hypertension overview

Hypertension: There’s Nothing “Uncomplicated” About It

Jon Zlabek MD, FACP

Learning Objectives

• Confront the cold hard truth

• Understand the dangers of “Therapeutic Inertia”

• Review the basics of hypertension management

• Understand the approach to resistant hypertension

The Problem

As health care providers, we stink at managing hypertension, and our patients die needlessly because of it.

The Cold Hard Truth

Hypertension

• Affects ~31% of U.S. adults Most common primary diagnosis Incidence is increasing

• Control is poor: Only 53% are on therapy Only 31% are controlled

Hypertension 2006;47:345-51Stroke 2006;37:577-617

Why Should I Care?It’s just a number, right?

Target Organ Damage

• Brain Stroke or transient ischemic attack

• Heart Left ventricular hypertrophy Coronary artery disease Heart failure Peripheral arterial disease

• Kidney Chronic kidney disease

• Eye Hypertensive retinopathy

Hypertension

• About 60% of all strokes are attributable to hypertension That’s 468,000 strokes per year in USA

• Blood pressure control decreases initial stroke rate by 35-40% CHF decreased by >50% MI decreased by 20-25%

JNC-7 NHLBI

We Missed the News Flash!

• Stroke & heart disease death rises linearly from 115/75 mmHg

JNC-7 NHLBI


• Stroke & heart disease death rises linearly from 115/75 mmHg

• 141/88 should take on a new meaning with this tidbit Get them off the bubble and into the

“safe zone”

JNC-7 NHLBI

The Dangers of “Therapeutic Inertia”

Therapeutic Inertia?

Definition

Healthcare providers’ failure to increase therapy when treatment

goals are unmet

Hypertension 2006;47:345-51

Therapeutic Inertia?

• Blood pressure control rates haven’t changed much in the last 15 years

• Lots of reasons given: Patient compliance Access to care Cost


Therapeutic Inertia

• 7253 patients with hypertension seen by 168 physicians at 40 sites in the southeast US Seen in the clinic 4 times in 2003 Recorded the last BP taken while sitting At least one visit with BP 140/90


Therapeutic Inertia

• A visit with “therapeutic inertia” was defined as one where an elevated blood pressure was recorded, but there was no increase in dose or number of antihypertensive medications


Therapeutic Inertia

• Medications were changed at only 13.1% of visits with an elevated blood pressure


Therapeutic Inertia

• Overall, patients’ BP improved from the first to the final visit 39.5% controlled at first visit 45.1% controlled at final visit

• Patient were placed into quintiles based on the therapeutic inertia they experienced


Therapeutic Inertia

• Quintile 1 patients experienced low therapeutic inertia Their physicians were “doers”

• Quintile 5 patients experiencedhigh therapeutic inertia Their physicians were “watchers”


Therapeutic Inertia

• “Doer” group: SBP decreased by 6.8 mmHg Increased control rate

◊ 53.0% to 75.5%

• “Watcher” group SBP increased by 1.8 mmHg Worse control rate

◊ 22.2% to 7.7%


“Watchers”“Doers”

Therapeutic Inertia

• Patients in the “doer doctor” group were 33 times more likely to have achieved blood pressure control at the last visit than those in the “watcher doctor” group


Therapeutic Inertia

• If medication changes were made at 30% of the visits, instead of 13% . . . BP control would increase from

45% to 66% Cardiovascular and all-cause mortality

in this group would be reduced ~10-15%


What Causes Therapeutic Inertia?

• We think we’re better than we really are Physician self-reported care is

overestimated when compared to actual care

Annals of Internal Medicine 2001;135(9):825-34


• Use of “soft” reasons to avoid intensification of therapy Perception that control was improving Patient aversion to medication therapy



• Lack of training/education Not understanding the need for multiple

medications at maximal doses

• Lack of practice organization focused on therapeutic goals Poor or no quality initiatives Lack of electronic aids (flowsheets, etc)


How to Fix Therapeutic Inertia???

• Be aware that we as humans “drift” toward this

• Continually remind yourself and your patients of the devastation that comes with stroke and heart disease

How to Fix Therapeutic Inertia???

• Some providers may need to be more “industrious” during clinic visits It’s much easier to “see you in 6 months”

than to prescribe a medication

• “Watching” 141/88 takes on a new light when we realize that risk of death goes up linearly from 115/75

Tips Compiled from GL’s Best HTN Providers

• Intense focus on rechecking the BP and getting it into the CWS Theme of patients sitting and relaxing

for a while before taking/retaking BP Provider rechecks it and gives it to MA to

enter MA rechecks it after the provider leaves


• Repeated, intense follow up every month until patient is at goal

• Theme of not hesitating to consult a hypertension specialist


• Up-front and repeated speech about the “evils” of hypertension Scare them with reality Talk about end organ effects “What you can’t feel can kill you” “Can’t enjoy retirement with a stroke”


• Use medications before or as they change their lifestyle, then take them away if/when they change Don’t fall into the “I’ll try harder from

now on” trap

• Push BP down to the “safe zone”, not just barely to goal levels


• Remind patients: Importance of lifestyle changes It will take at least 3 medicines to get

to goal Importance of their engagement in this

◊ Involve them in treatment decisions◊ Make sure they are clear on BP goal number◊ Get a home BP monitor


• More tips: Use medications combinations to save

money and improve compliance Offer nurse-only (free) BP checks Monthly audits by MA to find patient

that are missing things or needs appt◊ Very strong theme of a close working

relationship with their MAs

Other Tips To Improve . . .

• Make sure patients take their BP medications the morning of the appointment even if they are fasting

• Make sure your MA/RN does not “round off” to zeros or fives 140 mmHg counts as not controlled;

139 mmHg counts as controlled

Other Tips To Improve . . .

• RE-CHECK and RE-RECORD At the end of your history – You

◊ Write it on a sticker and give to your nurse/MA to enter in CWS

◊ If it is not entered discretely in CWS, it doesn’t count

After you are long gone – Your nurse/MA◊ Minimizes “white coat” effect

The Basics of Hypertension Management

New Guidelines Coming!

• JNC 7 released in 2003

• JNC 8 upcoming Summer 2010

• Data presented here from JNC 7 with my predictions of JNC 8 in red italics

Basics of Measurement

• Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level.

• Use an appropriate sized cuff Small cuff = falsely high readings

Initial Strategy

1. Make the diagnosis At least 3 visits over weeks-months, assuming no

end organ damage or BP less than 180/110

2. Define the goal blood pressure level

3. Use history, exam and tests to: Seek out easily correctable causes Assess target organ damage

◊ Remember the vascular milieu

4. TREAT AND REPEAT!

Goal Blood Pressure Levels

• <130/80 for: Diabetes Chronic kidney disease CAD or CAD equivalent:

◊ Carotid disease◊ PAD◊ AAA◊ 10 year cardiovascular risk ≥ 10%

• <140/90 mmHg for others

JNC-7 NHLBICirculation 2007;115:2761-2788

Initial Tests

• Creatinine• Urinalysis• Potassium and Sodium• Calcium• TSH• Hemoglobin or Hematocrit• Glucose• Fasting Lipid Panel• EKG

What to Tell Patients Now, and Reinforce at Each Visit

• “We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure”

• “Most patients eventually need 3-4 medications to achieve goal blood pressure levels”

What to Tell Patients Now, and Reinforce at Each Visit

• “I will be seeing you for brief 5 minute appointments with lab tests every month until your blood pressure goal is reached”

• Tip: Double book these patients – they are quick Very high yield “bread and butter”

E&M code for the time spent

Coding a 5 minute uncontrolled HTN follow up

• S: Mr. Smith returns for a blood pressure follow up. It has been running 160/85 at home. He has no hyper- or hypotensive side effects on his meds.

• O: BP 159/87. He appears well.• A: Uncontrolled hypertension• P: Increase lisinopril to 40 mg a day. Check

potassium and creatinine. F/U in 1 month.

2

2

1

99213 = 0.97 RVU and $143

Treatment – First 3 Drugs

1. Thiazide diuretic Triamterene/HCTZ 37.5/25 in AM Using a thiazide alone makes a lot of

extra work chasing K levels

F/U one month with Na, K, Creatinine

Option for dihydropyridine calcium channel blocker, e.g. amlodipine or ACE-I/ARB

JNC-7 NHLBINEJM 2009;361:878-87


2. Add a low dose ACE-I e.g. lisinopril 10 mg daily Stop Triamterene/HCTZ and replace

with Chlorthalidone (best) or HCTZ 25 mg daily

Change to ARB if cough develops

F/U one month with K, Creatinine

JNC-7 NHLBI


2. Titrate ACE-I Increase to lisinopril 20 mg F/U one month with K, Creatinine

Increase to lisinopril 40 mg F/U one month with K, Creatinine

• A bump of up to 35% in creatinine with ACE-I is acceptable

JNC-7 NHLBI


3. Add a dihydropyridine calcium channel blocker e.g. amlodipine 5 mg daily

◊ Warning – don’t add non-dihydropyridine here (diltiazem), as decreases in pulse limit your future beta blocker use

F/U one month – no lab needed

Titrate amlodipine to 10 mg daily

JNC-7 NHLBI

Don’t Forget Lifestyle!

Don’t Forget Lifestyle

• Proven approaches: Weight reduction (5-20 mmHg/10 kg) DASH eating plan (8-14 mmHg)

◊ Dietary Approaches to Stop Hypertension◊ dashdiet.org

Sodium restriction (2-8 mmHg) Physical activity (4-9 mmHg) Moderation of alcohol (2-4 mmHg)

JNC-7 NHLBI

Still Not At Goal?

• If you’ve come this far and still haven’t reached your goal, you officially have “resistant hypertension”

• Don’t throw in the towel!

• This is a good time to consider a consult with a hypertension specialist

The Approach to Resistant Hypertension

Resistant Hypertension

• Blood pressure of ≥140/90 or ≥130/80 with diabetes or renal disease, despite full doses of 3 medications, including a diuretic

• What is the PRIMARY reason for uncontrolled resistant hypertension?

NEJM 2006;355:385-92


NEJM 2006;355:385-92

“A suboptimal medical regimen has been shown to be the primary cause of resistant hypertension . . .”

Other Causes

• Medications/drugs (<2%) NSAIDS Stimulants Herbals (ginseng and yohimbine) Appetite suppressants Steroids

• Adherence to therapy

NEJM 2006;355:385-92

Other Causes

• Inadequate diuresis

• High sodium intake (>150 mmol/day)

• Alcohol (>3-4 drinks/day)

• Obesity

JNC-7 NHLBINEJM 2006;355:385-92

“Secondary” Causes

• Affects 10% of all patients with resistant hypertension

• Affects 18% of those over age 60 with resistant hypertension

NEJM 2006;355:385-92

“Secondary” Causes

• Renal parenchymal disease (1-8%)• Renovascular disease (3-4%)• Aldosteronism (1.5-15%)• Thyroid disease (1-3%)• Cushing’s syndrome (<0.5%)• Pheochromocytoma (<0.5%)• Coarctation of the aorta (<1%)• Sleep apnea (unknown)

NEJM 2006;355:385-92

Treatment – After the First 3

4. Add a beta blocker e.g. metoprolol 25 mg twice a day F/U one month Titrate to a pulse around 60


5/6. Add a direct renin inhibitor Aliskiren (Tekturna) 150 mg daily F/U one month with K, Creatinine

Titrate to 300 mg daily in a month


5/6. Add an alpha blocker e.g. doxazosin 1 mg daily Warn of orthostatic

hypotension/lightheadedness F/U one month

Titrate to 2 mg, 4 mg and 8 mg at monthly F/U visits

Treatment – Drug 7 and Beyond

• Spironolactone (aldosterone blocker) Watch K carefully

• Hydralazine (direct vasodilator) Must be beta-blocked and diuresed

• Nitrate if coronary disease and angina

Treatment – Drug 7 and Beyond

• Avoid centrally acting drugs due to poor side effect profile Clonidine Reserpine Guanfacine


• Consider consultation with a “hypertension specialist” per JNC-7

• That’s us in Vascular Medicine!

We love these patients!

JNC-7 NHLBINEJM 2006;355:385-92

Take Home Points

• “We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure”

• Stroke and heart disease death rises linearly from 115/75 mmHg Get them off the bubble and into the

“safe zone”

Take Home Points

• Be diligent in management and follow up 5 minute monthly appts until controlled Avoid “Therapeutic Inertia” RE-CHECK and RE-RECORD in CWS

• Consult a HTN specialist if control is difficult or for secondary evaluation

Thanks!

hypertension overview

Health & Medicine

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