improving the care of the hypertensive patient: us perspective william cushman, md professor,...
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Improving the Care of the Improving the Care of the Hypertensive Patient:Hypertensive Patient:
US PerspectiveUS Perspective
William Cushman, MDWilliam Cushman, MDProfessor, Preventive Medicine and MedicineProfessor, Preventive Medicine and MedicineUniversity of Tennessee College of MedicineUniversity of Tennessee College of Medicine
Chief, Preventive MedicineChief, Preventive MedicineMemphis VA Medical CenterMemphis VA Medical Center
DISCLOSURE OF RELATIONSHIPS
For William C. Cushman, MD Over the Past 12 Months
Grant/Research support: Astra-Zeneca, Sanofi-
Aventis, King, GlaxoSmithKline, Novartis
Consultant: Sanofi-Aventis, BMS, Novartis, Pfizer,
Daiichi Sankyo, Forest, King Pharmaceuticals,
Boehringer-Ingelheim, Roche
Speakers Bureau: none
Major stock shareholder: none
Other Support, Tangible or intangible: none
25 2529 28
30
0
10
20
30
40
50
1988-91 1991-94 1999-2000 2001-02 2003-04
Prevalence of Hypertension in U.S.: Prevalence of Hypertension in U.S.: 1988-20041988-2004
70 million Americans70 million Americans
Prevalence of Hypertension in U.S.: Prevalence of Hypertension in U.S.: 1988-20041988-2004
70 million Americans70 million Americans
Po
pu
lati
on
Wit
h
Hyp
erte
nsi
on
(%
)
From Bernard CheungFrom Bernard CheungOng, et al, Hypertension 2007Ong, et al, Hypertension 2007
Increase in prevalence of HTN from 1988 to 1999;Increase in prevalence of HTN from 1988 to 1999;No significant increase between 1999 and 2004.No significant increase between 1999 and 2004.
25
5
27
58
30
7
33
66
0
20
40
60
80
All 18-39 40-59 60+
1988-91 1991-94 1999-2000 2001-02 2003-04
Prevalence of Hypertension in U.S.: Prevalence of Hypertension in U.S.:
1988-2004 1988-2004
Prevalence of Hypertension in U.S.: Prevalence of Hypertension in U.S.:
1988-2004 1988-2004
Po
pu
lati
on
Wit
h
Hyp
erte
nsi
on
(%
)
From Bernard CheungFrom Bernard CheungOng, et al, Hypertension 2007Ong, et al, Hypertension 2007
2629
17
29
39
28
0
10
20
30
40
50
Non-Hisp White Non-Hisp Black Mex Amer
1988-91 1991-94 1999-2000 2001-02 2003-04
Prevalence of Hypertension in U.S. Prevalence of Hypertension in U.S. by Race/Ethnicity: by Race/Ethnicity:
1988-2004 1988-2004
Prevalence of Hypertension in U.S. Prevalence of Hypertension in U.S. by Race/Ethnicity: by Race/Ethnicity:
1988-2004 1988-2004
Po
pu
lati
on
Wit
h
Hyp
erte
nsi
on
(%
)
From Bernard CheungFrom Bernard CheungOng, et al, Hypertension 2007Ong, et al, Hypertension 2007
51
7368 70
31
55 5459
10
29 2734
0
20
40
60
80
100
1976-80 1988-91 1991-94 1999-2000
Per
cen
t o
f H
TN
Po
pu
lati
on
Awareness Treatment Control
Awareness, Treatment and Control in Adults Awareness, Treatment and Control in Adults Ages Ages 18-74 Yrs18-74 Yrs with Hypertension in US with Hypertension in US
NHANES NHANES 1976-20001976-2000
Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.
69 7176
58 6065
29 33 37
0
20
40
60
80
100
1999-2000 2001-2002 2003-2004
Per
cen
t o
f H
TN
Po
pu
lati
on
Awareness Treatment Control
Awareness, Treatment and Control in (Awareness, Treatment and Control in (AllAll) ) Adults with Hypertension in US NHANES Adults with Hypertension in US NHANES
1999-20041999-2004
Not adjusted for age.Not adjusted for age.*P<0.05 compared to 1999-2000.*P<0.05 compared to 1999-2000.
From Bernard CheungFrom Bernard CheungOng, et al, Hypertension 2007Ong, et al, Hypertension 2007
*
*
NHANES 1999-2004NHANES 1999-2004ConclusionsConclusions
• HTN prevalence HTN prevalence from 1988-1999, but no from 1988-1999, but no significant significant in the prevalence of HTN between in the prevalence of HTN between 1999 and 2004.1999 and 2004.
• From 1999 to 2004: BP control in HTN From 1999 to 2004: BP control in HTN (to 37%). (to 37%).
• Improvement in BP control observed in both Improvement in BP control observed in both sexes, in non-Hispanic black and Mexican sexes, in non-Hispanic black and Mexican Americans.Americans.
• In the young, awareness and treatment rates are In the young, awareness and treatment rates are low, but BP is easy to control.low, but BP is easy to control.
• In the elderly, awareness and treatment rates are In the elderly, awareness and treatment rates are high, but BP targets are less easily reached.high, but BP targets are less easily reached.
From Bernard CheungFrom Bernard CheungOng, et al, Hypertension 2007Ong, et al, Hypertension 2007
Lifestyle Modification for Lifestyle Modification for Prevention in PreHTN and Prevention in PreHTN and
Treatment in HTNTreatment in HTN
ModificationApproximate 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
JNC 7. JAMA. 2003; 289:2560fJNC 7. JAMA. 2003; 289:2560f
90% previously treated90% previously treated10% untreated10% untreated
42,418 high-risk42,418 high-riskhypertensive patientshypertensive patients
ChlorthalidoneChlorthalidone12.5-25 mg12.5-25 mg
AmlodipineAmlodipine2.5-10 mg2.5-10 mg
LisinoprilLisinopril10-40 mg10-40 mg
DoxazosinDoxazosin1-8 mg1-8 mg
N=15,255N=15,255 N=9,048N=9,048 N=9,054N=9,054 N=9,061N=9,061
Hypertension TrialHypertension Trial
STEP 1 AGENTS (Double-blind)STEP 1 AGENTS (Double-blind)
Blinded drugs titrated and atenolol, clonidine, reserpine, Blinded drugs titrated and atenolol, clonidine, reserpine, and/or hydralazine added as needed to achieve BP goal: and/or hydralazine added as needed to achieve BP goal: <140/90 mm Hg<140/90 mm Hg
ALLHAT
JAMA 2002;288:2981-2997JAMA 2002;288:2981-2997
Blood Pressure ControlBlood Pressure Control
31
58 60 64 67 67
92%91%90%88%86%
68% 66656258
27
55
0
20
40
60
80
100
0 1 2 3 4 5
Years of Follow-up
Percent
DBP<90 SBP<140 BP<140/90
1.41.41.61.6 1.71.7 1.81.8
2.02.0
2.0 = = mean number of drugs number of drugs
ALLHATALLHAT
Cushman, et al. J Clin Hypertens 2002; 4:393-404Cushman, et al. J Clin Hypertens 2002; 4:393-404
26
49
66
0
20
40
60
80
1 1 or 2 Any
Number of Prescribed Drugs
Perc
ent
ALLHATALLHATCumulative Percent Controlled Cumulative Percent Controlled
(BP <140/90 mm Hg) at Five Years(BP <140/90 mm Hg) at Five Years
Derived from Cushman et al. J Clin Hypertens. 2002;Derived from Cushman et al. J Clin Hypertens. 2002;4:393-4044:393-404
Inadequate Management of BP in a Inadequate Management of BP in a VA Hypertensive PopulationVA Hypertensive Population
800 hypertensive men @ 5 VAs in New England over a 800 hypertensive men @ 5 VAs in New England over a 2 yr period in early 1990s.2 yr period in early 1990s.
>6 HTN-related MD visits/yr; ave age: 65.5 years.>6 HTN-related MD visits/yr; ave age: 65.5 years. BP control:BP control:
40% had BP 40% had BP >>160/90 mm Hg160/90 mm Hg <25% had BP <140/90 mm Hg<25% had BP <140/90 mm Hg Increases in therapy: only 6.7% of visits.Increases in therapy: only 6.7% of visits.
More intensive Tx lead to better control of BP (p<.01).More intensive Tx lead to better control of BP (p<.01). ““Many physicians are not aggressive enough in their Many physicians are not aggressive enough in their
approach to hypertension.”approach to hypertension.”
Berlowitz, et al: NEJM 1998;339:1957-63Berlowitz, et al: NEJM 1998;339:1957-63
Response to Berlowitz, et al, Response to Berlowitz, et al, Article and Other Changes in VAArticle and Other Changes in VA
• BP control rates were made a BP control rates were made a performance performance measuremeasure: audited by Office of Quality : audited by Office of Quality Performance (OQP) as part of the External Peer Performance (OQP) as part of the External Peer Review Program (EPRP).Review Program (EPRP).
• Electronic medical record systemElectronic medical record system VA-wide since VA-wide since 1997-98.1997-98.
• Clinical reminderClinical reminder in electronic medical record if in electronic medical record if BP above goal.BP above goal.
• VA HTN Field Advisory Committee conducted a VA HTN Field Advisory Committee conducted a series of national series of national teleconferencesteleconferences: ALLHAT, JNC : ALLHAT, JNC 7, VA-DoD HTN guidelines, BP and thiazide 7, VA-DoD HTN guidelines, BP and thiazide diuretic performance measures, et al.diuretic performance measures, et al.
Outpatient hypertension treatment, Outpatient hypertension treatment, treatment intensification, and control in treatment intensification, and control in
Western Europe and the United States Western Europe and the United States
4640
31
4036
63
15 1621 20
28
38
53 5559 59
44
64
0
10
20
30
40
50
60
70
France Germany Italy Spain UK US
HTN Control Med increase if uncontrolled 2+ AHT classes
Wang, et al. Arch Int Med 2007;176:141-7
Cross-sectional analyses of the nationally representative CardioMonitor 2004 Cross-sectional analyses of the nationally representative CardioMonitor 2004 survey: 291 cardiologist and 1284 PCPs (n=21,053 hypertensive patients)survey: 291 cardiologist and 1284 PCPs (n=21,053 hypertensive patients)
JNC 7 Algorithm for JNC 7 Algorithm for Treatment of Treatment of HypertensionHypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99
mmHg) Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
JNC 7. JAMA. 2003; 289:2560fJNC 7. JAMA. 2003; 289:2560f
Recommendation for Initial Antihypertensive Drug Therapy in JNC 7
Thiazide-type diuretics should be used as initial therapy Thiazide-type diuretics should be used as initial therapy for most patients, either alone or in combination with one for most patients, either alone or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) that have of the other classes (ACEIs, ARBs, BBs, CCBs) that have also been shown to reduce one or more hypertensive also been shown to reduce one or more hypertensive complications in randomized controlled outcome trials.complications in randomized controlled outcome trials.
Selection of one of these other agents as initial therapy is Selection of one of these other agents as initial therapy is recommended when a diuretic cannot be used or when a recommended when a diuretic cannot be used or when a compelling indication is present that requires the use of a compelling indication is present that requires the use of a specific drug ...specific drug ...
If the initial drug selected is not tolerated or is If the initial drug selected is not tolerated or is contraindicated, then a drug from one of the other classes contraindicated, then a drug from one of the other classes proven to reduce CV events should be substituted.proven to reduce CV events should be substituted.
JNC 7. Hypertension 2003;42:1206–1252.JNC 7. Hypertension 2003;42:1206–1252.
0.400.40 0.650.65 0.900.90 1.151.15
Diuretics Diuretics Diuretics Diuretics betterbetter worse worse
Meta-analysis of Low-dose Meta-analysis of Low-dose Diuretics versus PlaceboDiuretics versus Placebo
Psaty, et al. JAMA. 2003;289:2534-2544
CHDCHD 0.79 0.79 0.002 0.002
Heart failureHeart failure 0.51 0.51 <0.001 <0.001
StrokeStroke 0.71 0.71 <0.001 <0.001
CVD eventsCVD events 0.76 0.76 <0.001 <0.001
CVD mortalityCVD mortality 0.81 0.81 0.001 0.001
Total mortalityTotal mortality 0.90 0.90 0.002 0.002
OutcomeOutcome RR RR PP
Relative Risk and 95% Confidence IntervalsRelative Risk and 95% Confidence Intervals
Final Outcomes ResultsDoxazosin vs. Chlorthalidone
Favors Doxazosin Favors ChlorthalidoneFavors Doxazosin Favors Chlorthalidone0.500.50 11 22 33
CHD
All-Cause Mortality
Combined CHD
Stroke
Heart Failure
Combined CVD, p< 0.0001 1.20 (1.13 - 1.27)
1.80 (1.61 - 2.02)
1.26 (1.10 - 1.46)
1.07 (0.99 - 1.16)
1.03 (0.94 - 1.13)
1.03 (0.92 - 1.15)
Hypertension 2003;42:239-246Hypertension 2003;42:239-246
ALLHAT
Major Outcomes
Amlodipine/Chlorthalidone
0.50 1 2
ESRD 1.12 (0.89-1.40)
Heart Failure 1.38 (1.25-1.52)
Combined CVD 1.04 (0.99-1.09)
Stroke 0.93 (0.82-1.06)
All-Cause Mortality 0.96 (0.89-1.02)
CHD 0.98 (0.90-1.07)
Favors FavorsAmlodipine Chlorthalidone
Relative Risks and 95% Confidence IntervalsALLHAT
JAMA 2002;288:2981-2997JAMA 2002;288:2981-2997
Lisinopril/ChlorthalidoneLisinopril/Chlorthalidone
0.500.50 11 22
1.11 (0.88-1.38)1.11 (0.88-1.38)
1.19 (1.07-1.31)1.19 (1.07-1.31)
1.10 (1.05-1.16)1.10 (1.05-1.16)
1.15 (1.02-1.30)1.15 (1.02-1.30)
1.00 (0.94-1.08)1.00 (0.94-1.08)
0.99 (0.91-1.08)0.99 (0.91-1.08)
Favors FavorsLisinopril Chlorthalidone
ESRD
Heart Failure
Combined CVD
Stroke
All-Cause Mortality
CHD
Major OutcomesRelative Risks and 95% Confidence Intervals
ALLHAT
JAMA 2002;288:2981-2997JAMA 2002;288:2981-2997
Hypertension Treatment by Drug ClassHypertension Treatment by Drug Class
0
10
20
30
40
50
60
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Year
% o
f T
reat
ed P
atie
nts
on
Med
icat
ion
Calcium Channel Blockers
Beta Blockers
Diuretics
ACE Inhibitors
ARBs
IMS Health NDTI, 1978-2004IMS Health NDTI, 1978-2004
0
100000
200000
300000
400000
500000
600000
700000
800000
900000
1000000
02Q1 02Q2 02Q3 02Q4 03Q1 03Q2 03Q3 03Q4 04Q1 04Q2 04Q3 04Q4
To
tal
Pre
scri
pti
on
s
Diuretics
ACE Ihhibitors
Calcium Channel Blockers
ARBs
IMS Health NDTI, 1978-2004IMS Health NDTI, 1978-2004
Hypertension Treatment by Drug ClassHypertension Treatment by Drug Class
Drug Utilization by DrugDrug Utilization by Drug
0
1000
2000
3000
4000
5000
6000
7000
8000
02Q1 02Q2 02Q3 02Q4 03Q1 03Q2 03Q3 03Q4 04Q1 04Q2 04Q3 04Q4
To
tal
Pre
scri
pti
on
s
Lisinopril
HCTZ
Amlodipine
IMS Health NDTI, 1978-2004IMS Health NDTI, 1978-2004
0%
5%
10%
15%
20%
25%
2001 2002 2003 2004 2005 2006 2007
Thiazide Diuretic Use for Hypertension, US, 2001-06Proportion of all compound uses, IMS Health NDTI
U.S. Hypertension Guidelines
• JNC 7: Thiazide-type diuretics should be initial drug
therapy for most, either alone or combined with
other drug classes.
• VA-DoD CPGs: Thiazide-type diuretics are preferred
in patients with uncomplicated hypertension; most
compelling indications should include a diuretic.
VA Pharmacy Benefits VA Pharmacy Benefits ManagementManagement
Antihypertensive Medications in VAPercent Patient Utilization
56
37
23
44
18
95 3
115
1720
3841
49
63
0
20
40
60
80
ACEI BB Thiazide CCB Alpha Loop Other ARB
2000
2001
2002
2003
2004
2005
Multi-Drug Therapy in VAMulti-Drug Therapy in VAPercent on ThiazidePercent on Thiazide
54
40
0
10
20
30
40
50
60
2 Meds 3 Meds
2000
2001
2002
2003
2004
2005
VA Pharmacy Benefits VA Pharmacy Benefits ManagementManagement
Antihypertensive Medications in VAPercent Monotherapy
41
20
14 15
52
0.54
0
10
20
30
40
50
ACEI BB Thiazide CCB Alpha Loop Other ARB
2000
2001
2002
2003
2004
2005
Achieving BP Goal With or Without Drug Achieving BP Goal With or Without Drug in 2-Drug Combinations:in 2-Drug Combinations:
VA Single-Drug Therapy StudyVA Single-Drug Therapy Study
Achieving BP Goal With or Without Drug Achieving BP Goal With or Without Drug in 2-Drug Combinations:in 2-Drug Combinations:
VA Single-Drug Therapy StudyVA Single-Drug Therapy Study
69
5856 56
54 5351
58 58 5961 60
40
50
60
70
80
HCTZ CLON DILT ATEN CAPT PRAZ
With Without
% D
BP
<90
mm
Hg
% D
BP
<90
mm
Hg
Materson, et al. J Human Hypertens 1995;9:791-796Materson, et al. J Human Hypertens 1995;9:791-796
VA Thiazide Diuretic Performance Measurement starting in FY 07
Universe: Outpatients with a diagnosis of hypertension AND Actively on antihypertensive therapy
Measure(s): Outpatients with a diagnosis of uncomplicated hypertension on: Antihypertensive mono-drug therapy
which consists of a thiazide diureticAntihypertensive multi-drug therapy
which includes a thiazide diuretic
VA Thiazide Diuretic Measure Uncomplicated Exclusions due to Compelling Indications
Patients with an outpatient diagnosis at any facility within the past twenty-four months prior to the end date of the rolling three month period being evaluated as follows: Diabetes Post AMI Supraventricular Tachycardia Angina
Initial Combinations of Medications*
DiureticsDiuretics
ACE inhibitorsACE inhibitorsoror
ARBsARBs
CalciumCalciumantagonistsantagonists
* Compelling indications may modify this.
Can add: reserpine, aldosterone antagonist or Can add: reserpine, aldosterone antagonist or amiloride, amiloride, -blocker, alternative CCB, vasodilator, -blocker, alternative CCB, vasodilator, -blocker, -blocker, -blocker, and/or central agonist-blocker, and/or central agonist
Hypertension in the U.S. increased in prevalence until 1999: 70 million.
Preventive efforts should be intensified on many fronts, especially lifestyle changes in prehypertensive individuals.
BP control rates have increased in the U.S. since 1999-2000, especially in minorities, but still remains less than the 50% “Healthy People 2010” goal.
Improving the Care of the Improving the Care of the Hypertensive Patient: US Hypertensive Patient: US
PerspectivePerspective Conclusions - 1 Conclusions - 1
BP control rates have increased even more in some practice settings such as the VA: audit and feedback appear central.
Better BP control is associated with increases in dosing and numbers of drugs.
Thiazide diuretic use should continue to increase both for better CV prevention and improved BP control.
We have an excellent armamentarium of lifestyle methods and AHT drugs – further education is needed on how to use them.
Improving the Care of the Improving the Care of the Hypertensive Patient: US Hypertensive Patient: US
PerspectivePerspective Conclusions - 2 Conclusions - 2