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2021-9-26 published at Product Training/ Manuals category

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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.
2.Disclosure I have no financial relationships with manufacturers, industry related to this lecture to disclose. I am an employee of Renal Care Associates.
3.Agenda 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
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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
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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 Syndrome Patients with hypertension have more cardiovascular disease 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.
14.Metaanlaysis of 147 trials: Clinical trials and Observational Studies Demonstrate Similar Risk Reduction associated with lowering BP 10 mm Hg systolic or 5 mm Hg diastolic 22-25% for CHD; 34-40% for Stroke Law, M R et al. BMJ 2009;338:b1665 Copyright ©2009 BMJ Publishing Group Ltd.
15.Unequivocal Benefits of Lowering BP: Relative Risk Reduction Constant Absolute Risk Reduction Varies Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
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.
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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 directors. 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.
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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.
25.http://www.ash-us.org/ASH-CHC-Providers.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: quantitative echocardiography exercise testing ankle-brachial index carotid Doppler Evaluation of Autonomic function Renal angiography Renal vein renin sampling
27.Requirement for approval of HTN center: Doppler renal ultrasound CT Angiography MR Angiography Adrenal vein sampling of aldosterone. Interventions: Renal angioplasty with/without stenting. Laparoscopic adrenalectomy. Sleep Lab. 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 We are one click away!
31.Our Team: Holy Walker
32.Extensive Testing: Renal Doppler Echo 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 ‘Correct’ ‘Incorrect’
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 environment ABPM is indicated for evaluation of ‘suspected’ white- coat HTN (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 Hypotensive episodes
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; Agarwal 2011)
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 Glucocorticoids Decongestants. Weight loss medications Erythropoietin Cyclosporine 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 ● Pheochromocytoma ● 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).
45.Initial Treatment: Thiazide diuretics 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.
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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 ICH 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 contra-indicates (troponin), and thrombolytic encephalopathy warrant approach lower goals 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: IV Labetalol IV Nicardipine 2nd line IV nitroprusside: increase ICP and platelet dysfunction.
52.TRIALS OF LONG-TERM ANTIHYPERTENSIVE THERAPY PROGRESS trial PRoFESS trial — The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) PATS trial — The Post-stroke Antihypertensive Treatment Study (PATS) Meta analysis.
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.
56.METANALYSIS: 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. Combined; 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.
60.Combination Therapies • > 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
61.Resistant Hypertension • Failure to achieve targets on 3 drugs (including diuretic) Older age, BMI, African American, excess sodium, alcohol Secondary causes: Aldo, Sleep Apnea, RVH Excess sympathetic tone, increased aldo Lifestyle, diuretics, aldosterone blockade Renal Nerve ablation: investigational
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
64.Lifestyle modifications 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 Quit smoking Dietary Approaches to Stop Hypertension diet High in fruit and vegetables High in low-fat dietary products Whole grains Low total and saturated fat
65.Catheter-based radiofrequency ablation of renal sympathetic nerves DENERHTN 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.

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