hypertension update 2013

7/25/2019 Hypertension Update 2013

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AndrewS.Bombac

CDCReport(9/4/12):AwarenessandTreatmentofUncontrolled

HypertensionAmongUSAdults,20032010

MMWRSep2012; 61(35):703709

Outlineoftopics

1. Bloodpressuregoals howlowdoweneed

togo?

2. Diureticswhyiseveryonetalkingabout

chlorthalidone again?

3. Resistanthypertension arethereanynew

tricksforthisveryoldgame?

Bloodpressuregoals

SeventhReportoftheJointNationalCommitteeonPrevention,

Detection,Evaluation,andTreatmentofHighBloodPressure:JNC7

Chobanian, A. V. et al. JAMA 2003;289:2560-2571

FraminghamHeartStudy:Lifetimeriskforcardiovasculardiseaseand

mediansurvivalformenandwomenaccordingtobloodpressureatage50

MEN WOMENLifetime risk for CV

disease

Median

Survival

Lifetime risk for CV

disease

Median

Survival

Systolic or

diastolic BP,mm Hg

to 75

years(%)

to 95

years(%)

years to 75

years(%)

to 95

years(%)

years

100

or treated

51.3 65.1 28 35.0 50.6 31

LloydJonesDM,LeipEP,LarsonMG,etal.Circulation.Feb142006;113(6):791798

StratificationofCVriskinto4categoriesinthe

ESHESCguidelines

ManciaG,DeBackerG,DominiczakA,etal.2007Guidelinesforthemanagementofarterialhypertension:TheTaskForceforthe

ManagementofArterialHypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC).Eur

Heart

J.

Jun2007;28(12):14621536.


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Copyright restrictions may apply.

Group (Year) Goal BP (mm Hg)

American Society of HTN (2008)


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AndrewS.Bombac

HYVET:HypertensioninVeryElderlyTrial

BeckettNSetal.NEngl JMed.2008;358(18):18871898

HYVET:HypertensioninVeryElderlyTrial

BeckettNSetal.NEngl JMed.

2008;358(18):1887 1898

Copyright 2012 American Medical Association. All rights reserved.

From: Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults: The Impact of Frailty

Arch Intern Med. 2012;172(15):1162-1168

Figure 2. Sensitivity analyses of the association of elevated systolic blood pressure (SBP) (140 mm Hg) and mortality, stratified bywalking speed, in National Health and Nutrition Examination Survey participants 65 years and older (1999-2002) , followed up until

December 31, 2006.

Figure Legend:

ACCORDTRIAL:MeanSystolicBPLevelsatEachStudyVisitinDiabetics

TheACCORDStudyGroup.NEngl JMed2010;362:15751585.

ACCORDTRIAL:KaplanMeierAnalysesofSelectedOutcomes

TheACCORDStudyGroup.NEngl JMed2010;362:15751585.

AASK:BloodPressureLevelsinPatients withChronicKidneyDisease

Appel LJetal.NEngl JMed2010;363:918929.


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AASK:Eventratesforprimaryandsecondaryoutcomes AASK:Incidenceofthecompositeprimaryoutcome(doublingof

Scr,ESRD,ordeath)accordingtobaselineproteinuria


Keypoints:BPgoals

140/90foruncomplicatedhypertension Thiswillnotchange

Guidelinesstillcallfor130/80inpresenceofcomorbidities JNC8willlikelynotendorsethisgoal

ElderlypatientwithisolatedsystolicHTN ToleratehigherSBP goalof150/70maybeappropriateand

maybeendorsedbyJNC8

Reasonabletotarget130/80inpresenceofcomorbiditiesbutcantolerate130140/8090

Approach

goals

Diuretics




Copyright restrictions may apply.

Network Meta-analysis o f First-Line Treatment Strategies in

Randomized Controlled Clinical Trials in Hypertension

Psaty, B. M. et al. JAMA 2003;289:2534-2544


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ACCOMPLISH BPOUTCOMES

Jamerson Ketal.NEngl JMed2008;359:24172428.

ACCOMPLISH CVOUTCOMES

Jamerson Ketal.NEngl JMed2008;359:24172428.

Primaryoutcome=compositeofdeathfromCVcauses,nonfatalMI,

nonfatalstroke,hospitalizationforangina,resuscitationaftersudden

cardiacarrest,andcoronaryrevascularization

HR 0.80, 95% CI 0.72 to 0.90, p


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AndrewS.Bombac

Copyright 2011 American HeartAssociation

Dorsch, M. P. et al. Hypertension 2011;57:689-694

Adjust ed event-f ree pro babil ity of CVEs

Keypoints:Diuretics

OkaytocontinuetouseHCTZ No needtochangecoursesforwellcontrolledpatients

Probablybettertousechlorthalidone Approximationrule:1mgdailychlorthalidone =1mgbid

HCTZ

Hypokalemia usuallynotaproblemifchlorthalidone dose 140/90mmHg(or> 130/80mmHginCKDorDM)on3antihypertensivemedications,includingadiuretic

Addresstheetiology improveBPcontrol

ResistantHTN=upto40%ofhypertensivepatients

Firstruleoutpseudoresistance

Cause Example

Improper blood pressure

measurement

Inappropriately sized cuff

Whi te-coat hypertens ion Pers is tent ly lower home blood

pressuresDifficult to compress heavily

calcified or sclerotic arteries

Very elderly patients

Poor patien t adherence Complica ted dosing schedules,

high costs of medications

Inadequate antihypertensive

medication

Inappropriate combinations,

insufficient doses

Physician inertia Failure to change or increase dose

regimens Drugtherapyforresistanthypertension: simplifyingtheapproach.MannSJ.

JClinHypertens (Greenwich).2011Feb;13(2):12030.

HEY!!!WEWANTANALGORITHM!!!!


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Addressvolume

TheprevalenceofresistantHTN>50%innephrology

clinics 515%rangeingeneralmedicalpractices

Pressurenatriuresistheory renalhandlingof

sodiumistheultimatedeterminantofblood

pressure

Normalrenalfunction effectivelyexcreteNaloads

ImpairedrenalfunctionmustraiseBPtoefficientlyexcreteNaandstayinsteadystate

BloodPressureFollowstheKidney

geneticallyhypertension pronerat normotensiverat

BloodPressureFollowstheKidney

Thehumanversionofthe

experiment

LEFT:BillEvans(publicist,kidney

donor,friend)

RIGHT:NeilSimon(playwright,kidney

recipient,friend)

Drugtherapy

for

resistant

hypertension:

simplifying

the

approach.

MannSJ.

JClinHypertens (Greenwich).2011Feb;13(2):12030.

Randomized, crossoverevaluationof12obesesubjectswith

resistantHTNonlow(1.2g/day)andhighsodiumdiets(5.8g/day)

Pimenta, E. et al. Hypertension 2009;54:475-481


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EffectofDietarySodiumReductionisGreatestin

PatientswithResistantHypertension

DietaryNa+ (mg) BPeffect

1Nonhypertensives 1800 2.0/1.0

2Hypertensives 1800 5.0/2.7

3Resistanthypertensives 1800 22.7/9.1

1HeFJandMacGregor GA.JHumanHypertens 2002;16:7612PimentaE.Hypertension54:4753BrayGA.AmJCardiol.2004;94:222

AddresstheRAAS

MossoL,CarvajalC,GonzalezA,etal.Primaryaldosteronismandhypertensivedisease.Hypertension.Aug2003;42(2):161165.

Prevalence(%)ofprimaryaldosteronismac cordingtohypertensionstage(JNCVIclassification)

ASCOT:Useofspironolactoneforresistant

hypertensionin1411subjects

ChapmanN,DobsonJ,WilsonS,etal.Hypertension.Apr2007;49(4):839845. Hypertension 2011;57(6):10691075

Rationaleforchronotherapy

Many,ifnotall,specifichumanphysiologicalfunctionsareunderthecontrolofacircadiantimingsystem includeskidneyfunctionand,byextension,thecontrolofblood

pressure

mostobviousexampleofcircadianrhythmicity ofrenalfunction

isthe

well

recognized

difference

in

urine

volume

formation

and

excretionbetweendaytimeandnighttime

Urinaryexcretionofallmajorsolutesincludingsodiumalsofollowsacircadianpattern;whenthispatternisimpaired,diseasemayensue Abnormalcircadianrhythmforrenalsodiumreabsorption is

consideredoneofthemajorfactorsleadingtothelossofnocturnalbloodpressuredipping

BurnierM, ColtamaiL, MaillardM, BochudM. SeminNephrol. Sep 2007;27(5):565-571.

BankirL, BochudM, Maillard M, Bovet P, Gabriel A, BurnierM. Hypertension.Apr 2008;51(4):891-898.

Addressneurogenic:chronotherapy Addressneurogenic

HermidaRC, AyalaDE,FernandezJR,Calvo C.Hypertension 2008;51(1):6976.


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AndrewS.Bombac

Chronotherapy inCKD(meaneGFR 46ml/min/1.73m2)

restoresnocturnaldipperstatus

MinutoloR,GabbaiFB,BorrelliS,etal.AmJKidneyDis2007;50(6):908917

Survival curves as a function of time-of-day of

hypertension treatment in CKD patients

Hermida R C et al. JASN 2011;22:2313-2321

TotalCVevents

MajorCVDevents=

cardiovasculardeaths,

MI,ischemicCVA,and

hemorrhagicCVA

Keypoints:ResistantHTN

Optimizediuretics

Anotherreasontostartthinkingmoreabout

chlorthalidone

ThinkoftheentireRAAS

Aldosterone blockadeisacheapandeffectivetherapy

Chronotherapy forhypertension

Timingofdrugsmaybeasimportantaschoiceof

drugs

JNC8mayincorporatechronotherapy intothe

definitionof

resistant

HTN

Conclusion

Anewideaisfirstcondemned

asridiculousandthendismissed

astrivialuntil,finally,it

becomeswhateverybody

knows

WilliamJames

Question1

TheActiontoControlCardiovascularRiskinDiabetes(ACCORD)trialfoundnodifferencebetweenintensive(SBP


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AndrewS.Bombac

Question3

A65yearoldmanwith10yearsofhypertensionthathasconsistentlyremainedabovetargetpresentsto

youroffice

with

ablood

pressure

of

160/95.

His

home

BPdiaryshowsthathispressuresathomegenerallyrangefrom150160/90100.Hiscurrentantihypertensiveregimenincludes:hydrochlorothiazide 37.5mgdaily,lisinopril 20mgdaily,andamlodipine 10mgdaily.Whichofthefollowingmedicationswouldbemostreasonabletoaddatthispoint?

1. Spironolactone

2. Clonidine

3. Hydralazine

4. Minoxidil

hypertension update 2013

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