Pickering.ppt

Diagnostic Evaluation of the Hypertensive Patient-

How much is enough?

Thomas Pickering MD, DPhilBehavioral Cardiovascular Health and

Hypertension ProgramColumbia Presbyterian Medical Center

New York


How much is enough?

• How high is the blood pressure?

• Why is it high?

• What is the risk?


How much is enough?


How should it be measured?

How should the Blood Pressure be Measured?

In the ClinicBy the doctor?By a nurse?By an automated device?

Outside the ClinicHome monitoring?Ambulatory monitoring?

Ambulatory BP and Cardiovascular Disease in the Elderly with Systolic Hypertension:The Syst-Eur Study (N = 808)

Active treatment

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Staessen et al. JAMA 1999; 282: 539-46.

High risk group- Clinic BP underestimates risk

Low risk group- WCH Clinic BP overestimates risk

24 Hour Ambulatory Monitoring

The White Coat Effect in the Real World(Little et al, BMJ 2002; 325: 254)

• 173 hypertensive patients in 3 general practices in the UK

• Clinic (MD and RN), self-monitoring, and ABPM

• White coat effect estimated as difference between other measures of BP and daytime BP:-

Physician 19/11 mmHg

Nurse 1 5/8 mmHg

Nurse 2 5/6 mmHg

Self-monitoring in clinic 10/13 mmHg

Self-monitoring at home 5/6 mmHg

135/85 Ambulatory Pressure

140/90

Clinic Pressure Sustained

HypertensionWhite Coat Hypertension

True Normotension

Masked Hypertension

• Measurement error

• Small number of readings

• Effects of recent activities

• Expense & Inconvenience

• White coat effect

A Diagnosis of Hypertension

based exclusively on Physician readings is no longer acceptable

Prospective Studies Showing that Home BP Predicts CV Morbidity Better than Clinic BP

Author Year Population N Comments

Imai 1996 Population 1789 ABP & HBP predict, not CBP

Bobrie 2004 Treated 4939 HBP predicts, not CBP

Sega 2005 Population 2051 HBP predicts better than CBP

Call to Action for the Reimbursement of Home BP

Monitoring

Supported by

American Heart Association

American Society of Hypertension

Preventive Cardiovascular Nurses Association

Which measure of Blood Pressure should we worry about most?

• Systolic?

• Diastolic?

• Pulse?

Change of Blood Pressure with Age (NHANES- Black Women)

60

80

100

120

140

160

20 30 40 50 60 70

Blood Pressure

mm Hg

Age

Systolic

Diastolic

Relations Between SBP, DBP and Stroke in Different Age Groups

(Prospective Studies Collaboration Lancet 2002; 360: 9349)

Relations Between SBP, DBP and Stroke in Different Age Groups

(Prospective Studies Collaboration Lancet 2002; 360: 9349)

Even at ages 80-89 DBP risk

0

20

40

60

80

100

<120 120-139 140-159 >160

<7070-74

75-7980-89

>100

Systolic Pressure (mm Hg)

Diastolic Pressure (mm Hg)

CHD Deaths Per

1000 Pt-Years

Neaton et al. Arch Intern Med. 1992;152;56.

CHD Deaths Versus SBP And DBP In MRFIT


How much is enough?


• Why is it high?


JNC 7: Identifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

JNC 7 Recommendations for Routine Work-up of Hypertensive Patients

Routine Tests• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,

and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and

low-density lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Dyslipidemia and the risk of Hypertension (Halperin et al Hypertens 2006: 47:45)

• 3110 men followed for 14 years in Physicians’ Health Study

• Baseline lipids analyzed by quintiles

LDL Chol HTN Risk by 39%

Tot Chol HTN Risk by 23%

HDL Chol HTN Risk by 32%Baseline

Antihypertensive Effect of Pravastatin in Patients with Hypertension and Hypercholesterolemia (Glorioso et al; Hypertens 1999: 34:1281)

135

140

145

150

155

2

3

4

5

6

0 4 8 12 16 20 24 28 32 36 40 Weeks

Systolic pressure mmHg

LDL cholesterol mmol/l

Placebo Placebo

Placebo Statin

Statin Placebo

ASCOT: Main Results (Blood Pressure-Lowering Arm: BPLA & Lipid-Lowering Arm: LLA)

Endpoint BPLA* LLA** Blood Pressure Lipids

Primary 10%- NS 36%

Death 11% 13%- NS

Stroke 23% 27%

Total events/ 16% 21% procedures

* BPLA- ACEI/CCB vs. BB/Diuretic

** LLA- Statin vs. placebo

Effects of intervention on events

Cardiovascular Risk Factors in “Prehypertension” (TROPHY)

Two- 22%

None -4%

One- 14%Three or more- 59%

(Nesbitt et al, AJH 2005;18:980)

Cardiovascular Risk Factors in “Prehypertension” (TROPHY)

Two- 22%

None -4%

One- 14%Three or more- 59% Cholesterol >200HDL <40TG >150BMI > 25Glucose >110Insulin >20Heart rate >80Hematocrit >43 or 41

(Nesbitt et al, AJH 2005;18:980)

Overlap of Four Common Conditions

Sleep Sleep Disordered Disordered BreathingBreathing

HypertensionHypertension

ObesityObesity

DiabetesDiabetes

Association Between SDB and Hypertension- SHHS Parent Study

(Nieto et al, JAMA 2000;283,1829)

1

1.25

1.571.73

2.27

1 1.071.2 1.25

1.37

0.5

1

1.5

2

2.5

<1.5 1.5-4.9 5-14.9 15-29.9 >30

Odds Ratio of HTN

Apnea-Hypopnea Index per Hour

Adjusted for BMI etc.Not adjusted for BMI

Sleep Disordered Breathing Predicts Hypertension- the Wisconsin Study

(Peppard et al, NEJM 2000; 342: 1378)

1.4

1.7

2.77

1

1.5

2

2.5

3

<5 5-14.9 >15

Apnea-Hypopnea Index

Odds Ratio for Hypertension*

*Adjusted for baseline BP, BMI, age etc.

No Relationship between Isolated Systolic Hypertension & Sleep Apnea: SHHS Study

(Haas, Pickering et al, Circ 2005)

0

0.5

1

1.5

2

2.5S/D 40-59ISH 40-59ISH >60

<1.5 1.5-5 5-15 15-30 >30 AHI

Odds Ratio for HTN

P<0.002

NS

Clinic BP140/90 mmHg

Awake ABP

135/85 mmHg

0

10

20

30

40

50

HighLow

High

Low

SHT

WCHT

MHT NT

%

% of SDBAHI > 15/hr

Prevalence of SDB in Hypertension

Abnormalities Associated with the Metabolic Syndrome

Hypertension

Non-dipping pattern of 24 hr BP

Salt sensitive

Dyslipidemia

High triglycerides

Low HDL cholesterol

Increased small dense LDL

Insulin resistance

Type II diabetes

Increased NEFAs

Endothelial dysfunction

Increased PAI-I

Increased platelet aggregation

Microalbuminuria

Obstructive Sleep apnea

Central Obesity

High Prevalence of Sleep Apnea in Resistant Hypertension

(Logan et al J Hypertens 2001:19:2271)

• 41 consecutive patients with 3 drug-resistant hypertension evaluated with PSG and ABPM

• Clinic BP was 168/94 on 3.6 drugs; most were obese • 83% had OSA (AHI >10); commoner in men (96%) than

women (65%)

• ABPM showed that 64% were non-dippers; no difference in dipping between those with and without OSA

Situations in which Renin/Aldosterone Measurement

May Be Helpful

• Suspected secondary hypertension, e.g. hypokalemia (measure off drugs)

• Refractory hypertension (measure on drugs)

• Intolerance to multiple drugs (measure off drugs)


How much is enough?


• Why is it high?


JNC 7: CVD Risk Factors Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD

(men under age 55 or women under age 65)*Components of the metabolic syndrome.

JNC 7: Target Organ Damage

Heart• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure

Brain• Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

Why Is Echocardiography Useful In Hypertensive Patients?

“No other biological variable (except advancing age) predicts cardiac risk better

than left ventricular hypertrophy”.

(De Simone et al, J Hypertens 12;1129, 1994)

How Common is LVH in Hypertensive Patients?

• ECG LVH in about 5% of ht patients

• Echo LVH in 15-30% of unselected ht patients• Echo LVH in 20 to 60% of ht patients in referral centers

Indications for Echocardiography in Hypertensive Patients

• Coexistent Heart Disease

• Resistant Hypertension

• Decision to Start Treatment Uncertain

Echocardiographic LVMI as a Predictor of CV Risk (Schillaci et al, Hypertens 2000; 35: 580)

0.85

1.66

2.24

2.86

4.34

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1

2

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4

5

1st 2nd 3rd 4th 5th

CV Events per 100-pt years

Quintiles of LVMI

Microalbuminuria

Category Spot collection 24 hour g/mg creatinine mg/24 hr

Normal <30* <30

Microalbuminuria 30-300 30-300

Albuminuria >300 >300

Normal levels a bit lower in men (25 vs 35)

Microalbuminuria Relation to other CV Risk Factors

• Hypertension

• Hyperlipidemia

• Central obesity

• Smoking

• LVH

• Coronary Disease

• Non-dipping BP pattern

Urine Albumin Predicts CV and Non-CV Mortality in the General Population

(Hillege et al Circ 2002; 106: 1777)

0

1

2

3

4

5

6

10 100 1000

Hazard Ratio for Death

Urinary Albumin (mg/L)

Cardiovascular

Non-cardiovascular

Microalbuminuria and CHD risk in Hypertension (Borch-Johnsen et al ATVB 1999;19:1992)

0

2

4

6

Nl

Hi

Systolic Pressure

Urine albumin

Relative risk of CHD

<140 140-160 >160 Low

High

Effects of Enalapril and Nitrendipine on Urine Albumin (Bianchi et al AJH 1991; 4:291)

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35

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45

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55

60

65

70

75

80

0 4 8 12 16

Urine albumin (mg/24 hr)

Enalapril

Nitrendipine

Weeks


How much is enough?

In all patients

• Sleep history

• BMI

• Out-of-office Blood Pressures (home monitoring)

• Microalbuminuria


How much is enough?

In selected patients

• Plasma renin/aldosterone

• Out-of-office Blood Pressures (ambulatory monitoring)

• Echocardiogram

Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

National Heart, Lung, andBlood Institute

National High Blood PressureEducation Program

LVHSyst /DiastdysfunctionSilentischemia

SilentinfarctionDeep whitematterlesions

Micro-albuminuria

WallthickeningPlaque

CoronaryHeartDisease

CerebrovascularDisease

ChronicRenalFailure

PeripheralVascularDisease

Heart Brain Kidneys Arteries

Clinically Overt Target Organ Disease

Hypertension

Clinical Significance of Hypertensive Target Organ Damage

Silent Target Organ Damage

Other Risk Factors & Grade 1 Grade 2 Grade 3

Disease History 140-159/90-99 160-179/100-109 >180/>110

I No other risk factors LOW RISK MED RISK HIGH RISK

II 1-2 risk factors MED RISK MED RISK V. HIGH RISK

III 3 or more risk factors HIGH RISK HIGH RISK V. HIGH RISK

IV ACC V. HIGH RISK V. HIGH RISK V. HIGH RISK

TOD or Diabetes

Blood Pressure mm Hg

Classification of Risk in Hypertension

Classification of Obesity by BMI

Obesity class BMI

Underweight <18.5

Normal 18.5-24.9

Overweight 25.0-29.9

Obesity grade I 30.0-34.9

II 35.0-39.9

Extreme obesity III >40

Total & HDL Cholesterol as Predictors of ED

(Wei et al, Am J Epidemiol 1994;140:930)

• 3250 healthy men attending Cooper Clinic in Dallas• 71 developed new onset ED during a 2 year follow-up.

• Strongest predictors were total and HCDL cholesterol.

The Massachussets Male Aging Study(Feldman et al, J Urol 151,54, 1994)

Predictors of ED

1. Disease• 39% with treated heart disease• 28% with treated diabetes• 15% with treated hypertension

(10% in general population)

When to Suspect Sleep Apnea

Predictors of Stroke and MI- PIUMA

Study (Verdecchia et al Circ 2001; 103; 2579)

Stroke Myocardial Infarction

Age Age

Gender Gender

Diabetes Diabetes

24-hr Mean BP 24-hr Pulse Pr

Cholesterol

Smoking

Rationale- One Size Does Not Fit All

1. Level of risk varies greatly in hypertensive patients

2. Responsiveness to treatment varies greatly in hypertensive patients




1. Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria




1. Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria

2. Need tests to improve prediction of treatment response, e.g. renin

Recommendations for Clinical Use of ABPM: JNC 7 & WHO-ISH

JNC 7 WHO-ISH

ABPM endorsed Yes Yes

Indications:

White Coat HTN Yes Yes

Labile BP Yes Yes

R/O hypotensive episodes Yes Yes

Resistant HTN Yes Yes

Autonomic dysfunction Yes No


Active treatment

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Active treatment

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High risk group- Clinic BP underestimates risk

Two Types of Hypertension

1. Systolic and Diastolic Hypertension

- Younger and obese patients

- Evidence for increased sympathetic nerve activity

2. Isolated Systolic Hypertension

- Older and lean patients

- No evidence for increased sympathetic nerve activity

- Attributable to increased arterial stiffness

Patient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM

• Some type of out-of-office BP monitoring (home or ambulatory) is advisable in ALL patients

• ABPM is indicated when there is a discrepancy between either successive clinic readings or clinic and home readings

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography

• Echocardiography is indicated if any of the following occur

– Coexistent heart disease

– Refractory hypertension

– Decision to treat uncertain

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement

• Renin measurement is indicated in the following situations:

- Suspected secondary hypertension

- Refractory hypertension

- Intolerance to multiple drugs

Pickering.ppt

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