1. The document discusses guidelines and strategies for the prevention, treatment, and control of hypertension.
2. It outlines 4 stages of intervention for hypertension: preventive, primary, secondary, and resistant hypertension. Treatment approaches differ depending on the stage.
3. The challenges of controlling hypertension include special patient populations, factors influencing drug choice, and issues related to resistant hypertension when blood pressure remains high despite treatment with 3 drug classes.
2. 10 tips to better knowledge
1. Introduction to hypertension effects
2. Assessment of hypertension control in India
3. Updated guidelines
4. Hypertension intervention stages
5. Challenges in hypertension control
6. Doctor expectations to improve control
7. Hypertension in special conditions
8. Microalbuminuria and cardiovascular events
9. Important Hypertension trials
10. Telmisartan range
4. Hypertension - Introduction
Hypertension is the single largest risk factor for
cardiovascular disease mortality, accounting for 45%
of all CVD deaths
Many surveys continue to show that BP remains↑
under diagnosed, undertreated & poorly controlled.
Diastolic pressure is more commonly elevated in younger people.
But, with ageing, systolic hypertension becomes a more
significant problem.
Hypertension is often symptom less, so screening is
vital - before damage is done.
5. Effects of Systolic and Diastolic BP on CHD Mortality:
MRFIT*
Neaton JD, et al. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart
disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152:56-64
*
Data shown only for 316,099 white men 35 to 57 years
of age who were followed for a mean of 12 years.
CHD = coronary heart disease
MRFIT = Multiple Risk Factor Intervention Trial
<120<120
120-139120-139
140-159140-159
160+160+
CHD Death RateCHD Death Rate
Per 10,000Per 10,000
Person-YearsPerson-Years
100+100+
80-8980-89
70-7470-74
<70<70
75-7975-79
90-9990-99
SystolicSystolic
Blood PressureBlood Pressure
(mm Hg)(mm Hg)
DiastolicDiastolic
Blood PressureBlood Pressure
(mm Hg)(mm Hg)
48.348.3
37.437.4
34.734.7 43.843.8
38.138.1
80.680.6
31.031.0
25.525.5
24.624.6
25.325.3
25.225.2
24.924.9
23.823.8
16.916.9
13.913.9
12.812.8
12.612.6
11.811.8
20.620.6
10.310.3
11.811.8
8.88.8
8.58.5
9.29.2
6. <117
Systolic Blood Pressure (mm Hg)
Effects of Systolic Blood Pressure on ESRD : Multiple Risk
Factor Intervention Trial*
Klag MJ, et al. End-stage renal disease in African-American and white men.
16-year MRFIT findings. JAMA. 1997;277:1293-1298.
IncidenceofESRDper
100,000Person-Years
*
The original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
White Men (n = 300,645)
Black Men (n = 20,222)
117-123 124-130 131-140 >140
5.4
15.8
5.4
9.1
14.2
32.4
27.3 26.2
37.2
83.1
7. RelativeRiskof
StrokeDeath
<112
<71
Effects of Systolic and Diastolic BP on Stroke related
Death : MRFIT
1 2 3 4 5 6 7 8 9 10
Decile
112−
71−
118−
76−
121−
79−
125−
81−
129−
84−
132−
86−
137−
89−
142−
92−
≥151
≥98
(Lowest 10%) (Highest 10%)
SBP
DBP
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
* * * *
*
†
†
†
†
†
8. Effects of Systolic BP reduction
Stambler .Hypertension.
1991; 117-120.
After
Intervention
Before
Intervention
Reductions
in SBP
% Reduction in Mortality
Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7
Reduction
in BP
9. Hypertension - the need for control
Approximately 1 in 3 have hypertension.
Only 46% of adults with hypertension have adequately
controlled blood pressure.
The risk associated with increasing blood pressure is
continuous with
Each 2 mmHg in systolic BP =↑
• 7% increased risk of mortality from ischemic heart disease, &
• 10% increased risk of mortality from stroke.
A 10mmHg lower systolic blood pressure (SBP) – or
5mmHg lower diastolic blood pressure (DBP) – is
associated with an approximately 20–25% lower risk of
CVD & an approximately 40% lower risk of stroke.
10. Hypertension Control - comprehensive approach
The Million Hearts™ initiative has set a goal of 65%
control by 2017 overall.
Focused clinical interventions with Lifestyle advice &
complication-based strategies
Stages of Intervention in hypertension
1. Preventive – Before risk factors develop
2. Primary – Treatment of risk factors
3. Secondary – After a CVD event occurs
12. Patient pattern
• Prescription patterns of antihypertensive drugs and
adherence to JNC 7 guidelines in a tertiary care hospital in
north India
• Out Patient Department of Punjab Institute of Medical
Sciences Hospital, Jalandhar.
International Journal of Medical and Clinical Research, BAJAJ J.K et al
ISSN:0976-5530 & E-ISSN:0976-5549, Volume 3, Issue 2, 2012, pp.-118-120.
17. Hypertension Control – stages of intervention
Stages of Intervention in hypertension
Preventive – Before risk factors develop
Primary – Treatment of hypertension + risk factors
Secondary – Treatment of hypertension after a CVD event
occurs
18. DASH Trials
Dietary Approaches to Stop Hypertension (DASH) Trial
Compared the effects of 3 diets –
• typical American diet,
• fruits and vegetable diet, and
• Diet rich in fruits and vegetables and low fat dairy, and reduced in
saturated fat, total fat, and cholesterol
All diets provided ~ 3,000 mg sodium per day
Combination diet (DASH) produced the largest blood
pressure reduction after 8 weeks – average of 5.5 / 3.0↓
mm Hg
• Participants with hypertension experienced an average BP of 11.4 /↓
5.5 mm Hg
19. Sodium and Hypertension
9 in 10
people eat
too much
sodium
44% of the
sodium we
eat comes
from 10
types of
foods
Reducing
sodium by
1,200
mg/day can
save lives
Every 39
seconds an
adult dies of
heart attack,
stroke, or other
cardiovascular
disease
Nearly 1 in 2
people with
hypertension
doesn't have it
under control
Image adapted from CDC Vital Signs Fact
Sheet, Where’s the Sodium
Image adapted from CDC Vital Signs Fact Sheet,
High Blood Pressure and Cholesterol
20. Effect of sodium intake on BP
Sodium intake is 1 of several dietary factors that BP↑
Sodium is the principal cation of the extracellular fluid
Sodium functions as the osmotic determinant in regulating
extracellular fluid volume and plasma volume
Sodium is stored in the blood and in the fluid surrounding the cells;
Absorbed Na+ remains in the extracellular
compartments & maintains BP in the normal range
Sodium affects BP by changing blood volume
↑ sodium intake = blood volume = blood pressure↑ ↑
Sodium = blood volume = blood pressure↓ ↓ ↓
21. Effect of sodium intake on BP
In most individuals blood pressure is reduced within days
to weeks of reducing sodium intake
Average blood pressure was reduced by 22.7/9.1 mm
Hg in patients with resistant hypertension when switched
from a high to low sodium diet
Patients may be able to lower the required dose of blood
pressure medicines through ↓ sodium intake
Patients with normotension or prehypertension may ↓ or
prolong their risk for developing hypertension through ↓
sodium.
22. DASH Sodium Trials
Dietary Approaches to Stop Hypertension (DASH
Sodium Trial)
DASH diet and 3 levels of sodium intake –
1. 1,150 mg,
2. 2,300 mg, and
3. 3,450 mg
DASH diet at the low level of sodium SBP by 7.1 mg Hg↓
• Participants with HTN experienced a BP of 11.5 mm Hg↓
Actual average daily sodium intake is >3,300 mg/day
↓ sodium intake to 2,300 mg/day could ↓ cases of hypertension by
11 million & Gain 312,000 Quality Adjusted Life Years (QALYs)
↓ sodium intake to 1,500 mg/day may ↓ cases of hypertension by
16 million & Gain 459,000 Quality Adjusted Life Years (QALYs)
23. Sources of sodium
Mattes RD, et al. Relative
contributions of dietary
sodium sources. J AM Coll
Nutr 1991;10:383–393.
25. Factors affecting choice of antihypertensive
drug
1. The cardiovascular risk profile of the patient
2. Coexisting disorders / risk factors
3. Target organ damage
4. Interactions with other drugs used for concomitant
conditions
5. Tolerability of the drug
6. Cost of the therapy
26. Special Populations
Minorities
Genetically predisposed patients with increased rate of
conversion from pre-hypertension to hypertension
Over age 80
Significant benefits from treatment
May be more sensitive to medication side effects or
drug interactions due to an increased number of
medications taken
Selassie A, et al. Progression is accelerated from prehypertension to hypertension in blacks. Hypertension. 2011;
58:579-587.
27. BP Treatment in the very elderly, i.e. aged over
80yrs
New evidence suggests that BP lowering reduces the
risk of stroke, heart failure and death in people aged
over 80yrs;
Offer people aged >80yrs same treatment as people
aged >55yrs, taking account of co-morbidities;
Initiate therapy in people aged > 80yrs at stage 2
hypertension;
Treat to <150/90mm Hg.
28. Step 1 Treatment Recommendations
To people aged < 55 years, step 1 antihypertensive
treatment is started with an ACE inhibitor or a low cost
ARB. If an ACE inhibitor is used and not tolerated, offer
an ARB. [new 2011]
Do not combine an ACE inhibitor with an ARB to treat
hypertension. [new 2011]
To people aged > 55 years, step 1 antihypertensive
treatment is started with a CCB.
If a CCB is not suitable, for example due to oedema or intolerance,
or if there is evidence of heart failure, or a high risk of heart failure,
offer a thiazide-like diuretic . [new 2011]
29. Why is a CCB preferred to Diuretic?
CCB (usually amlodipine) = the most cost-effective
treatment option for treating BP unless the patient↑
had CCF or high risk of developing it – i.e. older patient
≥75yrs;
CCB is metabolically neutral – easy to use;
CCB is best at reducing BP variability
BP variability is an independent predictor of clinical outcomes -
especially stroke;
30. Why is a BB not preferred as 1st choice?
These days, Beta-blockers are not a preferred initial
therapy for hypertension but beta-blockers may be
considered in younger people, particularly:
Those with an intolerance or contraindication to ACE inhibitors
and ARBs, or
Women of child-bearing potential or
People with evidence of increased sympathetic drive. [2006]
If therapy is initiated with a beta-blocker and a second
drug is required, add a CCB rather than a thiazide-like
diuretic to reduce the person’s risk of developing
diabetes. [2006]
31. Step 2 Treatment Recommendations
If step 2 antihypertensive treatment is required, offer a
CCB in combination with either an ACE Inhibitor or an
ARB.
If a CCB is not suitable, for example because of oedema or
intolerance, or if there is evidence of heart failure or a high risk of
heart failure, offer a thiazide-like diuretic [new 2011]
Why?
At step 2, the combination of A + CCB is seen as superior to A + D
in clinical outcomes↓ .
32. Step 3 Treatment Recommendations
Before considering step 3 treatment, review
medication to ensure step 2 treatment is at optimal or
best tolerated doses. [new 2011]
If treatment with three drugs is required, the
combination of ACE inhibitor or an ARB + CCB +
thiazide-like diuretic should be used. [2006]
33. Step 4 - RESISTANT HYPERTENSION
When Hypertension is not controlled using a
combination of 3 antihypertensive drug classes &
remains higher than 140/90 mmHg with the optimal or
best tolerated doses of an ACE inhibitor or ARB + CCB +
diuretic, it is known as resistant hypertension
Study from Colorado Kaiser Permanente, found that 1.9% of
patients (1 in every 50 patients) with incident hypertension who
were on treatment; developed resistant hypertension within a
median of 1.5 years from initial treatment
• They found 16% of patients on 3 or more drugs continued to have
resistant hypertension
34. Step 4 - RESISTANT HYPERTENSION
Reasons include -
Non-compliance / adherence with medication
Fluid imbalance – renal failure
Hormonal imbalance - hyperkalaemia.
Therapy consists of adding a fourth antihypertensive
drug [new 2011]
If blood potassium levels
1. < than 4.5 mmol/l, consider further diuretic addition with low-
dose spironolactone (25 mg once daily) OR amiloride.
2. > than 4.5 mmol/l, consider therapy addition with a higher-dose
thiazide-like diuretic treatment.[new 2011]
Caution is required in patients with ↓ renal function
who are at higher risk of developing hyperkalaemia.
35. Step 4 - Treatment Recommendations
When using further diuretic therapy for resistant
hypertension at step 4, monitor monthly & repeat
thereafter as needed
blood Na+ & K+ and
renal function.
If further diuretic therapy for resistant hypertension at
step 4 is not tolerated, contraindicated or ineffective;
Consider an alpha- or beta-blocker. [new 2011]
If blood pressure remains uncontrolled with the optimal
or maximum tolerated doses of 4 drugs,
Seek expert advice if it has not yet been obtained.[new 2011]
36. Summary - Antihypertensive Drug Treatment
Aged <55yrsAged <55yrs Aged ≥55yrsAged ≥55yrs
Step 1 AA C*C*
A + C*A + C*
A + C* + DA + C* + D
A + C* + D + Further DiureticA + C* + D + Further Diuretic++
Consider specialist AdviceConsider specialist Advice
Step 2
Step 3
Step 4
Resistant
Hypertension
A = ACEi or ARB
C = CCB
D = Thiazide-like diuretic
C* = CCB preferred but
D is an alternative in
people intolerant of C or
at high risk of heart
failure
Further Diuretic:
Consider low dose
spironolactine or higher
dose thiazide
38. Proven improvement support
To improve compliance!
Combipills
Weekly / monthly packs /
combipacks
Range to tailor make fit
decisions
Strengths to tailor make fit
decisions
Easy to recall brand names
Enhanced product appeal
To improve care!
Alerts
Follow up Reminders
Templates for management
Built-in access to reporting
Report monitoring
Measures to enhance
implementation of quality
improvement initiatives
39. What happens if Hypertension isn’t controlled?
if Hypertension is not controlled, complications will
develop like -
1. Left ventricular hypertrophy (LVH)
2. Heart failure
3. Chronic kidney failure
4. Stroke (cerebral hemorrhage)
5. Vascular dementia
6. Retinopathy
41. Hypertension in special conditions
HTN in Young - Causes
HTN in elderly - Difference
HTN and Pregnancy - Cautions
HTN and Diabetes - Proteinurea
HTN and Renal Failure – Drug dosing
Hypertensive Emergencies - Urgency, Emergency
50. Microalbuminuria
• Microalbuminuria – what is it?
• The term microalbuminuria refers to a level
of urinary albumin excretion, commonly
defined as being between 30 and 299 mg
albumin per day and below the sensitivity
threshold of conventional dipsticks.
• It is usually detected by measuring the
albumin-creatinine ratio, either in a spot
urine sample or in a timed urine collection.
51. Microalbuminuria
• Microalbuminuria – why is it important?
• Microalbuminuria is considered the earliest
detectable stage of diabetic nephropathy
– This finding should alert the clinician to signs
of vascular disease at other sites in the body
in addition to the kidney.
– This stage is potentially reversible with
prompt but correct intervention.
52. Microalbuminuria
• Microalbuminuria is an indicator of ↓ renal
function and an accepted risk marker for
cardiovascular events and mortality
• Coexistence of type 2 diabetes and arterial
hypertension significantly risk of cardio-↑
renal disease & development of CV events,
to potentially mortality.↑
• This has led to the recommendation of use
of albuminuria as a therapeutic target.
53. Microalbuminuria
• Most antihypertensive
treatment trials [but not
all] —have shown that
in patients with type 2
diabetes, a reduction in
microalbuminuria was
consistently associated
with evidence of renal
protection.
Annual risk of cardiovascular (CV)
death in patients with
type 2 diabetes mellitus and different
degrees of nephropathy in
the UKPDS (United Kingdom
Prospective Diabetes Study).
54. Microalbuminuria
• Microalbuminuria – why is antihypertensive
choice important?
• Antihypertensive drugs or combinations
differ in their ability to prevent major renal
and cardiovascular events, even if they
produce similar reductions in BP.
• Adding further antihypertensives may not
improve renal & mortality outcomes even if
it produces further ↓ in BP.
56. Microalbuminuria
• Renin-angiotensin-aldosterone system
(RAAS) Overactivity is known to cause
deterioration of renal function in patients
with diabetic nephropathy.
• Increases in microalbuminuria are ↓ by BP
reduction using inhibitors of the RAAS.
• ACEIs are medication of choice in reducing
microalbuminuria in diabetic hypertensives.
57. Microalbuminuria
• Studies with telmisartan clearly show that
blocking of RAAS in patient with type II
diabetes mellitus
1. Reduces the risk of progression of
microalbuminuria to overt proteinuria and
2. may even revert back to normoalbuminuria.
59. Important Hypertension Trials
• SHEP (Systolic Hypertension in the Elderly Program)
– In persons aged 60 years and over with isolated systolic hypertension, antihypertensive stepped-care drug
treatment with low-dose chlorthalidone as step 1 medication reduced the incidence of total stroke by 36%
• ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial)
– The mean systolic blood pressure was 4mm Hg higher in blacks and 2 mm Hg higher in non-blacks in the lisinopril
group than in the chlorthalidone group. Blood pressure control was 8-13% better in the chlorthalidone group than
in the lisinopril group for blacks. Although in the trial overall the chlorthalidone group was better controlled than
the lisinopril group, this difference between the two groups among blacks is quite striking.
• MRFIT (Multiple Risk Factor Intervention Trial)
– Changed protocol in clinics using primarily HCTZ to chlorthalidone due in part to an a higher trend in mortality in
clinics using predominantly hydrochlorothiazide. Changing to chlorthalidone was associated with a trend toward
better outcomes.
• TROPHY (Trial of Preventing Hypertension)
– Found that it is possible to prevent or delay the onset of clinical hypertension in people with blood pressure that
falls within the "prehypertension" category
60. Important Hypertension Trials
• TOHP (Trials of Hypertension Prevention)
– Sodium reduction, previously shown to lower blood pressure, may also
reduce long term risk of cardiovascular events.
• TONE (Trial of Nonpharmacologic Interventions in the
Elderly)
– Reduced sodium intake and weight loss constitute a feasible, effective,
and safe nonpharmacologic therapy of hypertension in older persons.
• HYVET (Hypertension in the Very Elderly Trial)
– According to Timothy Gardner, M.D., President of the American Heart
Association: ‘The results of HYVET demonstrate that effective
antihypertensive treatment with indapamide (Natrilix SR) in persons
aged 80 years old or older, is beneficial in reducing the risk of
cardiovascular events, and thus extends the patient group in whom
prevention must be pursued.’
62. Take home message
The brand The application
Telmisartan Step 1 case, Intolerance to ACE
inhibitors
Telmisartan-H Step 2 case with slight pedal oedema
Telmisartan-AM Step 2, Type 2 diabetic nephropathy,
Diabetic microalbuminuria
Telmisartan-MT Hypertension in patients who have
IHD or Myocardial Infarction or heart
failure.
Telmisartan-AMH Step 3 case
Metoprolol H ?????
64. Metoprolol
• Metoprolol is a competitive, beta-1 selective
(cardioselective) adrenergic antagonist, which is
most similar to atenolol but more lipid soluble &
– Has good lipid solubility,
– Has membrane stabilizing activity (MSA), and
– Lacks intrinsic sympathomimetic activity (ISA)
Without ISA actvity With ISA actvity
65. Metoprolol
• Less lipid soluble than propranolol with relatively
short elimination half-life compared to other
cardioselective beta-blockers.
• In low doses, selectively blocks beta1-receptors in
the heart and vascular smooth muscle.
► But, selectivity for the beta1-receptor is lost at higher
doses.
• Consequences:
– ↓ in both resting /exercise heart rate & cardiac output,
– ↓ in both systolic and diastolic BP.
– ↓ of renin release from the kidneys.
– ↓ reflex orthostatic hypotension.
66. Metoprolol
• Metoprolol affects blood pressure via multiple
mechanisms.
1. Reduction in the heart rate and cardiac output at
rest and upon exercise,
2. Reduction of systolic blood pressure upon
exercise.
67. Metoprolol
• Absorption: Rapid and complete
• First pass metabolism: approx. 50%
• Plasma protein binding: 12%
• Half life: Ranges from 3-7 hours
• Metabolized in Liver & excreted via kidney
► IndicationsIndications
Hypertension, Angina pectoris, Heart failure
► ContraindicationsContraindications
Hypersensitivity & Severe bradycardia
68. Metoprolol
• Warnings and Precautions
– Use cautiously in bronchospastic disease
patients.
– Use cautiously in diabetic patients
– Use cautiously in patients with impaired
hepatic function.
69. Metoprolol H
• Combination of metropolol succinate [ short
acting is metoprolol tartarate]
The combo The application
Telmisartan-Mt Great value in HF cases with
hypertension with no fluid overload
Metoprolol-H Great value in HF cases with
hypertension and fluid overload
Editor's Notes
This module provides an overview of strategies to control hypertension
Effects of Systolic and Diastolic Blood Pressures on CHD Mortality: MRFIT
The importance of systolic blood pressure as a risk factor for coronary heart disease (CHD) is highlighted by the results of observational studies such as the one whose results are illustrated on this slide.
An analysis of the 316,099 white men between the ages of 35 and 57 years who were screened between 1973 and 1975 for the Multiple Risk Factor Intervention Trial (MRFIT) assessed the influence of blood pressure and other risk factors on death due to CHD over a mean follow-up of 12 years. These men indicated that they had not been previously hospitalized for a heart attack or were not taking medication for diabetes.
A strong risk gradient was evident for systolic blood pressure for each category of diastolic blood pressure. As you can see, systolic blood pressure was a stronger predictor of CHD death than was diastolic blood pressure. While the increase in risk for CHD death was evident as systolic blood pressure increased at each and every chosen level of diastolic blood pressure, the independent effect of increasing diastolic blood pressure at any given level of systolic blood pressure was very little, if any. The highest risk was seen among men with the highest systolic blood pressure and the lowest diastolic blood pressure.
Reference:
Neaton JD, Wentworth D, for the Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152:56-64.
Slide downloaded from http://www.hypertensiononline.org/slides2/slide01.cfm?q=MRFIT
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor Intervention Trial
This study by Klag et al. (1997) examined the incidence of end-stage renal disease (ESRD), stratified by systolic blood pressure, among the 322,544 men from the original cohort of the Multiple Risk Factor Intervention Trial (MRFIT) who were prospectively followed for an average of 16 years. As depicted in this slide, the incidence of ESRD increased over time in both white and black men as systolic blood pressure increased, even within a range of blood pressures below those considered to be hypertensive. These data also dramatically illustrate the 2- to 4-fold higher incidence of ESRD among black men when compared to white men within any systolic blood pressure category.
Reference:
Klag MJ, Whelton PK, Randall BL, Neaton JD, Brancati FL, Stamler J. End-stage renal disease in African-American and white men: 16-year MRFIT findings. JAMA. 1997;277:1293-1298.
Slide downloaded from http://www.hypertensiononline.org/slides2/slide01.cfm?q=MRFIT
Risk of Stroke Death According to Blood Pressure (mm Hg): MRFIT
The Multiple Risk Factor Intervention Trial (MRFIT), which enrolled 347,978 men between the ages of 35 and 57 years who were initially screened from 1973 to 1975 and then followed for major fatal outcomes, permits a close look at the relationship of blood pressure to stroke mortality. During 11.6 years of follow-up, there were 733 stroke-related deaths, representing an 8-fold gradient of risk across systolic blood pressure deciles and a 4-fold risk across diastolic blood pressure deciles. Statistical significance was found between systolic blood pressure and the relative risk of stroke for the 4th and 6th deciles (P &lt; 0.01) and for the 7th, 8th, 9th, and 10th deciles (P &lt; 0.001), and between diastolic blood pressure and the relative risk of stroke for the 7th, 8th, and 9th deciles (P &lt; 0.01) and for the 10th decile (P &lt; 0.001) after the relative risk was adjusted by proportional hazards regression for age, race, serum cholesterol, cigarettes smoked per day, use of diabetes medication, and income.
Aside from the marked gradient in stroke risk with increasing systolic blood pressure, you should note that stroke risk is elevated among those with pre-hypertension as well as those with hypertension.
References:
He J, Whelton PK. Elevated systolic blood pressure and risk of cardiovascular and renal disease: overview of evidence from observational epidemiologic studies and randomized controlled trials. Am Heart J. 1999;138(Pt 2):211-219.
Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks: US population data. Arch Intern Med. 1993;153:598-615.
Slide downloaded from http://www.hypertensiononline.org/slides2/slide01.cfm?q=MRFIT
Providers play a pivotal role in helping their patients reduce sodium intake. Importantly, patients may be able to lower the required dose of blood pressure medicines through reduced sodium intake. Even patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction.
Some things you can do in your practice to support sodium reduction include referring your patients to a registered dietitian for counseling. Other efforts include providing patient education during routine BP screenings on the importance of sodium reduction in their diet, even if their blood pressure reading is within the normal range.
CDC has developed a downloadable resource: Reducing Sodium in Your Diet to Help Control Your Blood Pressure to assist with educating your patients on sodium reduction. This one page handout offers tips for patients on how to successfully reduce sodium intake. Counseling that can be offered in your practices includes
Advising consumption of fresh fruits and vegetables, frozen fruits and vegetables without sauce, and no salt added canned vegetables.
Advising that patients limit processed foods high in sodium.
Finally as public health professionals consider opportunities for nutrition standards in your work environment, we can set a good example by
Choosing to purchase health options and talking to our grocers about stocking lower sodium choices
Comparing and choosing foods with lower sodium content
Asking for lower sodium options at restaurants
And eating fresh fruits and vegetables and frozen fruit and vegetables with no sauce
For patients and people who need more information on lowering their sodium the DASH eating plan is a good resource.
A meta-analysis of multiple cohort studies from the US such as we saw on the last two slides, and from the Asia-Pacific region, reinforced the tremendous benefit of lowering blood pressure in preventing stroke and MI at the patient level.
A 10mmHg lower systolic blood pressure (SBP) – or 5mmHg lower diastolic blood pressure (DBP) – is associated with an approximately 20–25% lower risk of coronary heart disease (CHD) and an approximately 40% lower risk of stroke.
As practitioners, you have a great opportunity to reduce stroke and coronary heart disease.
A comprehensive approach to hypertension control includes focusing clinical interventions for those at high risk; patient-level interventions, focusing on lifestyle advice for all patients regardless of their level of risk or age; and also population-based strategies like sodium consumption reduction which we will discuss in more detail later on.
First, we will look at some of the epidemiology of hypertension to understand the magnitude of the problem from the public health perspective.
First, we will look at some of the epidemiology of hypertension to understand the magnitude of the problem from the public health perspective.
A healthy lifestyle should begin in childhood and while JNC VII recommends these interventions for those with pre-hypertension and hypertension, they are highly beneficial for all.
JNC VII recommended therapeutic lifestyle change for most people with pre-hypertension as well as for those with hypertension.
This includes weight reduction,
adherence to the DASH diet – Dietary Approaches to Stop Hypertension. DASH provides various calorie levels of a well balanced diet with low-sodium foods, and can be tailored for those who are overweight as well. We will talk more about the DASH diet a little later on.
dietary sodium reduction – which we will get to later
physical activity – on most days,
and moderate alcohol consumption.
A comprehensive approach to hypertension control includes focusing clinical interventions for those at high risk; patient-level interventions, focusing on lifestyle advice for all patients regardless of their level of risk or age; and also population-based strategies like sodium consumption reduction which we will discuss in more detail later on.
When looking at the Dietary Approaches to Stop Hypertension (DASH) Trial and the DASH Sodium Trial, we see that improving dietary patterns can help reduce blood pressure, but greater effects are seen when an improvement in dietary pattern is coupled with sodium reduction.
The DASH trial assessed the effects of three diets – typical American diet, fruits and vegetable diet, and a diet rich in fruits and vegetables and low fat dairy, and reduced in saturated fat, total fat, and cholesterol. All diets provided ~ 3,000 mg sodium per day. The combination diet (DASH diet) produced the largest blood pressure reduction after 8 weeks – an average ↓ of 5.5 / 3.0 mm Hg. Participants with hypertension experienced an average blood pressure ↓ of 11.4 / 5.5 mm Hg. The nutrient composition of the control diet was typical of the diets of a substantial number of Americans. The potassium, magnesium, and calcium levels were close to the 25th percentile of U.S. consumption, and the macronutrient profile and fiber content corresponded to average consumption. The fruits-and-vegetables diet provided potassium and magnesium at levels close to the 75th percentile of U.S. consumption, along with high amounts of fiber. This diet provided more fruits and vegetables and fewer snacks and sweets than the control diet but was otherwise similar to it. The combination diet was rich in fruits, vegetables, and low-fat dairy foods and had reduced amounts of saturated fat, total fat, and cholesterol. This diet provided potassium, magnesium, and calcium at levels close to the 75th percentile of U.S. consumption, along with high amounts of fiber and protein. The sodium content of each diet was similar — approximately 3 g per day.
The DASH sodium trial assessed the impact of the DASH eating pattern with three levels of sodium intake - 1,150 mg, 2,300 mg, and 3,450 mg. Greater blood pressure reductions were seen when the DASH diet was coupled with reduced sodium compared to the DASH diet alone. The DASH diet and a low level of sodium ↓ SBP by 7.1 mg Hg. Participants with HTN experienced a BP ↓ of 11.5 mm Hg.
Providers play a pivotal role in helping their patients reduce sodium intake. Importantly, patients may be able to lower the required dose of blood pressure medicines through reduced sodium intake. Even patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction.
Some things you can do in your practice to support sodium reduction include referring your patients to a registered dietitian for counseling. Other efforts include providing patient education during routine BP screenings on the importance of sodium reduction in their diet, even if their blood pressure reading is within the normal range.
CDC has developed a downloadable resource: Reducing Sodium in Your Diet to Help Control Your Blood Pressure to assist with educating your patients on sodium reduction. This one page handout offers tips for patients on how to successfully reduce sodium intake. Counseling that can be offered in your practices includes
Advising consumption of fresh fruits and vegetables, frozen fruits and vegetables without sauce, and no salt added canned vegetables.
Advising that patients limit processed foods high in sodium.
Finally as public health professionals consider opportunities for nutrition standards in your work environment, we can set a good example by
Choosing to purchase health options and talking to our grocers about stocking lower sodium choices
Comparing and choosing foods with lower sodium content
Asking for lower sodium options at restaurants
And eating fresh fruits and vegetables and frozen fruit and vegetables with no sauce
For patients and people who need more information on lowering their sodium the DASH eating plan is a good resource.
Sodium intake is one of several dietary factors that contribute to increased blood pressure. Of all the dietary factors impacting blood pressure, sodium intake is one not under our control given that the majority of sodium has already been added to packaged and processed food.
Even though currently recommended thresholds for initiation of drug therapy are 140 mm Hg (systolic) and 90 mm Hg (diastolic) for uncomplicated hypertension (Chobanian et al., 2003), these thresholds are operational and do not correspond to a change point in the relationship between blood pressure and cardiovascular disease (DRI).
Sodium reduction benefits those with normortension, prehypertension, and hypertension. Vascular mortality increases throughout the range of blood pressures beginning at 115 mm Hg.
People with resistant hypertension may see even greater benefits when sodium intake is reduced. When switched from a high (5700 mg) to low (1150 mg) sodium diet an average blood pressure reduction of 22.7/9.1 mm Hg was seen.
In most individuals blood pressure is reduced within days to weeks of reducing sodium intake.
When looking at the Dietary Approaches to Stop Hypertension (DASH) Trial and the DASH Sodium Trial, we see that improving dietary patterns can help reduce blood pressure, but greater effects are seen when an improvement in dietary pattern is coupled with sodium reduction.
The DASH trial assessed the effects of three diets – typical American diet, fruits and vegetable diet, and a diet rich in fruits and vegetables and low fat dairy, and reduced in saturated fat, total fat, and cholesterol. All diets provided ~ 3,000 mg sodium per day. The combination diet (DASH diet) produced the largest blood pressure reduction after 8 weeks – an average ↓ of 5.5 / 3.0 mm Hg. Participants with hypertension experienced an average blood pressure ↓ of 11.4 / 5.5 mm Hg. The nutrient composition of the control diet was typical of the diets of a substantial number of Americans. The potassium, magnesium, and calcium levels were close to the 25th percentile of U.S. consumption, and the macronutrient profile and fiber content corresponded to average consumption. The fruits-and-vegetables diet provided potassium and magnesium at levels close to the 75th percentile of U.S. consumption, along with high amounts of fiber. This diet provided more fruits and vegetables and fewer snacks and sweets than the control diet but was otherwise similar to it. The combination diet was rich in fruits, vegetables, and low-fat dairy foods and had reduced amounts of saturated fat, total fat, and cholesterol. This diet provided potassium, magnesium, and calcium at levels close to the 75th percentile of U.S. consumption, along with high amounts of fiber and protein. The sodium content of each diet was similar — approximately 3 g per day.
The DASH sodium trial assessed the impact of the DASH eating pattern with three levels of sodium intake - 1,150 mg, 2,300 mg, and 3,450 mg. Greater blood pressure reductions were seen when the DASH diet was coupled with reduced sodium compared to the DASH diet alone. The DASH diet and a low level of sodium ↓ SBP by 7.1 mg Hg. Participants with HTN experienced a BP ↓ of 11.5 mm Hg.
It can be a challenge to reduce sodium intake because, most of the sodium in our diet is not added at the table. This chart shows sources of sodium in our diets. The orange piece of the pie represents sodium from processed and restaurant foods. More than 75% of the sodium in our food is already there and mostly invisible in processed and restaurant foods. Only 12 percent is naturally occurring and only about 11% is added in cooking and at the table.
Other populations that present challenges in hypertension control include minorities who have an increased rate of conversion from pre-hypertension (systolic 120-139 or diastolic 80-89) to hypertensive, and elderly patients who may be more sensitive to medication side effects or drug interactions due to an increased number of medications taken.
A recent study from the Colorado Kaiser Permanente found that 1 in every 50 patients with incident hypertension who was started on treatment developed resistant hypertension within a median of 1.5 years from initial treatment. With over 60 million adults in the US having hypertension this represents a significant number of patients developing resistant hypertension each year.
This study found 16% of patients on 3 or more drugs continued to have resistant hypertension.
You may already be using clinical decision support through electronic medical records. There are many examples of reminder systems that provide patient reminders to come in for a blood pressure check, and systems that allow you to create a report on the % of your patients that are in control, and reminders within your health system that alert you when your patient is seen anywhere in the system and had their blood pressure measured whether it was elevated.
Does your system allow you to quickly produce a report on which patients are uncontrolled? Or, who have pre-hypertension?
Can you rapidly identify drug classes prescribed for those that are poorly controlled? Does the system allow for other ways to drill-down on patients who aren’t controlled?
Does your system not only have pop-up alerts for patients with uncontrolled blood pressure, but does it also pop-up recommended guidelines?
Do you use a hypertension template for workup and management?
Do you use your system to implement small tests of change in your patient processes to manage hypertension in your patient population? Using a simple Plan-Do-Study-Act or PDSA cycle, you can implement small process changes in your practice and rapidly follow your progress with hypertension control over time to see if the change had an impact.
Do you have a regular schedule for reviewing the hypertension status of your patients?
A recent study from Duke University looked at hypertension control among their staff cardiologists. They found rates of sub-optimal BP control by this group ranged from 16% to 44% among 47 cardiologists. They also found 2/3 of uncontrolled patients were eligible for a medication change. Yet, of those eligible for a medication change, no intervention was documented in 38%. This not only points out that hypertension control among your patient panel is challenging, but it also points out the need for a QI intervention and develop an understanding of the role that physician inertia plays.
Hypertension causes target organ damage in many organ systems leading to left ventricular hypertrophy, heart failure, chronic kidney failure, stroke, vascular dementia, and retinopathy. A few examples of the risk for target organ damage are seen in these next few slides from the MRFIT study – Multiple Risk factor Intervention Trial.
Hypertension confers a 2 to 3-fold increased risk of heart failure and an 8-fold risk of stroke.
A recent study found that well-controlled patients were 37% less likely to develop LVH and 50% less likely to experience a cardiovascular event or stroke. (Chobanian AV. Impact of nonadherence to antihypertensive therapy. Circulation. 2009, 120:1558-1560. )
Hypertension is responsible for about 25-30% of chronic kidney failure, and hypertension is the leading cause of vascular dementia, causing both micro-infarcts and micro-hemorrhages. Vascular dementia is largely preventable.
The presence of hypertensive retinopathy greatly increases one’s risk of having a stroke, and this increased risk is independent of other risk factors.
These clinical trials on this slide and the next slide have been important in shaping the current recommendations for hypertension control.
JNC VIII is once again performing a comprehensive literature review to inform the recommendations that they will release in the upcoming months.
There are several types of initiatives and interventions that are relevant to the clinician to improve hypertension control.
There are several types of initiatives and interventions that are relevant to the clinician to improve hypertension control.
There are several types of initiatives and interventions that are relevant to the clinician to improve hypertension control.