What Is Hypertension

What Is Hypertension? JNC 7 Definitions Blood Pressure (mm Hg) Systolic <120 120-139 140-159 ≥160 Diastolic and <80 or 80-89 or 90-99 or ≥100 Normal Prehypertension Stage 1 hypertension Stage 2 hypertension Category Chobanian AV, et al. Hypertension 2003;42:1206-52 Cardiovascular Mortality Risk Doubles With Each 20-mm Hg SBP or 10-mmHg DBP Increment* 8 7 6 Cardiovascular mortality risk 5 4 3 2 1 0 115/75 135/85 155/95 175/105 8x 4x 2x SBP/DBP (mm Hg) *Individuals aged 40-69 years, starting at blood pressure 115/75 mm Hg. CV, cardiovascular; DBP, diastolic blood pressure; SBP, systolic blood pressure. Chobanian AV et al. JAMA. 2003;289(19):2560-2572. Lewington S et al. Lancet. 2002;360(9349):1903-1913. Prevalence of Hypertension Increases with Age: NHANES 1999-2000 Data Non-Hispanic White Non-Hispanic Black Mexican American Hypertension* Prevalence (%) 100 Hypertension* Prevalence (%) ≥60 100 80 60 40 20 0 80 60 40 20 0 18-39 40-59 18-39 40-59 ≥60 Men (age, years) Women (age, years) *Hypertension defined as a BP of ≥140/90 mm Hg or reported use of antihypertensives. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Hajjar I, Kotchen TA. JAMA. 2003;290:199-206. Increasing Prevalence of Hypertension: Rise From 1988 to 2000 (NHANES) % Increase (1988–1994 to 1999–2000) 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Non-Hispanic Whites Non-Hispanic Blacks Mexican Americans Men Women NHANES = National Health and Nutrition Examination Survey. Fields, LE et al. Hypertension. 2004;44:398-404. Ethnic/Racial Differences in Prevalence of Hypertension • Blacks have a higher prevalence and incidence of hypertension than whites. Most studies in the United Kingdom and the United States report a higher prevalence and lower awareness of hypertension in black people than in white people. • In Mexican-Americans, the prevalence and incidence of hypertension is similar to or lower than in whites. NHANES III reported an ageadjusted prevalence of hypertension at 20.6% in Mexican-Americans and 23.3% in non-Hispanic whites. Hypertension Prevalence by Ethnic/Minority Groups • Group HTN Prevalence • White 21.2% • Black/African-American 29.2% • Hispanic/Latino 19.6% • Asians 16.9% • Native Hawaiian/other Pacific Islander 20.7% • American Indians/Alaska Natives 25.4% American Heart Association Heart Disease and Stroke Statistics 2007 Contributing Factors: Social, Environmental, or Genetic? • Environmental factors ultimately related to race (e.g. socioeconomic disadvantage, less access to health care) play roles in causing and sustaining hypertension 1, 2 • Despite similar African heritage, Africans living in Africa or West Indies have much less hypertension than African Americans 3,4 • In rural Africa, hypertension prevalence is very low and blood pressure does not rise with age as it does in all ethnic groups in US 3 1 Cooper RS, Rotimi CN, Ward R. The puzzle of hypertension in African-Americans. Sci Am. 1999;280:56–62. 2 Geronimus AT, Bound J, Waidmann TA, et al. Excess mortality among blacks and whites in the United States. N Engl J Med. 1996;335(21):1552–1558. 3 Cooper R, Rotimi C, Ataman S, et al. The prevalence of hypertension in seven populations of west African origin. Am J Public Health. 1997;87:160–168. 4 Ordunez-Garcia PO, Espinosa-Brito AD, Cooper RS, et al. Hypertension in Cuba: evidence of a narrow black-white difference. J Hum Hypertens. 1998;12:111–116. BP Reductions as Small as 2 mm Hg Reduce Risk of CV Events by Up to 10%  Meta-analysis of 61 prospective, observational studies  1 million adults  12.7 million person-years 2 mm Hg decrease in mean SBP 7% reduction in risk of CHD mortality 10% reduction in risk of stroke mortality Prospective Studies Collaboration. Lancet. 2002;360:1903-1913. BPLTTC Meta-analysis: Stroke and CHD Stroke 1.50 1.25 1.00 0.75 0.50 CHD 1.50 0.25 -10 Relative Risk of CHD 1.25 1.00 0.75 0.50 -8 -6 -4 -2 0 2 4 0.25 -10 -8 -6 -4 -2 0 2 4 SBP Difference Between Randomized Groups (mm Hg) SBP Difference Between Randomized Groups (mm Hg) Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2003;362:1527-1535. JNC7 Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal BP <140/90 mm Hg for most <130/80 for those with diabetes or CKD Initial Drug Choices No Compelling Indications Stage 1 140-159/90-99 Diuretics for most; consider ACEI, ARB, B, CCB Stage 2 BP 160/100 2-drug combo for most (diuretic + ACEI, or ARB, or BB, or CCB) Compelling Indications Drug(s) for compelling indications + BP meds as needed Not at Goal BP Chobanian AV, et al. JAMA. 2003;289:2560-2572. Optimize dosages or add drugs until goal BP is achieved. Consider hypertension specialist consult. ACEI = ACE inhibitor CCB = calcium channel blocker ARB = angiotensin receptor blocker B = -blocker CKD = chronic kidney disease JNC 7 Compelling Indications Diuretic Heart failure Post-MI High CHD risk Diabetes Chronic kidney disease Recurrent stroke prevention AA = aldosterone antagonist Chobanian AV, et al. JAMA. 2003;289:2560-2572. βB     ACEI      ARB  CCB AA            AHA Perspective/Hypertension Management and BP Goals Summary of Main Recommendations Area of concern General CAD prevention BP Target (mm Hg) <140/90 Lifestyle † modification Yes Specific Drug Indications Any effective antihypertensive drug or combination‡ ACEI or ARB or CCB or thiazide or combination High CAD risk* <130/80 Yes Stable angina <130/80 Yes Β-blocker and ACEI or ARB UA/NSTEMI STEMI LVD <130/80 <130/80 <120/80 Yes Yes Yes Β-blocker and ACEI or ARB § Β-blocker and ACEI or ARB § ACEI or ARB and Β-blocker and aldo antagonist and thiazide or loop diuretic and hydral/nitrate (blacks) * diabetes, CKD, CAD or equivalent † weight loss if appropriate, healthy diet, exercise, smoking cessation and alcohol moderation ‡ evidence supports ACEI or ARB, CCB, or thiazide as first-line § if anterior MI is present, if HTN persists, if LVD or HF is present, if diabetic adapted from Rosendorff C, et al. Circulation 2007;115:published online Lifestyle Modification • Lose weight if overweight • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (ie, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100proof whiskey) per day or 0.5 (15 mL) ethanol per day for women and people of lighter weight • Increase aerobic activity (30-45 min most days of the week) • Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium) • Maintain adequate intake of dietary potassium (approximately 90 mmol/d) • Maintain adequate intake of dietary calcium and magnesium for general health • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health JNC VII recommendations.Chobanian AV, et al. JAMA. 2003;289:2560-2572. Lifestyle Modification Modification Weight reduction Approximate SBP reduction (range) 5-20 mmHg / 10 kg weight loss Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption 8-14 mmHg 2-8 mmHg 4-9 mmHg 2-4 mmHg Hypertension Increases With Obesity in Women—Especially After Age 45 Multivariate RR* for Hypertension† According to Weight Change 7 6 Multivariate Relative Risk 5 4 3 2 1 0 Loss ≥10 Age <45 Age 45–54 Age ≥55 Loss 5.0–9.9 Loss 2.1–4.9 Change ≤2.1 Gain 2.1–4.9 Gain 5.0–9.9 Gain Gain Gain 1.0–19.9 20.0–24.9 ≥25 Weight Change After 18 Years, kg *Adjusted for age, BMI at age 18 years, height, family history of myocardial infarction, parity, oral contraceptive use, menopausal status, postmenopausal use of hormones, and smoking. †>140/90 mmHg. Huang Z et al. Ann Intern Med. 1998;128:81–88. Reasons for Inadequate BP Control • Poor compliance to lifestyle modifications • Acceptance of inadequate control by physician • Difficulty achieving BP control with one agent/suboptimal regimens • BP goals are more aggressive than in previous years • Lack of compliance due to: – perceived side effects of antihypertensive medication(s) – frequency of dosing/multiple agents to attain control (Adapted from JNC VI. Arch Intern Med. 1997) Prevalence of Nonbiomedical Expectations in African-Americans (N = 93) Nonbiomedical Expectations Yes No Don’t Know Cure of hypertension Take medications for life Take medications only with symptoms Having at least one nonbiomedical expectation 38% 48% 23% 65% 51% 38% 67% 35% 85% 11% 14% 10% 0% 0% Having all three 15% nonbiomedical expectations Ogedegbe G. J Natl Med Assoc. 2004;96:442–449. The Gap Between Rates of Hypertension Awareness and Control 80 70 60 73 68 51 70 59 Patient Awareness Treatment 55 54 Adults, % 50 40 30 20 10 0 31 29 34 27 Control 10 NHANES II 1976–1980 NHANES III 1988–1991 NHANES III 1991–1994 1999–2000* *Computed by M. Wolz (unpublished data cited by Chobanian et al.) Adapted from Chobanian AV, et al. JAMA. 2003;289:2560-2572. Age-Adjusted Blood Pressure Control Rates in Different Groups Group HBP control 2003-04 • • • • • • Mexican-American men Mexican-American women Non-hispanic white men Non-hispanic white women Non-hispanic black men Non-hispanic black women 31.1% 24.6% 34.8% 41.8% 26.8% 30.3% Monotherapy for Hypertension Is Inadequate in ≈40–50% of Patients Patients With Response*, % 80 60 40 20 0 50% response Placebo (captopril) (diltiazem) Agonist (clonidine) ACEI CCB Alpha2 (atenolol) Beta Blocker Diuretic (HCTZ) Alpha1 Antagonist (prazosin) *Response=diastolic blood pressure (DBP) <90 mmHg at the end of titration period and having maintained a DBP of <95 mmHg for 1 year without drug tolerance. Mean baseline blood pressure=152/99 mmHg. Adapted from Materson BJ et al. Am J Hypertens. 1995;8:189–192. Blood Pressure Control Usually Requires Combination Therapy Vicious Cycle of Therapeutic Failure Inadequate Management of Blood Pressure in VA Hypertensive Population • Retrospective chart review of 800 hypertensive men followed over 2 years at 5 VA hospitals • Mean age = 65, Ave duration of HTN = 12 yrs • Approx 40% had BP≥ 160/90 mm Hg • Mean no of visits/year = 6.4 • Antihypertensive meds were increased at 6.7% of the HTN visits • More intensive therapy was associated with better BP control Berlowitz DR NEJM 1998;339:1957 In Clinical Practice, Most Patients Undertreated Suboptimal number of antihypertensive medications* 60 60 Patients 40 (%) 20 30 10 0 1 2 3 Antihypertensive medications (n) *Framingham Heart Study, N = 4919 treated patients Lloyd-Jones DM et al. JAMA. 2005;294:466-72. Efficacy of Various Antihypertensive Medications in and Out of the Stroke Belt Treatment Success,* % 100 80 60 40 20 0 Hydrochloro Atenolol -thiazide Captopril Diltiazem Clonidine Prazosin Hydrochloride Hydrochloride 81 77 65 47 58 39 21 57 66 41 42 49 Antihypertensive Medications for African American Patients Treatment Success,* % 100 80 60 40 20 0 Hydrochloro -thiazide Atenolol Captopril Diltiazem Clonidine Prazosin Hydrochloride Hydrochloride Outside the Stroke Belt Inside the Stroke Belt 62 30 70 68 64 55 66 65 76 55 63 67 Antihypertensive Medications for White Patients *One-year treatment success rates in controlling diastolic blood pressure. Cushman WC et al. Arch Intern Med. 2000;160:825–831. ALLHAT: SBP Changes in AfricanAmericans and Non-Black* Participants Chlorthalidone Study Year: 0 2 4 Amlodipine 2 4 Lisinopril 2 4 –2 Blood Pressure Response, mmHg –4 –6 –8 –10 –12 –14 –8.6 –10.2 –10.5 –12.3 –7.1 –8.8 –3.4 –6.8 –9.5 –12.0 –9.8 –12.3 Black Non-Black *White, Asian, Native American, and other (92% White). Adapted from Wright JT Jr. et al. JAMA. 2005;293:1595–1608. Relative Risk Reduction With Ramipril vs. Amlodipine Besylate: AASK RRR=38% P=0.005 0.08 Ramipril Amlodipine besylate RRR=44% P=0.01 0.07 0.06 Events 0.05 per person-yr 0.04 0.03 0.02 0.01 0 RRR=41% P=0.03 GFR, glomerular filtration rate; ESRD, end-stage renal disease. Agodoa LY et al. JAMA. 2001;285:2719-2728. GFR ESRD GFR, ESRD, or death RAAS Activity in African-Americans – an Apparent Paradox African-American hypertensive patients have  ↓Plasma renin activity  ↑Salt-sensitivity  ↓Pressure natriuresis response But also have  ↑Activation of intrarenal RAAS  ↑Renovasoconstriction  Impaired renal vascular response to Ang II and RAS blockage Price DA, Fisher ND, Curr Hypertens Rep. 2003;5:225-230 Pulse Pressure and the Incidence of Cardiovascular Disease • A cross-sectional prospective study by Benetos et.al of 19,083 patients 40-69 yo, pulse pressure alone was shown to be an independent predictor of cardiac risks judged by degree of cardiac hypertrophy Hypertension, vol. 30, p. 1410, 1997 VALUE: Outcome and SBP Differences at Specific Time Periods: Primary Endpoint Time Interval (months) Overall study 0–3 3–6 6–12 12–24 24–36 36–48 Study end D SBP mmHg 2.2 3.8 2.3 2.0 1.8 1.6 1.4 1.7 4.0 0.5 1.0 2.0 Favors amlodipine Favors valsartan Julius S et al. Lancet. June 2004;363. PRIMARY ENDPOINT Odds Ratios and 95% CIs Mortality From High Blood Pressure Higher in African-Americans Overall Mortality Rates From Causes Related to Hypertension, 2003* Mortality Rate, % 60 50 40 30 20 10 0 Male Female African American Male Female White 49.7 40.8 14.9 14.5 In hypertensive African-Americans, 30% and 20% of all deaths in men and women, respectively, may be due to high blood pressure. *High blood pressure listed as a primary or contributing cause of death. High blood pressure=systolic ≥140 mmHg or diastolic ≥90 mmHg, taking antihypertensive medicine, being told ≥2 times by a physician that you have high blood pressure. Adapted from Thom T et al. Circulation. 2006;113:e85–e151. Complications Related to Hypertension in African-American Patients • Compared with the general population, African-Americans have a higher rate of: – hypertension 40% – heart disease mortality 50% – obesity 70% – stroke mortality 80% – diabetes mellitus 100% – ESRD 320% ESRD, end-stage renal disease. American Heart Association. 2001 Heart and Stroke Statistical Update. Burt JL et al. Hypertension. 1995;25:305-313. JNC VI. Arch Intern Med. 1997;157:2413-2446. Complications of Hypertension: Target-Organ Damage Hypertension Hemorrhage, stroke LVH, CHD, CHF Peripheral vascular disease Renal failure CHD, coronary heart disease; CHF, congestive heart failure; LVH, left ventricular hypertrophy. JNC VI. Arch Intern Med. 1997;157:2413-2446. Hypertensive Target-Organ Disease: Assessment • Check fundi • EKG or echocardiography • Atherosclerotic plaque (x-ray or ultrasound evidence in carotid, iliac, or femoral arteries or aorta) • Fasting blood sugar or 2-hr Post-prandial – Hgb A1c – Microalbumin:creatinine ratio – serum creatinine Hypertensive Retinopathy Causes of Resistant Hypertension • • • • • Pseudoresistance Poor compliance Drug Interactions Underdosing Improper combinations • • • • • Obesity Excess Alcohol Volume Overload Sleep Apnea Secondary Hypertension Causes of Secondary Hypertension Coarctation of aorta Conn’s syndrome Pheochromacytoma Cushing syndrome Thyroid Disease Acromegaly Hyperparathyroidism Renal Artery Stenosis Renin tumor Glomerulonephritis DM nephrosclerosis Polycystic disease Collagen disease Chronic Pyelonephritis Drug Induced Stenotic renal artery Clues to Suggest Secondary Hypertension • Historical Clues • Resistance to >4 drug therapy • Young age of onset of HTN (teens, 20’s) • Sudden increase in BP • Episodes of extreme BP’s • Low potassium & muscle cramps • Women age 35-55 new onset • Daytime sleepiness, snoring, poor sleep habits • • • • • • • • Physical Exam Clues Abdominal bruit, reduced LE pulses Femoral bruit/ Renal bruit Unequal BP in extremities Reduced pulse in extremities Severe LE edema Wide pulse pressure & cardiac murmur Buffalo hump, striae, central obesity Enlarged thyroid Managing Hypertension in African-Americans • Most will require combination therapy when initial therapy fails • All antihypertensive classes, including RAAS agents, are associated with BP-lowering effects in African-Americans • Be vigilant in pursuit of BP goals as stated in ISHIB Guidelines RAAS=renin-angiotensin-aldosterone system Douglas JG et al. Arch Intern Med. 2003; 163:525-541 Consensus Statement: Management of High Blood Pressure in African-Americans Patient with elevated BP Uncomplicated hypertension Goal BP: <140/90 mm Hg Diabetes/nondiabetic renal disease with proteinuria >1 g/24 h* Goal BP: <130/80 mm Hg If BP <145/90 mm Hg, If BP 145/90 mm Hg, monotherapy or combination therapy combination therapy including a including a RAS RAS blocker§ blocker§ Not at BP goal? Intensify lifestyle changes AND If BP <155/100 mm Hg, If BP 155/100 mm Hg, monotherapy† combination therapy‡ Not at BP goal? Intensify lifestyle changes AND Add a 2nd agent from a Increase dose different class or or add a 3rd agent increase dose from a different class Add a 2nd agent from a different class or increase dose Increase dose or add a 3rd agent from a different class *Preferable BP goal for patients with renal disease with proteinuria >1 gm/24 h is <125/75 mm Hg. †Initiate monotherapy at recommended starting dose with an agent from any of the following classes: diuretics, beta blockers, CCBs, ACE inhibitors, ARBs ‡To achieve BP goals more expeditiously, initiate low-dose combination therapy with any of the following combinations: beta blocker/diuretic, ACE inhibitor/diuretic, ACE inhibitor/CCB, or ARB/diuretic. §Consider specific clinical indications when selecting agents. When Monotherapy is Not Enough… • JNC 7: If BP exceeds goal by 20/10 mmHg begin combination therapy • ISHIB Consensus Statement: If BP exceeds goal by 15/10 mmHg begin combination therapy The majority of patients will require combination therapy to achieve target BP. Effective combinations are: – beta blocker/diuretic – ACE inhibitor/diuretic – ACE inhibitor/CCB – ARB/diuretic Douglas JG et al. (ISHIB HAAWG) Arch Intern Med. 2003;163:525-541. Chobanian AV et al. (JNC 7) JAMA. 2003;289:2560–2572 Risk-Factor Clustering in Patients with Hypertension Framingham offspring (ages 18 to 74 years) with hypertension are likely to have additional risk factors Men 2 RFs 3 RFs 2 RFs Women 3 RFs 26% 19% 25% 22% 27% 17% 12% 4 RFs No Additional RFs ≥5 RFs 24% 20% 4 RFs 8% No Additional RFs ≥5 RFs RF = risk factor. Kannel WB. Am J Hypertens. 2000;13:3S-10S. Elevated SBP Increases CHD Risk, Amplified by Hypercholesterolemia Results from MRFIT 33.7 n = 202,620 Age-Adjusted CHD Death Rates Per 10,000 Person-Years 16.7 13.7 21 22.6 17.1 12.7 17.7 10.9 8.5 7.9 5 5.6 7.9 6 3.4 3.1 6.3 4.3 <182 5.5 12.3 8.3 9.6 5.9 12.2 245 221–244 203–220 182–202 Cholesterol Quintile, mg/dL SBP Quintile, mm Hg MRFIT = Multiple Risk Factor Intervention Trial. Neaton JD, et al. Arch Intern Med. 1992;152:56-64. Most Patients Diagnosed with Hypertension and Dyslipidemia Were Not at Both Goals In a managed care population, the vast majority of patients diagnosed with hypertension and dyslipidemia (n = 154,235) were not at both goals More than 90% were not at both goals Fewer than 10% were at both goals As the number of CV risk factors increased, the rate of goal attainment decreased Adapted from Pettitt D, et al. Poster presented at: 26th annual meeting of the Society of General Internal Medicine; 2003; Vancouver, Canada. Knowing is Not the Same as Doing Survey of 21 physicians and 270 associated patient visits Aware, Agree with JNC-VI? Satisfied with BP control Visits with SBP < 140 mm Hg Visits with SBP < 150 mm Hg 7% 61% 76% Physician Report 35% Physician Practice 60% 80% 100% 0% 20% 40% Oliveria et al, Arch Intern Med 2002;162:413-420