2014 Update on HypertensionFocus on the Hispanic Patient

Aldo J. Peixoto, MDProfessor of Medicine (Nephrology)Associate Chair for Ambulatory Services, Dept. of MedicineClinical Chief, Section of Nephrology

Educational Objectives

• To review the burden of HTN in the US with a focus on the Hispanic population

• To review the approach to treatment of hypertension in 2014

Hypertension Facts

• >1 billion people worldwide

• 30-45% of adults in developed countries

• Responsible for 13.5% of overall world deaths

– 12.9% low-income countries

– 17.6% high-income countries

• Responsible for 6% of overall world lost years due to disability from stroke or MI

Lawes et al. Lancet 2008

Each 20/10 mmHg increase in BP is associated with doubling of risk of death

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Meta-analysis of 61 observational studies>1,000,000 subjects12.7 million person-years

Lewington et al. Lancet 2002

Prevalence of HTN in the US according to age, sex and ethnicity

CDC, 2012 Report. MMWR 2012; 61: 703-9

There are differences in HTN rates among Hispanics according to country of origin

• US-born Hispanics:

– Mexicans: 19%

– Puerto-Ricans: 16%

– Cubans: 9%

– Central & South American (pooled): 9%

• Foreign-born Hispanics:

– Mexicans: 13%

– Puerto-Ricans: 32%

– Cubans: 29%

– Central & South American (pooled): 13%

Hypertension-related mortality (per 100,000) among different Hispanic subpopulations

From CDC. MMWR 2006; 55: 177

Awareness, Treatment and Control rates are lower among Hispanics in the US (NHANES 2003-2010)

Mexican Americans

Whites (NH)

Blacks (NH)

Awareness 69% 79% 81%

Treatment 59% 71% 72%

Control 36% 49% 43%

Stage 2 HTN (BP >160/100)

19% 12% 18%

CDC 2013 Report. MMWR 2013; 62: 351-5

Factors responsible for worse HTN control among Hispanics

• Limited access to care

• Communications barriers

• Less leisure time physical activity

• Dietary patterns

Perez. Clin Nurs Res 2011; 20: 347

Healthcare access and rates of awareness, treatment and control of HTN among Hispanics

Mexican Americans

Whites (NH)

Blacks (NH)

Health care coverage

65% 92% 83%

Routine place for health care

81% 95% 95%

> 2 times receiving health care in the past year

67% 82% 81%

CDC 2013 Report. MMWR 2013; 62: 351-5

Control is achievable when care is accessibleLessons from Hispanics in clinical trials

• BP Control in ALLHAT:

– 72% Hispanic Whites

– 69% Hispanic Blacks

– 67% Non-Hispanic Whites

– 59% Non-Hispanic Blacks

• BP Control in women in INVEST:

– 75% Hispanics (all)

– 68% Non-Hispanic Whites (P <0.001)

Guzman. Am J Cardiovasc Drugs 2012; 12: 165

Factors responsible for worse HTN control among Hispanics

• Limited access to care

• Communications barriers

– Patient teaching in Spanish improves health behaviors

– Preference for direct management in PC rather than referrals

• Less leisure time physical activity

• Dietary patternsPerez. Clin Nurs Res 2011; 20: 347

Factors responsible for worse HTN control among Hispanics

• Limited access to care

• Communications barriers

• Less leisure time physical activity

• Dietary patterns

Perez. Clin Nurs Res 2011; 20: 347

Factors responsible for worse HTN control among Hispanics

• Limited access to care

• Communications barriers

• Less leisure time physical activity

• Dietary patterns

– Excess salt intake

– “Salt titration”

– Cultural issues related to food sharing

Perez. Clin Nurs Res 2011; 20: 347

Summary #1

• HTN is less common among Hispanics than other groups

• Treatment and control rates are lower in Hispanics

• Limited access to care is a major issue

• Modifiable social/cultural factors need attention – important role of Hispanic healthcare providers

Management of Hypertension

What’s new in 2014?

Basic Clinical Evaluation of HTN

• Clinical history• Focused exam• Accurate BP• Focused laboratory testing:

– Basic metabolic panel– Ca– CBC– Urinalysis– EKG

Home BP Monitoring

• Identifies risk better than office BP• Improves treatment adherence• Improves BP control rates• Technique:

– Twice a day (AM and PM)– Duplicate readings– 7 days at a time

• Target: <130/85

Niiranen. Hypertension 2013; 61: 27ESH Practice Guidelines. J Hum Hypertens 2010; 24: 779

2013 JNC8 TargetsGeneral Population

• Age >60:

– BP <150/90 mmHg (A)

• Age <60:

– Diastolic BP <90 mmHg (A for ages 30-59; E for ages 18-29)

– Systolic BP <140 mmHg (E)

JNC8. JAMA 2013: epub ahead of print Dec 18

2013 JNC8 TargetsSpecial Groups

• Diabetes

– 140/90 mmHg (E)

• Chronic Kidney Disease

– 140/90 mmHg (E)

JNC8. JAMA 2013: epub ahead of print Dec 18

Lifestyle Modification

Modification Approximate SBP reduction(range)

Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

2013 JNC8Initial Drug Recommendations

• Non-Black, including DM:

– ACEi or ARB or Thiazide Diuretic or Calcium Channel Blocker (B)

• Black, including DM:

– Thiazide Diuretic or Calcium Channel Blocker (B for all, C for DM)

• CKD, regardless of race or DM status:

– ACEi or ARB (B)

JNC8. JAMA 2013: epub ahead of print Dec 18

Summary #2

• Out-of-office BP is an essential part of the management of HTN

• New BP targets are less strict, 140/90 mmHg for most, 150/90 mmHg acceptable for older patients

• Lifestyle changes and drug treatment remain the cornerstones of therapy

• Initial drug choices include ACEi, ARB, CCB and diuretics, not beta-blockers