1 mark huffman, md, mph northwestern university feinberg school of medicine northwestern memorial...

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Mark Huffman, MD, MPHNorthwestern University Feinberg School of Medicine

Northwestern Memorial Hospital Healthy Transitions

21 November 2013

Blood Pressure Management & Cardiovascular Health

Blood Pressure Management & Cardiovascular Health

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• Normal vs. optimal blood pressure: does it make a difference?

• Raised blood pressure (hypertension) rates: Global, US, Cook County, and Chicago

• Diagnosis and evaluation of hypertension

• Management options: 2013 AHA/ACC/CDC guidelines

Blood Pressure Management & Cardiovascular Health

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• Normal vs. optimal blood pressure: does it make a difference?

• Raised blood pressure (hypertension) rates: Global, US, Cook County, and Chicago

• Diagnosis and evaluation of hypertension

• Management options: 2013 AHA/ACC/CDC guidelines

Normal vs. Optimal

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Q1: What is a normal blood pressure?

Q2: What is an optimal blood pressure?

Q3: What was FDR’s blood pressure in 1945?

Normal vs. Optimal

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Q1: What is a normal blood pressure?

“Normal” describes the bell-shaped distribution of a continuous measure, such as blood pressure within a population.

Blood Pressure Curves, US Women (2001-2008)

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Wright J, et al. NCHS 2011.

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Average US Blood Pressure, Men

Wright J, et al. NCHS 2011.

Average US Blood Pressure, Women

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Wright J, et al. NCHS 2011.

Observed SBP and Prevalence of BP Lowering Therapy (UK)

Wills AK, et al. PLoS Med 8(6): e1000440.

Men Women

Normal vs. Optimal

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Q1: What is a normal blood pressure?

Q2: What is an optimal blood pressure?

Q3: What was FDR’s blood pressure in 1945?

Normal vs. Optimal

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Q2: What is an optimal blood pressure?

“Optimal” describes the blood pressure that is associated with the greatest health outcomes, such as low rates of heart disease, strokes, or heart failure.

(What is it? And over what time period?)

Optimal Blood Pressure ~115/75

12Lewington S, et al. Lancet 2002;360: 1903–13.

Age-Dependent? U-shaped Curve

13Denardo S, et al. Am J Med 2010;123:719–26.

Normal vs. Optimal

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Q1: What is a normal blood pressure?

Q2: What is an optimal blood pressure?

Q3: What was FDR’s blood pressure in 1945?

Normal vs. Optimal

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Signs and Symptoms of Malignant Hypertension

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Evidence of end-organ damage:

• Blurred vision (eyes)• Headache (brain)• Chest pain (heart)• Shortness of breath, especially when lying down (heart)• Kidney damage (kidneys)

The rate of change in blood pressure tends to be more important than the absolute level due to the body’s ability to auto-regulate one’s blood pressure.

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Blood Pressure Management & Cardiovascular Health

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• Normal vs. optimal blood pressure: does it make a difference?

• Raised blood pressure (hypertension) rates: Global, US, Cook County, and Chicago

• Diagnosis and evaluation of hypertension

• Management options: 2013 AHA/ACC/CDC guidelines

Global Blood Pressure

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2008 global average adult blood pressureMen: 128.1 mmHg (126.7, 129.4)Women: 124.4 mmHg (123.0, 125.9)

Between 1980 and 2008, the average blood pressure decreased each decade by:

0.8 mmHg for men 1.0 mmHg for women

Danaei G, et al. Lancet 2011; 377: 568–77.

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Danaei G, et al. Lancet 2011; 377: 568–77.

US, Cook County, and Chicago Estimates of Hypertension:

Institute for Health Metrics & EvaluationChicago Health Atlas

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Blood Pressure Management & Cardiovascular Health

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• Normal vs. optimal blood pressure: does it make a difference?

• Raised blood pressure (hypertension) rates: Global, US, Cook County, and Chicago

• Diagnosis and evaluation of hypertension

• Management options: 2013 AHA/ACC/CDC guidelines

How is Hypertension Diagnosed?

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“The diagnosis of hypertension should be based on at least 3 different BP measurements, taken on 2 separate office visits to account for the natural variability of BP and other factors that can affect BP.

“To confirm the validity and reliability of the measurement, at least 2 measurements should be obtained once the patient is comfortable and settled for at least 5 minutes. BP should be measured in the sitting position with the back supported, feet on the floor, arm supported in the horizontal position, and the BP cuff at heart level.”

Aronow WS, et al. Circulation 2011; 123:2434-2506.

How is Hypertension Diagnosed?

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• Home blood pressure measurements are increasingly preferred as adjuncts to those taken in the doctor’s office.

• Automatic sphygmomanometers work well; Omron, upper arm cuffs are preferred ($45-$65 on amazon.com) and are often covered by insurance.

myamericanheart.org

How is Hypertension Evaluated?

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• Home blood pressure measurements are increasingly preferred as adjuncts to those taken in the doctor’s office.

• Check your BP right after you get up in the morning (consistency helps reduce the number of variables).

• On occasion, your doctor might ask you to wear a blood pressure cuff throughout an entire 24 hour period (ambulatory blood pressure monitoring) to check you blood pressure throughout the day.

• You can enter via MyChart to share with your blood pressure with your doctor.

How is Hypertension Evaluated?

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Blood Pressure Management & Cardiovascular Health

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• Normal vs. optimal blood pressure: does it make a difference?

• Raised blood pressure (hypertension) rates: Global, US, Cook County, and Chicago

• Diagnosis of and evaluation hypertension

• Management options: 2013 AHA/ACC/CDC guidelines

Meta-Analysis: SHEP, Syst-Eur, Syst-China

All Mortality

CVMortality

CVEvents Stroke CHD

% R

isk

Red

uctio

n

-17% -25% -32% -37% -25%

...and 50% reduction in CHF in SHEP!

Staessen J, et al. Lancet 2000:355:865

NNT for 5 Years to Prevent 1 Event(NNT=number needed to treat)

CV Event Stroke CHD

All patients 26 48 64

Men 18 34 44

Women 38 68 92

Age 60-69 39 99 89

Age 70+ 19 32 50

Staessen J, et al. Lancet 2000:355:865

Hypertension in the Very Elderly Trial (HYVET)

International multicenter trial; participants were ≥80 years

Baseline SBP 160 to 199 mm Hg; target BP <150/<80 mmHg

Randomized to indapamide 1.5 mg vs. placebo; could receive perindopril (2 or 4 mg) or placebo

Primary outcome: Fatal or non-fatal stroke

Secondary outcomes: Total mortality, CVD death, cardiac death, stroke death, fatal/NF heart failure

NEJM 2008; 358:1887

Hypertension in the Very Elderly Trial (HYVET)

3845 participants; baseline blood pressure=173/91 mmHg

Mean age = 83 years (range 80-105); 61% women; 12% with prior CVD

Mean duration of F/U: 2 years (0 to 6.5 years)

The trial was stopped early for significant reductions in primary endpoint and all-cause mortality

NEJM 2008; 358:1887

BP 29.5/12.5

BP 14.5/6.8

NEJM 2008; 358:1887

Hypertension in the Very Elderly Trial (HYVET)

17.7/1000 p-y

12.4/1000 p-y

30% RRR;NNT 94

over 2 years

NEJM 2008; 358:1887

Hypertension in the Very Elderly Trial (HYVET)

59.6/1000 p-y

47.2/1000 p-y

21% RRR;NNT 40

over 2 years

NEJM 2008; 358:1887

Hypertension in the Very Elderly Trial (HYVET)

2013 AHA/ACC/CDC Recommendations

35Go AS, et al. J Am Coll Cardiol 2013; Nov 12.

2013 AHA/ACC/CDC Recommendations

36Go AS, et al. J Am Coll Cardiol 2013; Nov 12.

Systems-level approach to hypertension control, including:

1. Identifying all patients eligible for management 2. Monitoring at the practice/population level 3. Increasing patient and provider awareness 4. Providing an effective diagnosis and treatment guideline 5. Systematic follow-up of patients for initiation and intensification

of therapy 6. Clarifying roles of healthcare providers to implement a team

approach 7. Reducing barriers for patients to receive and adhere to

medications as well as to implementing lifestyle modifications 8. Leveraging the electronic medical record systems being

established throughout the US to support each of these steps

Kaiser Permanente (2001-2009)

37Jafffe MG, et al. JAMA. 2013;310(7):699-705

Lifestyle: Foundation of Management

38Go AS, et al. J Am Coll Cardiol 2013; Nov 12.

Hypertension Treatment Algorithm

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Go AS, et al. J Am Coll Cardiol 2013; Nov 12.

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Medications: Certain Circumstances

41Go AS, et al. J Am Coll Cardiol 2013; Nov 12.

Especially for patients with multiple medical problems, pill boxes help increase adherence to blood pressure lowering medications by ~10%.

Only $5-$10 on amazon.com!

Step 4

Summary of antihypertensive drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

See slide notes for details of footnotes 1-5

Take Home Points: Management

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• Home BP monitoring is preferred method of diagnosis and evaluation of treatment.• Use an automated BP machine (upper arm cuff)• Sign up for MyChart BP log

• Lifestyle modification, particularly diet, can have a powerful effect on blood pressure.• Check out dashdiet.org for tips

• Combination pills are being increasingly used to improve blood pressure control.• Use a pillbox to make taking your meds easier

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Mark Huffman, MD, MPHNorthwestern University Feinberg School of Medicine

Northwestern Memorial Hospital Healthy Transitions

21 November 2013

Blood Pressure Management & Cardiovascular Health