The Changing World of Hypertension Kim Kohne, OD Jeff Perotti, OD

Transcription

1 The Changing World of Hypertension Kim Kohne, OD Jeff Perotti, OD Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Presenter Information Kimberly D. Kohne, OD Jeffrey D. Perotti, OD 2

3 Disclosure Statement: Kohne - Nothing to disclose Perotti Nothing to disclose

4 Learning Objectives To discuss the role of optometrists in diagnosing and managing hypertensive patients To become familiar with the public health impact of hypertension in the United States in and the world To review the systemic impact of hypertension To review the ocular impact of hypertension To review the history of JNC-7, JNC-8, and the recent ACC/AHA hypertension guidelines 4

5 Learning Objectives To discuss elements of the recent ACC/AHA hypertension guidelines, including Blood pressure classification, including changes from JNC-7 and JNC-8 Blood pressure measurement and establishing a diagnosis of systemic hypertension Causes of systemic hypertension Lifestyle changes used to control hypertension Pharmacological interventions used to control hypertension How hypertension affects special groups Techniques the optometrist can use to impact compliance with hypertension control 5

6 Learning Objectives Review basic coding for systemic and ocular hypertension CPT ICD-10 6

7 Why Optometry Should Be Concerned with Hypertension 7

8 Impact of Hypertension Worldwide 8

9 Global Impact of Hypertension Approximately 40% of worldwide population age 25 and older has been diagnosed with HTN An increase from 600 million in 1980 to 1 billion in 2008 Does not account for un-diagnosed HTN A Global Brief on Hypertension WHO

10 Global Impact of Hypertension In 2010, HTN was the leading cause of death and disability worldwide Approximately 17 million deaths annually caused by cardio-vascular disease (CVD) Of these, approximately 9.4 billion deaths annually are associated with complications from HTN A Global Brief on Hypertension WHO

11 Global Impact of Hypertension HTN is responsible for at least 45% of deaths due to heart disease HTN is responsible for at least 51% of deaths due to stroke A Global Brief on Hypertension WHO

12 Global Impact of Hypertension In adults age 25 and older Prevalence of HTN in the African Region 46% Prevalence of HTN in the Americas 35% With respect to income Prevalence of HTN in high-income countries 35% Prevalence of HTN in low-income countries 40% A Global Brief on Hypertension WHO

13 Impact of Hypertension United States 13

14 US Impact of Hypertension >50% of deaths from coronary heart disease and stroke occurred among individuals with hypertension (NHANES study) HTN accounted for more CVD deaths than any other modifiable CVD risk factor and was second only to cigarette smoking as a preventable cause of death for any reason HTN was a primary or contributing cause of death for more than 410,000 Americans in that's more than 1,100 deaths each day 14

15 US Impact of Hypertension Approximately 33% of US adults have HTN Over 75 million US adults 2% of US children under the age of 18 have hypertension 59% of diagnosed hypertensives receive treatment 34% of those undergoing treatment are effectively controlled Poor compliance - 50% stop treatment after one year Poor access to healthcare 15

16 Ocular Effects of Hypertension 16

17 Vascular Response to Hypertension The eye is the only place in the body where you can see blood vessels Initial response to BP increase is vasoconstriction - seen clinically as narrowing of the retinal arterioles and subsequent decrease in the artery-vein ratio (AVR) Ratio of diameter of artery relative to diameter of vein Normal is 2/3 to 3/4 17

18 Vascular Response to Hypertension Persistently elevated blood pressure gives rise to the sclerotic stage Arteriosclerosis and thickening of the arteriole wall Increased arterial light reflex (ALR) A/V crossing changes 18

19 Ocular Effects of Hypertension Sub-conjunctival hemorrhage 19

20 Ocular Effects of Hypertension Retinal Vein Occlusions Branch Retinal Vein Occlusion (BRVO) Central Retinal Vein Occlusion (CRVO) Retinal Artery Occlusions Branch Retinal Artery Occlusion (BRAO) Central Retinal Artery Occlusion (CRAO) 20

21 BRVO 21

22 Ocular Effects of Hypertension Cranial Nerve Palsy CN III CN IV CN VI 22

23 Ocular Effects of Hypertension Wong and Mitchell Hypertensive Retinopathy Classification Grade Signs Systemic Associations Mild Moderate Severe Generalized and focal arteriolar narrowing, arteriovenous nicking, arteriolar wall opacification (increased ALR) Mild retinopathy and flame and/or blot heme, cotton wool spots, hard exudates and/or microaneuysms Moderate retinopathy and optic disc swelling Moderate risk of stroke, ischemic heart disease, cardiovascular mortality Strong risk of stroke, cognitive decline, congestive heart failure, renal dysfunction, cardiovascular mortality Increased mortality 23

24 Optometry s Role in Hypertension Embrace your role as a primary care provider I will advise my patients fully and honestly of all which may serve to restore, maintain or enhance their vision and general health Optometric Oath 24

25 Optometry s Role in Hypertension Measure BP in office Refer to primary care provider (PCP) if BP is poorly controlled Refer to PCP if BP is high in-office for further evaluation Refer to ER if BP is dangerously high Perform dilated eye examination to uncover undetected retinal vascular issues Patient education Increased risk of stroke Increased risk of heart attack Continued monitoring with PCP Possible discontinuation of eye examination and/or immediate referral to ER if blood pressure in-office deemed a medical emergency 25

26 Optometry s Role in Hypertension Provider communication Letter to primary care provider (PCP) blood pressure was 124/76 right arm, seated at 3:15 pm If appropriate, ask the PCP to provide further monitoring Telephone call to PCP may be indicated Poorly controlled, previously diagnosed hypertensive No prior HTN diagnosis Refer for further evaluation if in-office BP is high 26

27 A Brief History of Hypertension Guidelines 27

28 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNC 7 Report Published December 2003 in Hypertension. 2003;42:1206 JNC 6 Report Published 1997 JNC 5 Report Published 1992 JNC 4 Report Published 1988 JNC 3 Report Published 1984 JNC 2 Report Published 1980 JNC 1Report Published

29 JNC-7 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 29

30 JNC-7 Work supported entirely by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health, which is part of the U.S. Department of Health and Human Services 30

31 National High Blood Pressure Education Program Coordinating Committee American Academy of Family Physicians American Academy of Neurology American Academy of Ophthalmology American Academy of Physician Assistants American Association of Occupational Health Nurses American College of Cardiology American College of Chest Physicians American College of Occupational and Environmental Medicine American College of Physicians American Society of Internal Medicine American College of Preventive Medicine American Dental Association American Diabetes Association American Dietetic Association American Heart Association American Hospital Association American Medical Association American Nurses Association American Optometric Association American Osteopathic Association American Pharmaceutical Association American Podiatric Medical Association American Public Health Association American Red Cross American Society of Health-System Pharmacists American Society of Hypertension American Society of Nephrology Association of Black Cardiologists Citizens for Public Action on High Blood Pressure and Cholesterol, Inc. Hypertension Education Foundation, Inc. International Society on Hypertension in Blacks National Black Nurses Association, Inc. National Hypertension Association, Inc. National Kidney Foundation, Inc. National Medical Association National Optometric Association National Stroke Association NHLBI Ad Hoc Committee on Minority Populations Society for Nutrition Education The Society of Geriatric Cardiology Federal Agencies: Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services Department of Veterans Affairs Health Resources and Services Administration National Center for Health Statistics National Heart, Lung, and Blood Institute National Institute of Diabetes and Digestive and Kidney Diseases 31

32 Why JNC-7? Publications of many new studies Need for a new, clear, and concise guideline for clinicians Need to simplify the classification of BP 32

33 33

34 JNC 8 The group was formed in 2008 The findings were expected to be reported in 2010 JNC-8 report was published in December 2013 When it was released the President-Elect of the AHA stated that the AHA had reservations about the recommendations Less than a month after publication 5 of the 17 authors wrote a dissenting paper explaining why they didn t agree with the guidelines ACC/AHA stated they anticipate new guidelines to be released in

35 SPRINT Study Systolic Blood Pressure Intervention Trial (SPRINT) Conducted by the NIH Began in Fall 2009 Had 9300 participants 50 and older Did not include patients with diabetes, prior stroke, or polycystic kidney disease 35

36 SPRINT Study The study had two groups One group was controlled to a SBP of < 140 mm Hg per JNC 8 guidelines One group was controlled to a SBP of < 120 mm Hg Compared to first group, this group had reduced risk of CV events such as heart attack, stroke and heart failure by almost 33% Compared to first group, this group had reduced risk of death by almost 25% An average of 3 medications were used to get the SBP in the second group below 120 mm Hg This increased the likelihood of serious side effects 36

37 SPRINT Study The SPRINT study only included patients at high risk of CVD Therefore, the findings and advice did not necessarily apply to patients at lower risk The SPRINT study strongly influenced the 2017 guidelines from the American College of Cardiology and the American Heart Association 37

38 ACC/AHA Guidelines Released late 2017 American College of Cardiology (ACC) American Heart Association (AHA) Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Discusses Awareness Treatment Control Resulted in tighter blood pressure cut-offs and eliminated the term pre-hypertension 38

39 Awareness Self-Report a Hypertension Diagnosis 39

40 Blood Pressure Measurement In Office - Prepare Patient Seated, relaxed, feet on floor, back supported > 5 minutes prior to measurement Avoid caffeine, exercise, and smoking at least 30 minutes prior to measurement Best on an empty bladder No talking Remove clothing covering location of cuff placement No sitting or lying on an examination table 40

41 Blood Pressure Measurement In Office - Proper Measurements At first visit, record BP in both arms. Use arm with higher BP reading for subsequent measurements Separate repeat measurements by 1-2 minutes Inflate cuff 20 to 30 mm Hg above the radial pulse obliteration pressure for auscultatory measurements Deflate cuff 2 mm Hg per second, listen for Korotkoff sounds I - V 41

42 Blood Pressure Measurement In Office Document Accurate BP Readings Record SBP and DBP to the nearest even number, with arm and time 128/72 RA 4:24 PM Record time of most recent BP medication administration 42

43 Blood Pressure Measurement In Office Average the Readings and Provide to Patient Average 2 readings from 2 occasions to estimate the patient s BP Provide patient with SBP/DBP readings verbally and in writing 43

44 White Coat Hypertension When BP measured in an office or healthcare setting, patient measures as hypertensive When measured at home, patient does not measure as hypertensive Recommend use of ambulatory or home BP measurement to rule-out white coat hypertension Prevalence of white coat hypertension Increases with increasing age Is higher in females than males Is higher in non-smokers than current smokers 44

45 Masked Hypertension When BP measured in an office or healthcare setting, patient does not measure as hypertensive When measured at home, patient does measure as hypertensive Recommend use of ambulatory or home BP measurement to rule-out masked hypertension Prevalence of masked hypertension 10% to 26% (mean 13%) in population-based surveys 2X greater risk of CVD than in normotensives 45

46 JNC-7 Classification of HTN Classification Systolic Diastolic Normal < 120 mm Hg AND < 80 mm Hg Pre-hypertension mm Hg OR mm Hg Stage 1 hypertension mm Hg OR mm Hg Stage 2 hypertension 160 mm Hg OR 100 mm Hg 46

47 2017 ACA/AHA Classification of HTN American Heart Association at heart.org/hbp 47

48 JNC-7 v. ACA/AHA Classification Systolic Diastolic Normal < 120 mm Hg AND < 80 mm Hg Pre-hypertension (Elevated BP) mm Hg ( mm Hg) OR (AND) mm Hg (< 80 mm Hg) 48

49 JNC-7 v. ACA/AHA Classification Systolic Diastolic Stage 1 hypertension mm Hg ( mm Hg) OR mm Hg (80-89 mm Hg) Stage 2 hypertension 160 mm Hg ( 140 mm Hg) OR 100 mm Hg ( 90 mm Hg) Hypertensive Crisis (ACA/AHA only) > 180 mm Hg AND/OR > 120 mm Hg 49

50 Causes of Secondary Hypertension Sleep apnea 50% of heart disease patients have it 60% of stroke patients have it 80% of hard to control HTN have it.bad news!! Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing s syndrome Pheochromocytoma Co-arctation of the aorta Thyroid or parathyroid disease 50

51 Hypertensive Emergencies JNC 7 Patients with markedly elevated BP but without acute target-organ damage (TOD) usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy Patients with marked BP elevations and acute TOD (e.g. encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding or aortic dissection) require hospitalization and parenteral drug therapy 51

52 Hypertensive Urgency JNC 7 BP >180/ mm Hg No target-organ damage Contact PCP Control BP within 7 days Target-organ damage present (increased ALR with A/V crossing defects): Contact PCP Control BP within 3 days Urgencies are patient age-dependent and may need to be seen and controlled in a shorter time 52

53 Hypertensive Emergency JNC 7 BP >210/>120 mm Hg No TOD Urgent referral/phone PCP Control BP within 72 hours TOD present (increased ALR with A/V crossing defects) Urgent referral/phone PCP Control BP within hours TOD present (increased ALR with A/V crossing defects + papilledema) Emergent case referral to ER Phone ER MD & PCP Control BP within minutes to 24 hours 53

54 Hypertensive Urgency ACA/AHA Guidelines Type of Hypertensive Crisis Systolic BP Diastolic BP Treatment or Follow-up Hypertensive Urgency >180 mm Hg and/or >120 mm Hg Many of these patients are noncompliant with antihypertensive therapy and do not have clinical or laboratory evidence of new or worsening target organ damage; reinstitute or intensify antihypertensive drug therapy, and treat anxiety as applicable 54

55 Hypertensive Emergency ACA/AHA Guidelines Type of Hypertensive Crisis Systolic BP Diastolic BP Treatment or Follow-up Hypertensive Emergency >180 mm Hg + target organ damage and/or >120 mm Hg + target organ damage Admit patient to an intensive care unit for continuous monitoring of BP and parenteral administration of an appropriate agent in those with new/progressive or worsening target organ damage 55

56 CPT Codes for BP Measurement in Optometry No specific code utilized in optometry A non-reimbursable component of an examination Public health value Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report 56

57 ICD-10 Code R03.0 Elevated blood-pressure reading, without diagnosis of hypertension 57

58 ICD-10 Codes for Systemic Hypertension I10 Essential (primary) hypertension I11 Hypertensive heart disease I12 Hypertensive chronic kidney disease I13 Hypertensive heart and chronic kidney disease I15 Secondary hypertension Must have an associated second code specifying the etiology of the hypertension 58

59 ICD-10 Codes for Hypertension H35.03 Hypertensive retinopathy H hypertensive retinopathy, right eye H hypertensive retinopathy, left eye H hypertensive retinopathy, bilateral H hypertensive retinopathy, unspecified Must include one of the systemic hypertension codes with a hypertensive retinopathy code Can t have hypertensive retinopathy without systemic hypertension 59

60 Case Report Subjective RFV Stye OD Demographics 44 yo Caucasian female Medical History Seasonal, sinus related HA OTC Pain reliever Generalized HA with 2 large spots temporal to line of sight OU 60

61 Case Report Objective Visual acuities 20/20 OD 20/50- OS NIPH EOM s Full Pupils PERRLA, with no afferent pupillary defect noted Screening visual field Enlarged blind spots OU 61

62 Case Report Objective Blood pressure 240/150 mm Hg, right arm, seated Limited neurological screening Normal with no deficits or signs of impending stroke DFEx Bilateral optic disc edema Flame hemorrhages Exudates Exudative macular stars OU See next slide 62

63 Case Report 63

64 Case Report Assessment and Plan Severe hypertensive retinopathy secondary to hypertensive emergency SBP > 180 mm Hg and DBP > 120 and TOD (ocular) Patient immediately sent to local ED 64

65 Case Report Follow up Admitted to the hospital IV antihypertensive medications administered EKG Sinus tachycardia with some nonspecific T-wave changes Blood chemistry Hb: 11.7 g/dl ESR: 4 WBC: 8,900 with normal differential Blood urea nitrogen and creatinine: normal Thyroxine and triiodothyronine uptake: normal Serum K: borderline low 65

66 Case Report Follow up After 4 days of intravenous and oral therapy patient was released At discharge, BP was 134/96 mm Hg in right arm 140/102 mm Hg in left arm 66

67 Treatment Use of pharmacological and non-pharmacological interventions to lower BP 67

68 Risk Factors - Unmodifiable Age 50% of US adults age have HTN 75% of US adults age 70 and greater have HTN Race 38% of African-Americans have HTN 28% of Caucasians have HTN 68

69 Risk Factors - Unmodifiable Socioeconomic status increased risk of HTN with Less education Lower income Hereditary increased risk with family history of HTN Diabetes Mellitus (DM) Renal disease Cardio-vascular disease (CVD) 69

70 Non-Pharmacological Intervention Weight Loss Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension Weight/Body Fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. 5 mm Hg decrease in SBP 2 to 3 mm Hg decrease in SBP Expect about 1 mm Hg for every 1-kg reduction in body weight. 70

71 Non-Pharmacological Intervention DASH Diet Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension DASH (Dietary Approaches to Stop Hypertension) diet Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. 11 mm Hg decrease in SBP 3 mm Hg decrease in SBP 71

72 Non-Pharmacological Intervention Sodium Reduction Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension Decrease dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. 5 to 6 mm Hg decrease in SBP 2 to 3 mm Hg decrease in SBP 72

73 Non-Pharmacological Intervention Dietary Potassium Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension Aim for mg/d, preferably by consumption of a diet rich in potassium Dietary potassium levels Fruits, vegetables, low-fat dairy, select fish and meats, nuts, and soy products are all excellent sources of potassium 5 to 6 mm Hg decrease in SBP 2 to 3 mm Hg decrease in SBP 73

74 Non-Pharmacological Intervention Aerobic Activity Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension Physical Activity Aerobic minutes/week 65% 75% heart rate reserve 5 to 8 mm Hg decrease in SBP 2 to 4 mm Hg decrease in SBP 74

75 Non-Pharmacological Intervention Dynamic Resistance Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension minutes/week Physical Activity Dynamic Resistance 50% 80% 1 rep maximum 6 exercises, 3 sets/exercise, 10 repetitions/set 4 mm Hg decrease in SBP 2 mm Hg decrease in SBP 75

76 Non-Pharmacological Intervention Isometric Resistance Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension Physical Activity Isometric Resistance 4 2 min (hand grip), 1 min rest between exercises, 30% 40% maximum voluntary contraction, 3 sessions/wk 8 10 weeks 5 mm Hg decrease in SBP 4 mm Hg decrease in SBP 76

77 Non-Pharmacological Intervention Alcohol Consumption Intervention Dose Impact on SBP in Hypertension Impact on SBP in Normotension In individuals who drink alcohol, reduce alcohol to: Alcohol Consumption Men: 2 drinks daily Women: 1 drink daily 4 mm Hg decrease in SBP 3 mm Hg decrease in SBP 77

78 Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy 78

79 Risk of Atherosclerotic Cardiovascular Disease Atherosclerotic Cardiovascular Disease (ASCVD) 10 Year Risk can be calculated using the ACC/AHA Pooled Cohort Equations at 10 year ASCVD risk for those > 79 years of age is generally assumed to be > 10% 79

80 Follow Up After Initial BP Elevation Elevated BP or Stage 1 Hypertension, estimated10-year ASCVD risk < 10% Manage with non-pharmacological therapy Repeat BP evaluation within 3 to 6 months Stage 1 Hypertension, estimated 10-year ASCVD risk 10% Manage initially with a combination of non-pharmacological and antihypertensive drug therapy Repeat BP evaluation in 1 month 80

81 Follow Up After Initial BP Elevation Stage 2 Hypertension Evaluated by or referred to a primary care provider within 1 month of the initial diagnosis Initiate a combination of non-pharmacological and anti-hypertensive drug therapy (with 2 agents of different classes) Repeat BP evaluation in 1 month 81

82 Follow Up After Initial BP Elevation Very High Average BP (e.g., SBP 180 mm Hg or DBP 110 mm Hg) Evaluation followed by prompt antihypertensive drug treatment is recommended Normal BP Annual repeat evaluation 82

83 Treatment Guided by Risk Assessment In patients with an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher Use of BP-lowering medications is recommended for primary prevention of CVD in adults with no history of CVD and an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD 83

84 Treatment Guided by Risk Assessment Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher 84

85 Monotherapy v. Combination Therapy Stage 1 Hypertension Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target Stage 2 Hypertension Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target This is more aggressive than prior guidelines 85

86 Treatment Goals New guidelines recommend less than 130/80 in most cases Tighter than prior controls Recommend monthly follow up until control is achieved 86

87 Hypertension in Women Oral contraceptives may increase BP, and BP should be checked regularly In contrast, hormone replacement therapy (HRT) does not raise BP If HTN develops, consider other forms of contraception Pregnant women with HTN should be followed carefully Methyl-dopa, BBs, and vasodilators are preferred for the safety of the fetus ACEI and ARBs contraindicated in pregnancy 87

88 Case Report Subjective RFV Annual Exam Demographics 58 YO Caucasian female Medical History HTN X 10 years Last visit to PCP X 2 years ago D/C medications X at least one year No HA complaint 88

89 Case Report Objective Visual acuities 20/20 OD 20/20 OS EOMS Full Pupils PERRLA, without afferent pupillary defect. Screening visual field Normal OD and OS 89

90 Case Report Objective Blood pressure measurement 220/120 mm Hg, right arm, seated (confirmed with second reading at the end of the examination) Limited neurologic screening Normal with no deficits or signs of impending stroke DFEx No swelling of the optic nerves No retinal hemorrhages or exudates Generalized arterial narrowing with arterio-venous nicking OU See next slide 90

91 Case Report 91

92 Case Report Assessment and Plan Refractive New reading Rx given Elevated blood pressure reading without diagnosis of hypertension (R03.0) A hypertensive urgency per 2017 guidelines no TOD Patient education on strict BP control Immediate phone call to the patient s physician - appointment made to see patient within 24 hours An examination report, including dilated fundus findings, was faxed to PCP 92

93 Case Report Patient seen the next morning by PCP BP of 230/120 mm Hg 2 oral anti-hypertensive medications given in office BP reduced to 160/100 mm Hg at PCP s office ECP 3 and 8 months Retinal findings stable BP stable at 130/80 mm Hg 93

94 Control Achievement of satisfactory BP with treatment 94

95 Population-Based Strategy SBP Distributions Reduction in SBP (mm Hg) Reduction in Stroke Risk Reduction in Coronary Heart Disease Risk Total Risk Reduction 2-6% -4% -3% 3-8% -5% -4% 5-14% -9% -7% 95

96 Statistics on BP Control Of those with HTN 40% do not know they have HTN 45% know they have HTN and are taking medication 16% know they have HTN and are not taking medication 54% who are prescribed medication do not have controlled HTN 89% report having a usual source of health care 85% report having insurance Morbidity and Mortality Weekly Report, Sept. 7, 2012, Vol 16, No 35 96

97 Strategies to Improve Adherence to Treatment Once-daily dosing of anti-hypertensive medications results in better adherence to treatment plan than multiple daily dosing Combination medications results in better adherence to treatment plan than individual medications 97

98 Strategies to Promote Lifestyle Modification Effective behavioral and motivational strategies to achieve a healthy lifestyle (i.e., tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension Optometry can Review adherence to lifestyle modifications Direct patients to pertinent resources Re-educate patients as necessary Reward successes 98

99 Team-Based Care A team-based care approach is recommended for adults with hypertension Optometry can be part of a team-based approach by Measuring BP Communicating/educating patient Communicating with PCP 99

100 The End 100

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