1.Hypertension and stroke: epidemiology, diagnosis and treatment; role of our dedicated hypertension clinic.
Muhammad W Khattak M.D.
Assistant Professor of Medicine UICOMP
Nephrology and Hypertension Specialist.
Renal Care Associates.
I have no financial relationships with manufacturers, industry related to this lecture to disclose.
I am an employee of Renal Care Associates.
Prevalence of Uncontrolled hypertension and its association with stroke.
Role of American Society of Hypertension certified ‘Hypertension clinic’ at OSF St Francis Peoria Illinois.
Diagnosis, monitoring and treatment of Hypertension in perspective of stroke prevention.
4.Global Burden of Hypertension:
1 billion 2000, 1.5 billion 2025
7.SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.
8.Has overall awareness, treatment, and control of hypertension changed since 2009–2010?
During 2011–2012, among adults with hypertension, 82.7% were aware of their hypertension, 75.6% reported currently taking prescribed medication to lower their blood pressure, and 51.8% had their blood pressure controlled (Figure 2).
There was no significant change from 2009–2010 in awareness, treatment, or control among adults with hypertension.
9.Hypertension is common: Framingham data shows, a person at age 55 has 90 % life time risk of HTN.
Vasan, et al. JAMA.2002;287:1003
11.Our results suggest that more than 90% of the stroke burden is attributable to modifiable risk factors, and achieving control of behavioral and metabolic risk factors could avert more than three-quarters of the global stroke burden.
12.Hypertension is a Component of a Chronic Cardiovascular
Patients with hypertension have more
Life Expectancy: reduced by ~ 5 yrs
(Franco et al; Hypertension, 2005)
Implications for treatment:
Treatment should focus on lowering
CV risk as well as lowering BP
13.CV mortality doubles with each 20/10 mm of Hg BP increase: starting at 115/75 mm of Hg.
16.Good news; HTN control has increased.
NHANES survey results suggested that control of hypertension has increased substantially over the past two decades, from:
29 percent in 1988 -----> 50 percent in 2008. T
his improvement in hypertension control is due to improvements in both awareness (73 to 81 percent) and treatment (55 to 72 percent).
Similarly, data from the Veterans Administration suggest that hypertension control rates have risen substantially.
19.Percentage of ACEi prescriptions dispensed as single-pill combination ACEI-HCTZ combination tablets for Kaiser Permanente Northern California members between 2001–2009.
20.How to improve control rates of HTN:
Implementation of quality improvement programs:
Control rates as high as 80 percent were achieved in a large-scale group practice that implemented a five-component quality improvement program that included:
• Formation of a registry to identify and track hypertensive patients.
• Treatment algorithms for providers.
• Follow-up with medical assistants for blood pressure checks.
• Promotion of single pill combination therapy
• Regular feedback about hypertension control performance provided to local practices and medical
JAMA. 2013 Aug 21;310(7):699-705. doi: 10.1001/jama.2013.108769.Improved blood pressure control associated with a large-scale hypertension program. Jaffe MG1, Lee GA, Young JD, Sidney S, Go AS.
21.Money makes the mare go…
Financial incentives to clinicians (pay for performance): Two cluster randomized trials showed that incentivizing small group practices or individual clinicians may improve blood pressure control.
JAMA. 2013 Sep 11;310(10):1031-2. doi: 10.1001/jama.2013.277575.Financial incentives in primary care practice: the struggle to achieve population health goals. Schulman et all.
• 84 small primary care practices implementing an electronic health record were randomly assigned
To receive or not receive financial incentives to achieve certain benchmarks, including adequate blood pressure control.
After approximately nine months, financial incentives significantly increased blood pressure control rates as compared with no incentive (by 9.7 versus 4.3 percent among those without other comorbidities; by 9.5 versus 1.7 percent among those with diabetes or preexisting vascular disease).
JAMA. 2013 Sep 11;310(10):1051-9. doi: 10.1001/jama.2013.277353.Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. Dudley et All.
• The effect of financial incentives to achieve blood pressure control was analyzed in 12 Veterans Affairs outpatient clinics . Financial incentives provided to individual clinicians, but not to whole practices, significantly increased control rates as compared with control (by 8.8 versus 0.5 percent).
JAMA. 2013 Sep 11;310(10):1042-50. doi: 10.1001/jama.2013.276303.Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. Woodard et All.
23.If a specific secondary cause of hypertension is suspected or if the blood pressure remains elevated despite six months of more intensive treatment, referral to a hypertension specialist is recommended.
24.The American Society of Hypertension (ASH) provides a list of hypertension specialists who are members of ASH. This list can be accessed at: www.ash-us.org/htn-specialist/htn-specialists-directory.aspx.
26.Requirement for approval of HTN center:
Director must be an ASH Certified Specialist in Clinical Hypertension.
Majority of practice must be devoted to patients with hypertension and related disorders.
Recognition as referral and treatment resource for resistant and secondary hypertension, and alternative therapies.
Personnel are certified in recording blood pressure and in maintaining equipment for both the Center and self-monitoring for patients.
Performs and interprets 24-hour ambulatory blood pressure recording.
Has access to facilities to perform extensive multi-specialty examination and treatment to assess complicated hypertension problems:
Evaluation of Autonomic function
Renal vein renin sampling
27.Requirement for approval of HTN center:
Doppler renal ultrasound
Adrenal vein sampling of aldosterone.
Renal angioplasty with/without stenting.
Participates in investigator-initiated research.
Practice performs ongoing quality improvement.
Ongoing hypertension educational activities
28.Our Hypertension Center : a joint venture of OSF and Renal Care associates.
29.2016: In patient Hypertension service in OSF
30.Add to your Favorites
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Pulse Wave velocity
24 hour BP monitoring
Detailed blood testing for 2ndary HTN.
33.What we do..
We help in managing Hypertensive emergency, urgency and resistant hypertension.
Will follow those patients in the clinic and work closely with primary Care providers.
Will help in preventing ER visits and re admissions due to uncontrolled HTN.
OSF St Francis is providing one stop shop for detailed 2ndary HTN work up on the same day of the visit to the clinic.
34.We have to break this cycle..
35.Measurement: Clinic or Office BP Has Been the
Benchmark for Clinical Trials and Practice Guidelines
36.Ambulatory Blood Pressure Monitoring
Better Predictor of Cardiovascular Risk
37.Blood pressure measurement
ABPM : Normal blood pressure: systolic <120 mmHg and diastolic <80 mmHg
Prehypertension: systolic 120 to 139 mmHg or diastolic 80 to 89 mmHg
Stage 1 hypertension: systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg
Stage 2 hypertension: systolic ≥160 mmHg or diastolic ≥100 mmHg
Isolated systolic hypertension: blood pressure of ≥140/<90 mmHg
Isolated diastolic hypertension: blood pressure <140/≥90 mmHg
Home blood pressure monitoring :Mean 24-hour blood pressure systolic >130 mmHg or diastolic >80 mmHg
-Mean daytime blood pressure systolic >135 mmHg or diastolic >85 mmHg
Office-based blood pressure measurement :Mean of multiple readings over seven days of systolic >135 mmHg or diastolic >85 mmHg
38.Ambulatory BP Monitoring
ABPM provides multiple readings away from medical
ABPM is indicated for evaluation of ‘suspected’ white-
(newly diagnosed stage 1, no target organ injury,
females, non smokers) .
Risk stratification: Non Dippers: BP drops by 10 to 20%
during the night; if not, signals possible increased risk
for cardiovascular events; higher nightime BP.
Evaluation of resistance to drug treatment
39.ABPM in large populations has revealed a significant number of patients who have elevated out-of-office readings despite normal office readings (masked hypertension)
40.Home Blood Pressure Monitoring
41.Home BP Monitoring
• Provides out of office readings, BP variability,
identification of WCH and MH
• Lower cost, high availability, easy application,
useful over long periods of time
• Improved BP, Fewer medications, better
results when used with a program for
adjustment of medications (McManus 2010;
42.SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION
Prescription or over-the-counter medications:
Oral contraceptives with estrogen.
Nonsteroidal anti-inflammatory agents, particularly chronic use.
Antidepressants, including tricyclic antidepressants and selective serotonin reuptake inhibitors
Weight loss medications
Stimulants, including methylphenidate and amphetamines
Illicit drug use – Drugs such as methamphetamines and cocaine
43.SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION
● Primary renal disease – Both acute and chronic kidney disease, particularly with glomerular or vascular disorders.
● Primary aldosteronism
● Reno vascular hypertension
● Obstructive sleep apnea
● Cushing's syndrome
● Other endocrine disorders: Hypothyroidism, hyperthyroidism, and hyperparathyroidism
● Coarctation of the aorta
44.In all other patients who have an elevated screening blood pressure, the diagnosis of hypertension should be confirmed using out-of-office blood pressure measurement, preferably ambulatory blood pressure monitoring (ABPM). Home blood pressure monitoring is an acceptable alternative to ABPM if ABPM is not possible.
USPSTF and the Canadian Hypertension Education Program (CHEP).
Long-acting calcium channel blockers (most often a dihydropyridine such as amlodipine)
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers (ARBs)
Combination therapy — In most cases, single-agent therapy will not adequately control blood pressure, particularly in those whose blood pressure is more than 20/10 mmHg above goal.
46.1/3 pills should be at bed time for non dippers.
Possible benefit from nocturnal therapy :
The average nocturnal blood pressure is approximately 15 percent lower than daytime values.
Failure of the blood pressure to fall by at least 10 percent during sleep is called "nondipping" and is a stronger predictor of adverse cardiovascular outcomes than daytime blood pressure.
48.Stroke and HTN tx:
Unlike the 2014 AHA/ASA guidelines:
It is suggested (a weaker recommendation) initiation of antihypertensive therapy for previously untreated patients with ischemic stroke or TIA of atherothrombotic, lacunar (small vessel occlusive), or cryptogenic type, whose baseline blood pressure is >120 mmHg systolic or >70 mmHg diastolic.
Not for nonhypertensive patients (i.e., blood pressure <140/90 mmHg) who have had an ischemic stroke or TIA due to a cardioembolic phenomenon (e.g., atrial fibrillation).
49.Acute Stroke: BP management 2009
Acute Ischemic Stroke
– Rx if SBP>200 or MAP >
– Not a lysis candidate:
150 mm Hg
• Consider Rx for
– If ICP possibly or definitely
>220/120 mm Hg
high try to keep SBP-ICP >
– 15-25% reduction
70* mm Hg
– Lysis candidate:
– If SBP >180 or MAP > 130
– Rx if SBP>180
mm Hg MAY Rx (to 160
SBP or 110 MAP) with care
• >185/110 mm Hg
– Condition like AHF, MI
Adams .. Stroke 2007;38:1655
Broderick .. Stroke 2007;38:2001
50.• Antihypertensive and by how much to
reduce BP are yet to be resolved.
Although BP lowering is effective for
recurrent stroke prevention, the degree of
BP reduction may be more important than
the class of agent used.”
Aiyagari Stroke June 2009; 40:2251-2256
51.IV BP medications of choice:
2nd line IV nitroprusside: increase ICP and platelet dysfunction.
52.TRIALS OF LONG-TERM ANTIHYPERTENSIVE THERAPY
PRoFESS trial — The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS)
PATS trial — The Post-stroke Antihypertensive Treatment Study (PATS)
53.PROGRESS: The Perindopril Protection Against Recurrent Stroke Study…..2ndary prevention.
Cumulative incidence of stroke (A) and major coronary events (B) among participants assigned active treatment and those assigned to placebo
54.PRoFESS: Prevention Regimen for Effectively Avoiding Second Strokes
Randomly assigned 20,332 patients with noncardioembolic ischemic stroke to receive either fixed-dose telmisartan (80 mg daily) or placebo.
All other antihypertensive drugs, except for angiotensin receptor blockers (ARBs), were permitted as add-on therapy.
no significant difference between the telmisartan and placebo groups in the primary outcome of recurrent stroke
55.PATS trial — The Post-stroke Antihypertensive Treatment Study (PATS)
Indapamide (2.5 mg daily) or placebo.
There were significantly fewer strokes in the active treatment compared with the placebo group.
Premature termination and a high drop-out rates.
Published in 2011 and included 40,300 patients from 16 randomized trials of antihypertensive therapy in patients with a prior stroke.
One-half of patients came from PRoFESS .
Antihypertensive therapy was associated with a significant reduction in recurrent stroke.
57.Bottom Line ….for 2ndary prevention of stroke
Monotherapy , Pick any :
angiotensin inhibitors (most trials have used ACE inhibitors)/ calcium channel blockers/ diuretics.
Do not got for BB.
angiotensin inhibitor plus a long-acting dihydropyridine calcium channel blocker: benazepril with amlodipine.
59.Medicine don’t work if you don’t take it….Non compliance.
• > 2/3 of hypertensives need > 1 drug
• Thiazide +
ACEi, ARB, CCB, b-blocker, non-thiazide diuretic
ACEi + Long-acting CCB
ARB + Long acting CCB
CCB + CCB, alpha blocker + beta blocker, alpha blocker + diuretic or RAS blocker
When to Use
initial therapy in those with Stage 2 hypertension
if BP > 15/10 mmHg above goal
62.Renin Profiling and Choice
of Antihypertensive Drugs
• 40% low renin; 15%-20% high renin;
40% medium renin
• Small studies demonstrate efficacy of
diuretics and calcium channel blockers in low-
renin HTN. ACE inhibitors and -blockers
demonstrate efficacy in high-renin HTN
• Small clinical trial (Egan et al) demonstrates
feasibility and efficacy of strategy
• Large studies evaluating this strategy have
not been done
63.Choosing Antihypertensive Drugs Based on Outcomes (Evidence Based Approach)
Drugs from all major classes (BB, CCB, ACE I, ARBs, Diuretics) reduce CVD
ACE inhibitors, ARBs, diuretics have similar cardiovascular benefits (CHF, MI); Calcium channel blockers may be less effective for CHF
Calcium channel blockers are particularly effective in preventing stroke
Reduce BP, prevent or delay the incidence of hypertension, enhance antihypertensive drug efficacy, and decrease cardiovascular risk.
Example: 1600 mg sodium DASH eating plan has BP effects similar to single drug therapy
Combinations of 2 (or more) lifestyle modifications better
Dietary Approaches to Stop Hypertension diet
High in fruit and vegetables
High in low-fat dietary products
Low total and saturated fat
65.Catheter-based radiofrequency ablation of renal sympathetic nerves
Due to the lack of benefit, a larger ongoing international trial (SYMPLICITY-HTN-4) was halted prematurely
Electrical stimulation of carotid sinus baroreceptors
66.THE END : Thanks for paying attention to those who did.