Prevention of Heart Failure: What s New with Hypertension

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1 Prevention of Heart Failure: What s New with Hypertension Ali AlMasood Prince Sultan Cardiac Center Riyadh 3ed Saudi Heart Failure conference, Jeddah, 13 December 2014

2 Background 20-30% of Saudi adults have HTN Prevalence increases with age Control of the disease is far from adequate (46 to 51 % of pts have BP under control)

3 The Magnitude of the Problem It is a major risk factor for HF, stroke, MI, CRF, cognitive decline and premature death. Untreated HTN cause vascular and renal damage leading to a treatmentresistant state.

4 The Magnitude of the Problem HTN is the single largest risk factor for CV mortality (45% of all CVD deaths ) A Population-Based Policy Approach to Control Hypertension,2010 INTERSTROKE Study concluded that HTN provides 34.6% of the population-attributable risk for stroke The Lancet, 2004: 9438, INTERHEART found it provides 17.9% of the PAR for myocardial infarction The Lancet 2010; 376:112 23

5 The Magnitude of the Problem Each 2 mmhg rise in systolic blood pressure associated with increased risk of mortality: 7% from heart disease 10% from stroke.

6 Treating Hypertension to Prevent HF Aggressive blood pressure control: Decreases risk of new HF by ~ 50% 56% in DM2 Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 80% Lancet 1991;338: (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:

7 Tools for Diagnosing HTN and Monitoring BP Office BP monitoring Ambulatory (ABPM) Home blood pressure monitoring (HBPM)

8 HTN definitions Multiple office BP measurements, taken on at least two separate visits, 1 4 weeks apart (CHEP) Hypertension: Stage 1: systolic mmhg or diastolic mmhg Stage 2: systolic 160 or diastolic 100 mmhg Severe HTN : systolic 180 or diastolic 110 mmhg lower BP measurements for defining hypertension based on ambulatory (ABPM) or home blood pressure monitoring (HBPM)

9 Ambulatory BP mmhg Manual office BP misses out on white coat and masked HTN Masked Hypertension Hypertension Normotension White Coat Hypertension Manual Office BP mmhg From Pickering et al. Hypertension 2002;40:

10 CV events per 1000 patient-year The prognosis of masked hypertension Prevalence is approximately 10% in hypertensive patients CV Events 0 Normal 23/685 White coat 24/656 Uncontrolled 41/462 Masked 236/3125 Okhubo et al. J. Am. Coll. Cardiol. 2005;46;

11 Indications for ABPM Suspected white coat HTN Suspected episodic HTN(eg, pheochromocytoma) Resistant to increasing medication Hypotensive symptoms while taking antihypertensive medications Autonomic dysfunction

12 Specialist referral Accelerated hypertension (180/110mmHg with signs of papilloedema and/or retinal haemorrhage) Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis). Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension.

13 Major consensus findings and discrepancies between guidelines Multiple office BP measurements are the gold standard for diagnosis Self-monitoring can aid diagnosis and long-term BP monitoring NICE states that ABPM is the gold standard for diagnosis before initiating therapy (daytime average BP [135/85 defined as HTN)

14 Blood Pressure Thresholds for Initiating Treatment

15 Blood Pressure Thresholds for Initiating Treatment

16 Initiating and monitoring HTN treatment For people aged <40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or DM, consider secondary causes of hypertension

17 Target Blood Pressure Levels

18

19 Health Behavior Intervention Strategies

20 Impact of lifestyle therapies on blood pressure Intervention Targeted change Expected BP change Sodium reduction < 1500 mg/day -5 / -3 Weight loss BMI < 25 kg/m 2-7 / -6 Alcohol reduction < 2 drinks/day -5 / -2 Exercise 4+ times/week -5 / -4 Dietary patterns DASH diet -11 / -6 Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999;Nov/Dec;191-8

21 consensus findings and discrepancies between guidelines Important role in combination with pharmacological treatment Focus on the same factors e.g., diet and exercise Initiation before (ASH/ISH, AHA/ACC/CDC, ESH/ESC, NICE, France) or in conjunction (China, Taiwan), with pharmacological treatment

22 Pharmacological Treatment Recommendations

23 Choice of therapy in HTN Thiazide-type diuretics Angiotensin - converting enzyme (ACE) inhibitors angiotensin II receptor blockers ( ARBs) Calcium channel blockers

24 Indications for specific drugs ACEI HF or asymptomatic LV dysfunction STEMI / NSTEMI Diabetes Proteinuric chronic kidney disease ARBS not tolerate ACEI Severe HTN with LVH LIFE study, Lancet. 2002;359(9311):99

25 Indications for specific drugs Thiazide diuretics The preferred thiazide diuretic in patients with primary hypertension is chlorthalidone CCB Long-acting dihydropyridines are most commonly used non-dihydropyridine CCB for AF and tachyarrythmia

26 B-Blockers Not advised for treatment of general population in the JNC 8, ASH/ISH. AHA/ACC/CDC, NICE, Taiwan guidelines and are restricted to those < 60 years of age in CHEP guidelines

27 Indications for specific drugs Spironolactone Used for resistant HT with normal aldosterone levels, mg/daily Additional benefits: antiproteinuric, improves heart failure survival (RALES) 10% gynecomastia Not when creatinine > 2.5, K > 5.0

28 General principles Each of the antihypertensive agents is roughly equally effective in lowering BP ( good response in 30 to 50 %) black patients respond better to with thiazide diuretic or CCB and poorly to ACE inhibitor or beta blocker

29 Drugs Dosing The largest reduction in BP was seen at a half dose with only modestly greater reductions standard or twice standard doses With thiazide diuretics, CCB and beta blockers, the adverse effects increased significantly with standard or twice standard doses compared to half standard doses. Very low rate of side effects with ACE inhibitors and ARBs and no dose dependence. BMJ. 2009;338:b1665

30 General principles If possible, offer drugs taken only once a day. Prescribe non-proprietary drugs if these are appropriate and minimize cost Do not combine an angiotensinconverting enzyme (ACE) inhibitor with an angiotensin II receptor blocker (ARB).

31 Choice of antihypertensive monotherapy does not predict outcome the amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension, not the choice of antihypertensive drug

32 Monotherapy is often not enough: medication use and BP control in ALLHAT % Drugs 2 Drugs 1 Drug 20 0 Baseline 6 mo 1 y 3 y 5 y

33 Number of drugs Monotherapy is often not enough, especially for those with diabetes UKPDS ABCD MDRD HOT AASK IDNT ALLHAT

34 2007 to 2013 ESH-ESC Guidelines: A trend to prescribe combination therapy earlier and more often There is now conclusive evidence from trials that combination treatment is needed to control blood pressure in the majority of patients Evidence has continued to grow that in the vast majority of hypertensive patients, effective BP control can only be achieved by combination of at least two antihypertensive drugs The advantage of initiating with combination therapy is - a prompter response - a greater probability of achieving the target - lower probability of discouraging patient adherence.

35 Cohort of 83,320 hypertensive patients Mean age 65, free of CVD, newly treated for HT ( ) RR for Congestive Heart Failure Perreault et al. J Int Med 2009 High vs low adherence = -11% events

36 Adherence can be improved by a multi-pronged approach Assess adherence at every visit Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth. Simplify medication regimens using long-acting once-daily dosing Utilize fixed-dose combination pills Utilize unit-of-use packaging e.g. blister packaging

37 Adherence can be improved by a multi-pronged approach Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure Educate patients and patients' families about their disease/treatment regimens verbally and in writing Use an interdisciplinary care approach coordinating with work-site health care givers and pharmacists if available Encouraging adherence by healthcare practitionerbased telephone contact, particularly, over the first three months

38 Assess global cardiovascular risk in all hypertensive patients 91% of hypertensive patients have at least 1 additional risk factor 91% Risk factors = Global CV risk Rantala A, et al. J Intern Med 1999;245; Wannamethee S, et al. J Hum Hypertens 1998;12;735-41

39 Impact of discussing coronary risk with patients on blood pressure treatment Grover SA, et al. J Gen Intern Med 2009;24(1);33-9

40 What s still important? Lifestyle changes are a critical component of hypertension management and prevention Single pill combinations help achieve blood pressure control The most important step in prescription of antihypertensive therapy is achieving patient buy-in The management of hypertension is all about global cardiovascular risk management and vascular protection

41 Take Home Message Individualise treatment to meet patient needs Simplify drug regimens by using long-acting drugs and SPCs Gaining BP control as soon as possible improves persistence Patient education improves persistence Regular monitoring is required

42 Take Home Message Optimum management of BP requires assessment of overall cardiovascular risk Home BP monitoring is an important tool in self-monitoring and self-management Treat to target Focus on adherence

43 What we already know High prevalence of untreated HTN Economic burden of inadequate BP control Controlling BP with medication is one of the most cost-effective methods of reducing premature CV morbidity and mortality

44

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