-12 mo

– RCTs – Observational studies

• 10-15% improved adherence • Possible 10% reduction in CVD events?

Perhaps avoid in frail elderly

Hypertension 2011; 58:523 J Clin Hypertension 2011; 13:898 Hypertension 2009; 53:646 Hypertension 2012; 59:1124

IMPROVE HTN CONTROL: CHLORTHALIDONE OFTEN PREFERRED DIURETIC

• CVD reduction in RCTs: – Yes → CTD, 12.5-25 mg/d; HCTZ, 25-50 mg/d – No → HCTZ, 12.5-25 mg/d

• BP reduction: – HCTZ, 12.5-25 mg/d → 5-8/3-5 mm Hg HCTZ, 50 mg/d → 13/5 mm Hg Others, 50% max. dose → 11-12/7-8 – HCTZ vs CTD at 12.5-25 mg/d: CTD ↓ SBP by 8.6 mm Hg

• Guidelines favor CTD: AHA (2008); ISHIB (2010); NICE (2011)

Am J Med 2011; 124:896 Am J Hypertens 2010; 23:440 JACC 2011; 57:590

IMPROVING HTN CONTROL: ASH: OPTIMAL* 2-DRUG RX FOR HTN

Preferred ACE-I/D ARB/D ACE-I/CCB ARB/CCB

Acceptable BB/D DHP-CCB/BB CCB/D DRI/D DRI/CCB Dual CCB

“Unacceptable” ACE-I/BB ARB/BB ACE-I/ARB DRI/ACE-I (ARB) Non-DHP CCB/BB Clonidine/BB

J Am Soc Htn 2010; 4:42 Eur Heart J 2011; 32:2499

**

*Based on BP reduction, side effects, outcomes ** Favored for pats at high CVD risk

ALDOSTERONE BLOCKADE AS STEP 4 RX Spironolactone, 12.5-50 mg/d:

Study # Patients BP

ASCOT, 2007 1411 -22/10

Engback, 2010 344 -26/11

DeSouza, 2010 175 -16/9

Lane, 2007 119 -22/9

Rodilla, 2009 88 -28/12

Nishizaka, 2003 76 -25/12

Mahmud, 2005 69 -28/13

Sharabi, 2005 48 -23/13

Alvarez-Alvarez, 2010 (RCT) 41 -32/11

Ouzan, 2002 23 -24/10

Eplerenone, 50-100 mg/d

Calhoun, 2008 52 -18/8

ALDOSTERONE BLOCKADE AS STEP 4 RX Clinical use:

• Contraindicated if eGFR < 30 or K+ ≥ 5.0 – Caution if eGFR< 45 or K > 4.5

• Minimize hyperkalemia risk: – Low K+ diet; off K+, salt substitute, triamterene

• Dosing: Initial Final Spironolactone 12.5-25 mg/d ≥ 50 mg/d (if PA) Eplerenone 50 mg/d 50 mg bid Amiloride 2.5-5.0 mg/d 10-20 mg/d • Adjust dose q 4 wk

– K+ at 1 and 4 wks DC if K+ > 5.5; ↓ dose 50% if K = 5.0-5.5

J Am Soc Hypertens 2008; 2:462 Curr Hypertens Rep 2008; 10:496

IMPROVING HTN CONTROL: MULTI-PRONGED APPROACH TO ADHERENCE

• Patient education: verbal and written – Inform about total cardiovascular risk – Excellent written tools: www.hypertension.ca/chep-resources-and-downloads-dp1 Spanish: www.ash-us.org/For-Patients/ASH-BP-Your-Health-Booklet.aspx

• Consider home BP monitoring with feedback

– Involve patients in self-management

IMPROVING HTN CONTROL: MULTI-PRONGED APPROACH TO ADHERENCE

• Once daily medications • Fixed-dose combination pills • Generic and formulary preferred medications • Ask if concerns about side effects • Ask about adherence/Morisky scale • Q 2-4 week follow-up until BP controlled

HOW TO IMPROVE OFFICE HTN CONTROL?

Determine current performance/establish follow-up system • List all HTN pts and last BP

– % with BP ≥ 140/90 → Monitor serially • FU appts in 2-6 weeks if BP ≥ 140/90

– Known HTN – No prior HTN Dx

• Call-back system for missed/cancelled appts • Team approach: front-desk, MA, LPN/RN,

pharmacy

ALGORITHM FOR HTN RX Cautions: Frail elderly, or Postural BP, or Volume depletion

BP < 20/10 above goal No cautions

BP ≥ 20/10 above goal No cautions

MonoRx: 1. White, age < 60y: ACE-I or ARB 2. White, age ≥ 60y: Thiazide or ACE-I or ARB 3. Black, any age: Thiazide or CCB

Low-dose 2-Drug Rx: 1. ACE-I or ARB ⊕ Thiazide 2. ACE-I or ARB ⊕ CCB 3. Consider fixed-dose combo

BP > goal after 2-4 wks 3-drug Rx: ACE-I or ARB ⊕ Thiazide ⊕ CCB

BP > goal after 2-4 wks Resistant HTN: 1. Evaluation 2. Select 4th drug ∝ clinical factors - Aldosterone blocker, or - CCB of other class, or - Alpha blocker - BB/vasodilating BB, if HR > 84/min

Consult HTN specialist

Clinician discretion

BP > goal after 2-4 wks

Titrate 2-drug Rx to maximal dose

BP > goal after 2-4 wks

BP > goal

*BID vs QD loop diuretic if eGFR < 30

SBP ≤ 150 SBP > 150

Community Health Centers, Inc. Beacon Blood Pressure

Improvement

Chris Hyer, PA-C, Medical Director

CHC Overview • Stephen D. Ratcliffe, Central City, 72nd St.,

OquirrhView • Beacon Team Members: - Jennifer Thomas, MBA - Chris Hyer, PA-C - Sue Urban - Linda Stearn, RN, PA - Monica Perez, Health Educator - Keith Horwood, M.D. - Sarah Woolsey, M.D. • 26 providers

CHC Patient Story

• Patient CM, 58 y.o. female with DM, HTN, Stage II CKD with a h/o CVA.

• HTN Rx: Atenolol 100mg daily, Losarten-HCTZ 100/12.5mg

• HTN Goal <120/80 (h/o CVA, CKD) • Started using Omron home BP cuff Feb 2012

when BP in office was 167/90

CHC Patient Story

• With close f/u and use of Home BP monitor, medications adjusted, patient now at BP goal of <120/80

Beacon B/P Data

Plan-Do-Study-Act Improvement

• AIM: Increase % of patients with controlled B/P by 5% by March 1, 2012

• Steps: - EMR documentation - Educational session all providers - MA training accurate B/P measurements - Purchase, training of automatic cuffs - Patient B/P home monitoring implementation

Patient B/P Self-Management Program

• Ideas from Dr. Stults talk at Beacon L.S. • Patient education tools -- “How To Take Your Blood Pressure” -- “How To Watch Your Sodium” • B/P monitoring training checklist • Standardized order in EHR for home b/p cuff • Home B/P monitoring log (English & Spanish)

Barriers to Success

• Cuff costs • Unsure of how to order cuff in EHR • Loading patient education materials in EHR

Results

• Denominator: 1947 adult patients with diabetes

• Improvement from 63%-73% • 130/80

Next Steps

• Continued Beacon participation - EMR registry recall of patients without control - Group visits - Development and implementation of patient portal - Meeting with other ECW users to share tips

“Go With The Flow” To Manage Hypertension!

Dr. Barbara Rizzardi

Jacklin – front desk receptionist Kristi – MA Katie – MA Barbara Rizzardi, M.D. – provider

November 18, 2011 – February 29, 2012

• Run report to identify patients >120/70. • Increase patient home BP monitors. • Implement shorter intervals for follow up. • Increase programs/education materials. • Utilize BP diaries/bring in monitors.

1) EHR starts over at beginning of each calendar year! 2) Holidays – Thanksgiving and Christmas holidays during duration of aim. 3) Home BP monitors/compliance. 4) Sampling difficulty – pt. visits twice within time frame of aim.

Managed care barriers to using most appropriate anti-hypertensive medications.

Discrepancy – home vs. clinic readings.

Cost – co-pays, self-pay resistant to additional visits/meds.

• Check BP regardless of reason for visit. • Readings done in both arms. • Rx refill requests were required to make

appointment. • Discussed cuff sizes/accurate readings. • Questioned last medication dose.

How are we doing?

Awareness, Treatment & Control of Hypertension*

* Survey participants were adults aged 18 years and older. Awareness of hypertension defined as patients with hypertension who had been told by a doctor or other healthcare professional that they had hypertension or high blood pressure. Treatment defined as currently taking prescription medication. Control defined as SBP <140 mm Hg and DBP <90 mm Hg. NCHS=National Center for Health Statistics; NHANES=National Health and Nutrition Examination Survey. 1.Chobanian AV et al. JAMA. 2003;289:2560-2572. 2.Rosamond W et al. Circulation. 2007;115:e69-e171. 3.Lloyd-Jones D et al. Circulation. 2010;121:e46-e215. 4.Egan BM et al. JAMA. 2010;303:2043-2050.

What improved for patients? 10% increase in control Benefits: decreased risk for MI, stroke, CHF. Increased awareness of HTN/benefits of control. Free cuffs! Improvement for clinic: Reached attestation and received check! What’s different? EHR benefits – ability to provide summary of visit. visual graph of improvement to patient..

• How to search EHR to identify patients. • How to code accurately. • Staff more informed, assertive, aware of importance. • MU quality measure awareness for timeframe. • 99% of patients in the door get BP checked (quality measure

NQF0013!). • Increased patient education as a “take-home” for patients.

This area: Continue to monitor frequently. More patients on home BP checks. Increase ambulatory checks. Improve ability of EHR to show graphs, charts for patients over time. Continue improvement to threshold of 90%.

Other areas: Work on LDL control. Continue/maintain vigilance on other measures. Obtain Stage 2 MU

Poll Results