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HYPERTENSION AROUND THE WORLD: STRATEGIES FOR CONTROLLING HYPERTENSION IN CHALLENGING SITUATIONS George Bakris, MD, F.A.S.N., FA.H.A., F.A.S.H. Professor of Medicine Director, ASH Comprehensive Hypertension Center University of Chicago Medicine Chicago, IL WHAT IS HYPERTENSION AND HOW IS IT DIFFERENT FROM HIGH BLOOD PRESSURE • Hypertension is a genetically predisposed sustained elevation in blood pressure that occurs usually between the 3rd-6th decade of life and not associated with a correctable hemodynamic or endocrine cause. • Elevated blood pressure is a periodic increase in pressure related to excess stress and resolves with relaxation or rest HIGH BLOOD PRESSURE IN THE UNITED STATES Having high blood pressure puts you at risk for heart disease and stroke, which are leading causes of death in the United States. About 75 million American adults (32%) have high blood pressure—that’s 1 in every 3 adults. About 1 in 3 American adults has prehypertension—blood pressure numbers that are higher than normal—but not yet in the high blood pressure range. Only about half (54%) of people with high blood pressure have their condition under control. High blood pressure was a primary or contributing cause of death for more than 410,000 Americans in 2014—that's more than 1,100 deaths each day. High blood pressure costs the nation $48.6 billion each year. This total includes the cost of health care services, medications to treat high blood pressure, and missed days of work. http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm-2016 http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm-2016 Prevalence of Hypertension by Gender, Race, and Survey U.S.: 1988-2006 Adapted from: Lloyd-Jones D, et al. Heart Disease and Stroke Statistics – 2009 Update. Circulation. 2009;119:e1-161. 5 Awareness, Treatment, and Control Rates by Race/Ethnicity % NHANES 2003–2004 Age adjusted. NHANES=National Health and Nutrition Examination Survey; hypertension=average BP ≥140/90 mm Hg, or patient was taking antihypertensive medications. Ong KL et al. Hypertension. 2007;49:69-75. Prevalence, Awareness, Treatment, for 1988–1994 & and Control 1999–2008 Egan B et.al. JAMA 2010;303:2043-2050 GLOBAL BURDEN OF HYPERTENSION* 2025 PROJECTION Year 2000 Year 2025 • 26.4% of world adult population had hypertension • 29.2% of world adult population will have hypertension • Total of 972 million adults • Highest prevalence is in established market economies (eg, North America, Europe) • Total of 1.56 billion adults (60% overall; 24% in developed nations, 80% in developing nations) • Highest prevalence will be in economically developing continents (e.g., Asia, Africa) will account for 75% of world’s hypertensive patients *As defined by a blood pressure >140/90 mm Hg; >130/80 mm Hg in diabetes and renal impairment Kearney PM et al. Lancet. 2005;365:217-223. DOES HYPERTENSION CAUSE ESRD? Age-Adjusted Rate of ESRD Per 100,000 Person-Years HTN Linked To Chronic Renal Disease Among 332,544 Men Screened for MRFIT 250 200 150 100 110 100-109 90-99 85-89 80-84 50 0 180 160-179 140-159 130-139 120-129 Systolic BP (mm Hg) Klag, MJ et al NEJM 1996;334:13-18 <120 <80 17 Year Follow-Up from VA Hypertension Clinics on ESRD H. M. Perry, Jr., et.al Early predictors of 15-year end-stage renal disease in hypertensive patients. Hypertension 25 (4 Pt 1):587-594, 1995. HYPERTENSION: THE 2 ND MOST COMMON CAUSE OF ESRD Primary Diagnosis For Patients Who Start Dialysis Other 10% 700 600 Glomerulonephritis 13% Hypertension 27% Diabetes 50.1% No of Patients Projection 95% CI 500 Number of Dialysis 400 Patients 300 200 520,240 281,355 243,524 100 0 R2 = 99.8% 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 United States Renal Data System. Annual data report. 2007. Risk of coronary events in people with CKD compared with diabetes: a population-level cohort study NHANES 2003−2006 48-month follow-up N=1,268,029 Tonelli M et al. Lancet 2012;380:807 PREVALENCE, AWARENESS, TREATMENT, AND CONTROL OF HYPERTENSION IN TOTAL KEEP COHORT BY CKD STAGE WITH140/90 MM HG AS THRESHOLD. (N=10,819) 100 90 80 Prevalence 70 % 60 50 Awareness 40 30 20 10 Treatment 10.9 12.7 20.3 21.3 Stage 1 (eGFR 90+) Stage 2 (eGFR 60-89) Stage 3 (eGFR 30-59) Stages 4+5 (eGFR <30) Sarafidis P et.al. Am J Med 2008;121:332-340 Control <130/80 mmHg) KEY POINTS TO ACHIEVE SUCCESS WITH BP GOAL • Need patient buy-in-best way is to educate as to disease and consequences with data • Need to see patient more frequently in beginning and encourage communication in the interim-Send a signal you care and disease is important PATIENT FACTORS OF COMPLIANCE • Influences on compliance involve • The patient, the disorder, the treatment, and the therapeutic environment • Study: Why patients discontinue treatment • 11% due to undesirable side effects • 25% thought their doctor told them to • 46% thought they were cured • 6% due to cost • Improving issues of compliance requires a multipronged approach 1. Mallion JM, Schmitt D. J Hypertens. 2001 Dec;19(12):2281-2283 2. Gallup G Jr, Cotugno HE. Am J Med. 1986; 81(suppl 6c): 20-24. 3. Whelton PK, et al. JAMA. 2002;288:1882-1888. BARRIERS TO ACHIEVING GOAL BLOOD PRESSURE Cultural norms Insufficient attention to health education by health care practitioners Lack of reimbursement for health education Lack of access to places for physical activity Larger servings of food in restaurants Lack of availability of healthy food choices in many schools, worksites, and restaurants • Lack of exercise programs in schools • Large amounts of sodium added to foods by the food industry and restaurants • Higher cost of food products that are lower in sodium and calories • • • • • • Whelton PK, et al. JAMA. 2002;288:1882-1888. AHA BP MEASUREMENT RECOMMENDATIONS 2005 Recommendations for Blood Pressure Measurement in Humans and Experimental Animals Part 1: Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research Hypertension 2005;45:142-161. Note: 19 pages! Systolic BP Differences Between Research Nurses During a 24 Month Study: Effect of Training (T). T 15 T T T Difference 21 mm Hg! Nurse 2 10 Nurse 4 Systolic Difference from Group Mean (mm Hg) 5 Nurse 3 0 12 -5 Difference 0 mm Hg! Nurse 1 -10 Month of Study Modified from Bruce et al, Observer bias in blood pressure studies. J. Hypertension 1988; 6: 375-380 BP RECOMMENDATIONS: • Multiple readings are needed for classification and to guide treatment. • Automated devices can take multiple readings but accuracy must be validated on each patient before they can be relied upon for individual accuracy. • Home BP readings predict risk better than office. • 24 hour BP measurements MAY be better at predicting risk. • Failure of BP to decline during sleep increases risk. • In obese adults and children appropriate cull selection is of paramount importance. NY Times: What’s wrong with this picture? Noisy Fan? Ear Pieces in wrong? Watching Manometer Room too cold? Stetho head at center of arm Eyes closed? Not at Using eye Cuff over Diaphragm level Clothes Tubing Stetho Observer’s +10/+5 too long. No Back Arms not flopping Lg Cuff above Support Resting on Manometer Cuff? Heart Level Table +10/+6 +2 mm / inch too far away Left arm Legs Crossed Arm not supported 100 mm Hg +10/+5 DIFFERENCE BETWEEN OFFICE AND TRIAL BP READINGS 1. 2. Routine Office BP measurements “automated office BP” (AOBP). Like the SPRINT method, AOBP measurement assesses BP after the patient has rested for 5 minutes, but adding to that a fully automated sequence of 5 readings over a 5-minute period, all with the patient resting quietly alone4. AOBP method corresponds more closely with mean daytime ambulatory BP (using ambulatory-awake monitoring) BP recorded in research studies using the standard BP measurement guidelines, which mandate a rest period prior to measurement (with or without AOBP), is on average 10/7 mmHg lower than BP measured in routine clinical practice . Bakris G Circulation, Sept 2016 LIFESTYLE MODIFICATION Modification Weight reduction Approximate SBP reduction (range) 5-20 mm Hg/10-kg weight loss Adopt DASH eating plan 8-14 mm Hg Dietary sodium reduction 2-8 mm Hg Physical activity 4-9 mm Hg Moderation of alcohol consumption 2-4 mm Hg Chobanian A et.al. JNC 7 Hypertension Dec 2003. SALT The INTERSALT Study 52 centers, averages for urinary Na+ excretion (reflects dietary Na+ intake) and blood pressure rise with age DASH-Sodium Results High Na+ – 150 mmol/d (3.3 g/d) Int Na+ – 100 mmol/d (2.5 g/day) Low Na+ – 50 mmol/d (1.5 g/day) Sacks FM et al. N Engl J Med 2001;344:6. Relationship between Salt Intake and Deaths from Strokes in 12 European countries. Perry IJ, Beevers DG. Salt intake and stroke: a possible direct effect. J Hum Hypertens 1992; 6: 23–25.; He FJ and MacGregor G. J Hum Hypertens 2009;23:363-384 Facts About Salt Intake in US • Average daily consumption is about 4500 mg/day. • Recommendation is 2400 mg. • Patients, in general have no concept about their salt intake http://www.americanheart.org/presenter.jhtml?identifier=4708 Changes in salt intake as measured by 24 h urinary sodium excretion (UNa), blood pressure, stroke and ischemic heart disease (IHD) mortality in England from 2003 to 2011. *p<0.05, ***p<0.001 for trend. He FJ et.al. BMJ Open 2014;4:e004549. doi:10.1136/ bmjopen-2013-004549 19 Year Survival Curve in Japan- The thick line indicates survival for the participants with the Reduced-Salt Japanese Diet Thick line-Reduced-Salt Japanese Diet Thin-line-Regular Japanese Diet Nakamura et.al. Br J Nutrition (2009);101:1696–1705 Daily Recommended Intake 1 teaspoon salt = 2,400 mg Sodium • ¼ teaspoon salt = 600 mg sodium • ½ teaspoon salt = 1,200 mg sodium • ¾ teaspoon salt = 1,800 mg sodium • 1 teaspoon salt = 2,400 mg sodium • 1 teaspoon baking soda = 1000 mg sodium • 1 teaspoon soy sauce = 1000 mg sodium Common Food Sources • • • • • • • • • • Table Salt Cured meats – deli meats, sausages, ham Baking soda- bicarbonate of soda Baking powder Antacids Snack foods – salted nuts, chips, pretzels, crackers Canned soups and bouillon cubes Cheeses Condiments – pickles, ketchup, mustard Seasonings and flavor enhancers – MSG • Ethnic Foods – Asian-( Chinese, Japanese) Saltiest Side Dishes 5. Saltiest Mexican Entrée Chili's Buffalo Chicken Fajitas-5,690 mg sodium, 1,730 calories 4. Saltiest Kids' Meal Così Kid's Pepperoni Pizza- 6,405 mg sodium, 1,901 calories 3. Saltiest Seafood Entrée Romano's Macaroni Grill Grilled Teriyaki Salmon- 6,590 mg sodium, 1,230 calories, 2. Saltiest Appetizer Papa John's Cheesesticks with Buffalo Sauce- 6,700 mg sodium, 2,605 calories, 1. The Saltiest Dish in America Romano's Macaroni Grill Chicken Portobello-7,300 mg sodium, 1,020 calories, 66 g fat http://health.msn.com/nutrition/articlepage.aspx?cp-documentid=100203758&page=3 THE AFRICAN-AMERICAN STUDY OF KIDNEY DISEASE AND HYPERTENSION For The AASK Study Group Investigators Wright JT Jr et.al. JAMA, 2002 Baseline Characteristics by Randomized Group Blood Pressure Goal Intervention Characteristic Age, mean (SE), y Female, No. (%) Blood Pressure, mean (SE), mm Hg Systolic Diastolic Mean arterial pressure GFR, mean (SE) mL/min per 1.73 m2 Serum creatinine, mean (SE), mg/dL Male Female Urine protein/creatinine ratio, mean (SE) Male Female Urine protein, mean (SE), g/24 h Male Female With urinary protein to creatinine ratio of at least 0.22, No. (%) Lower (n = 540) Usual (n = 554) 54.5 (10.9) 205 (38.0) 54.7 (10.4) 219 (39.5) 152 (25) 96 (15) 115 (17) 46.0 (12.9) 149 (23) 95 (14) 113 (15) 45.3 (133.2) 2.17 (0.75) 1.72 (0.55) 2.20 (0.77) 1.81 (0.57) 0.33 (0.50) 0.28 (0.48) 0.32 (0.52) 0.37 (0.58) 0.61 (1.01) 0.36 (0.63) 181 (33.5) 0.61 (1.08) 0.46 (0.81) 176 (31.8) Mean Arterial Pressure During Follow-up 130 Lower BP Goal (Achieved: 128/78) Usual BP Goal (Achieved: 141/85) MAP (mm Hg) 120 110 100 90 80 0 4 12 20 28 36 44 Follow-up Month Wright JT Jr. et.al. JAMA 2002 52 60 Composite Clinical Events: Declining GFR Event, ESRD or Death by BP Goal 40 Low (Achieved: 127/77) Usual BP ((Achieved: 140/85) % with Events 35 Low vs. Usual: RR=2%, (p=0.85) 30 25 20 15 10 5 0 0 6 12 18 24 30 36 42 48 54 60 Follow-Up Time (Months) RR=Risk Reduction Wright JT Jr, et.al. JAMA, 2002 Composite Clinical Events: Declining GFR Event, ESRD or Death by BP Goal Baseline UP/Cr 0.22 % with Events 70 Low (Achieved: 127/77) Usual BP ((Achieved: 140/85) 60 50 Low vs. Usual: RR= -31%, (p=0.11) 40 30 20 10 0 0 6 12 18 24 30 36 42 48 54 60 Follow-Up Time (Months) RR=Risk Reduction Composite Clinical Events: Declining GFR Event, ESRD or Death by BP Goal Baseline UP/Cr>0.22 % with Events 70 Low (Achieved: 127/77) Usual BP ((Achieved: 140/85) 60 50 Low vs. Usual: RR=17.8%, (p=0.18) 40 30 20 10 0 0 6 12 18 24 30 36 42 48 54 60 Follow-Up Time (Months) RR=Risk Reduction Blood Pressure Control Throughout AASK Cohort Period Only Trial Mixed Trial and Cohort Only Cohort 30 40 50 Composite 20 ESRD or Doubling SCr 10 Cumulative Incidence (%) 60 Cumulative Incidence of Events (Doubling SCr, ESRD, or Death) 0 Death 0 1 2 3 1064 986 5 6 7 8 9 10 490 331 176 Follow-up Time (Years) Appel L et al. Arch Intern Med 2008 Number at Risk: 1094 4 918 831 739 635 555 Comparison of clinic systolic BP (SBP) and nighttime ambulatory SBP N=617 Pogue V, et.al Hypertension2009;53(1):20-7. KNOW THE MOST EFFECTIVE AFFORDABLE AGENTS WITHIN THE CLASS * P-values reported are Bonferroni adjusted CERTAIN GENERICS HAVE DOCUMENTED POTENCY ISSUES • Angiotensin receptor blockersExample-Losartan-well documented impurities create side effects not associated with drug-branded agent does fine.pick another ARB-irbesartan tends to be much better. • Diuretics Mean Office SBP Change Week 2 Week 4 Week 6 HCTZ : -4.5±2.1 HCTZ : -7.6±2.8 HCTZ : -9.3±3.2 Chlor : -15.7±2.2 Chlor : -17.4±2.9 Chlor : -19.6±3.4 p=0.001* p=0.069* p=0.109* * P-values reported are Bonferroni adjusted Ernst ME, et al. Hypertension 2006; 47:352-358 Week 8 HCTZ : -10.8±3.5 Chlor : -17.1±3.7 p=0.842* FACTORS TO ENSURE BP REDUCTION AND CONTROL AMONG THOSE WITH LIMITED RESOURCES 1. Educate, which should lead to 2. Enpowerment, which should lead to 3. Enabling, which should lead to improved control