8/20/2017. No Conflicts. I struggled with everything cardiac in nursing school. Review background and definitions of hypertension with

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1 Cindy Weston, DNP, RN, CCRN, CNS CC, FNP BC Assistant Professor Texas A&M University College of Nursing Review background and definitions of hypertension with appropriate ICD 10 Discuss evidence for diagnosis and treatment of resistant hypertension Describe classifications of pharmacologic treatment of resistant hypertension Apply evidence based guidelines to the treatment of resistant No Conflicts I struggled with everything cardiac in nursing school. 1

2 34% US adults > 18 year old 6% undiagnosed 77% people with 1 st stroke BP > 140/90 76% of those diagnosed are on pharmacotherapy 46.5% are NOT controlled Health disparity black women Overall Death rate: 18.8 per 1000 per year Cost = $46.4 Billion $274 billion Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28 e Benjamin et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2017 update: a report from the American Heart Association [published online ahead of print January 25, 2017]. Circulation. doi: /CIR HDS 4 Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high (GOAL = 92.6% = 91.8%) HDS 5 Reduce the proportion of persons in the population with hypertension HDS 9 Increase the proportion of adults with prehypertension who meet the recommended guidelines HDS 10 Increase the proportion of adults with hypertension who meet the recommended guidelines HDS 11 Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure HDS 12 Increase the proportion of adults with hypertension whose blood pressure is under control (GOAL = 61.2%) 43.7% 50.3% objectives/topic/heart disease and stroke/objectives 2

3 HDS 4 Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high (GOAL = 92.6% = 91.8%) HDS 5 Reduce the proportion of persons in the population with hypertension HDS 9 Increase the proportion of adults with prehypertension who meet the recommended guidelines HDS 10 Increase the proportion of adults with hypertension who meet the recommended guidelines HDS 11 Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure HDS 12 Increase the proportion of adults with hypertension whose blood pressure is under control (GOAL = 61.2%) 43.7% 50.3% HDS 25 Increase the proportion of patients with hypertension in clinical health systems whose blood pressure is under control (58.3% 64.3%) objectives/topic/heart disease and stroke/objectives Measure Population NCQA CMS/AHIP ACO/PCMH Controlling High Blood Pressure CPC+ HEDIS Adult CMS165v6 Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period (exclusions: ESRD, renal transplant, pregnancy, hospice.) Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the measurement period CMS65v7 Percentage of patients aged years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period Patients whose follow up blood pressure is at least 10 mmhg less than their baseline blood pressure or is adequately controlled. and guidance/legislation/ehrincentiveprograms/ecqm_library.html 3

4 Bladder Width > 40% arm circumference Bladder length % arm circumference Cuff too small = False high BP Cuff too big = maybe ok but maybe False low BP mmhg higher in legs than arms Right Arm = standard No caffeine or Tobacco 30 minutes before measurement Empty bladder Seated, Back supported, Feet flat on floor for 5 minutes before measurement Arm at heart level resting on support 2 readings 1 minute apart & average (repeat other arm) If variation always use arm with higher readings Useful to take standing measurement to check postural effects (older adults) If high on automated machine should be repeated by auscultation 1 2 minutes. Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G.Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32: topics/topics/hbp/diagnosis BP > on 2 separate visits If 1 elevated BP reading bring patient back in 1 4 weeks for a repeat BP BP > 180/100 at any single visit Be mindful of white coat hypertension phenomenon Home BP readings/log (5 7 days minimum) Ambulatory Blood Pressure Monitoring Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G.Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32:

5 Cardiovascular Events Stroke/TIA (vascular dementia) CAD MI, angina, prior stents/cabg Heart Failure Left Ventricular Systolic function Chronic Kidney Disease Peripheral Arterial Disease Diabetes Mellitus OSA HTN Heart Disease Heart Failure Kidney Disease ICD 10 codes I Cardiac codes Description YES No No No I10 Essential (Primary) Hypertension YES YES No No I11.9 Hypertensive Heart Disease without Heart Failure YES YES YES* No I11.0 Hypertensive Heart Disease with Heart Failure YES No No Yes** I12.9 Hypertensive Chronic Kidney Disease stages 1 4 YES No No Yes** I12.0 Hypertensive Chronic Kidney Disease Stage 5 or endstage Renal Disease YES YES No Yes** I13.10 Hypertensive Heart Disease without Heart Failure WITH Chronic Kidney Disease stages 1 4 YES YES No Yes** I13.11 Hypertensive Heart Disease without Heart Failure WITH Chronic Kidney Disease stage 5 or end stage Renal Disease YES YES Yes* Yes** I13.0 Hypertensive Heart Disease with Heart Failure and Chronic Kidney Disease stages 1 4 YES YES Yes* Yes** I13.2 Hypertensive Heart Disease with Heart Failure and Chronic Kidney Disease stage 5 or end stage Renal Disease * Requires type of Heart Failure ICD 10 code ** Requires type of Renal Disease ICD 10 code Adapted from: Family Practice Management, Coding Hypertensive Diseases under ICD rt1.pdf CMP Fasting Lipids UA microalbuminuria ECG?H/H 5

6 Study Yr n Criteria Result Conclusion HOT Hypertension Optimization Treatment Study ALLHAT Antihypertensive and Lipidlowering Treatment to Prevent Heart Attack Trial ACCOMPLISH Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension HYVET Hypertension in the Very Elderly Trial ACCORD Action to Control Cardiovascular Risk in Diabetes AASK African American Study of Kidney Disease and Hypertension Trial ,790 Age HTN DBP ,357 HTN + 1 risk factor (1/3 DM) ,000 HTN, High CV risk , years old , year old DM II x 10 yrs with CAD or 2+ RF ,094 Black, HTN, nephrosclerosis, NO DM 3 groups: DBP < 80 DBP <85 DBP <90 All received Felodipine + 4 groups: Chlorthalidone Lisinopril Amlodipine Doxazosin **stopped CHF/Stroke 2 groups: Benazepril + Amlodipine Benazepril + HCTZ 2 groups Indapamide SR Placebo 2 groups Goal SBP < 140 mmhg Goal SBP < 120 mmhg 3 groups Metoprolol Ramipril Amlodipine Lowest CV event DBP = 82.6 mmhg, Lowest mortality DBP = 86.5 mmhg No difference in primary outcome or mortality Less CV events (9.6 % vs 11.8%) with ACEI/ combo Lower BP associated with risk reduction No difference in CV events No difference in GFR BUT ACEI more effective in slowing decline of GFR than BB or DBP < 90 mmhg No difference in CV event or stroke ACEI/ combo in thin, high risk Small decrease in stroke with intensive control group ACEI best, Lower BP may be benefit with proteinuria 1977 JNC JNC JNC JNC JNC JNC 6 AHA/ACC/CDC advisory algorithm ASH/ISH Canadian 2011 British 2012 European 2003 JNC 7 (delayed wait for ALLHAT) 2014 JNC 8 Chopra,. & Nanda, N. (). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers. BP Goal JNC JNC ASH/ISH ESC/ESH CHEP Age < 60 <140/90 <140/90 <140/90 <140/90 <140/90 Age <140/90 <150/90 <140/90 <140/90 <140/90 Age 80+ <140/90 <150/90 <150/90 <150/90 <150/90 Diabetes <130/80 <140/90 <140/90 <140/85 <130/80 CKD <130/80 <140/90 <140/90 <130/90 <140/90 Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9),

7 Comparison of expected and observed effects of a 7 mm Hg systolic blood pressure decrease on coronary heart disease and stroke outcomes 35% 30% 25% 20% 15% 10% 5% 0% Coronary heart disease Stroke BP 133/76 Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), Xie, X. et al. (2016). Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta analysis. Lancet, 387(10017),

8 Mediterranean (low evidence) DASH (high evidence) Reduce dietary Sodium (high evidence) Exercise Blood Pressure If DM or 3 risk factors < 6 7/2 3 mmhg Healthy < 2 3/1 2 mmhg Lipids No change < 5 6/3 mmhg < LDL 11mg/dL <HDL 4 mg/dl No change TG Lowers BP 1150mg/d < 3 4/1 2 mmhg < 2 5/1 4 mmhg (high evidence) No change < LDL 2.5 mg/dl < non HDL 6 mg/dl No change TG No change HDL (moderate evidence) EXERCISE: at least 12 weeks duration, 3 to 4 sessions per week, lasting on average 40 minutes per session, and involving moderate to vigorous intensity physical activity. Strength of evidence: High Eckel, R.H.. et al. (). AHA/ACC Guideline on lifestyle management to reduce cardiovascular risk. Circulation. Comparison of expected and observed effects of a 7 mm Hg systolic blood pressure decrease on coronary heart disease and stroke outcomes 35% 30% 25% 20% 15% 10% 5% 0% Coronary heart disease Stroke BP 133/76 Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15), Xie, X. et al. (2016). Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta analysis. Lancet, 387(10017),

9 Diuretics ACEI: Angiotensin Converting Enzyme Inhibitors ARB: Angiotensin Receptor Blockers Calcium Channel Blockers Beta Blockers Alpha Blockers Central Acting Vasodilators Potassium Channel Activators JNC Non black Black Diabetes Without CKD All races, BB, JNC ASH/ISH < 60 ACEI, ARB > 60,, ESC/ESH, BB, BB ACEI, ARB CHEP ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9),

10 Diuretics Drug Class Drug Dose Interval Benzophenone Chlorthalidone (Hygroton) mg Daily Benzothiadiazine HCTZ mg Daily Indapamide (Lozol) mg Daily Quinazolinones Metolazone (Zaroxolyn) mg Daily JNC Non black Black Diabetes Without CKD, BB, JNC ASH/ISH < 60 ACEI, ARB > 60,, ESC/ESH, BB, BB ACEI, ARB CHEP ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), ACEIs Renin Inhibitor ARBs Aldosterone Antagonist 10

11 Captopril (Capoten) Lisinopril (Zestril, Prinivil) Enalapril (Vasotec) Ramipril (Altace) Fosinopril (Monopril) Benazepril (Lotensin) Quinapril (Accupril) Trandolapril (Mavik) Perindopril (Aceon) Losartan (Cozaar) Candesartan (Atacand) Valsartan (Diovan) Telmisartan (Micardis) Irbesartan (Avapro) Omesartan (Benicar) Eprosartan (Teveten) 11

12 Aliskiren (Tekturna) CYP3A4! Avoid grapefruit juice, azoles JNC Non black Black Diabetes Without CKD, BB, JNC ASH/ISH < 60 ACEI, ARB > 60,, ESC/ESH, BB, BB ACEI, ARB CHEP ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Dihydropyridines Non dihydropyridines Amlodipine (Norvasc) Verapamil (Isoptin, Calan) Felodipine (Plendil) Diltiazem (Cardizem, Dilacor) Isradipine (DynaCirc) Nifedipine (Procardia XL, AdalatCC) Nisoldipine (Sular) Avoid grapefruit juice 12

13 JNC 7 Beta JNC 8 Blocker ASH/ISH Therapy ESC/ESH CHEP Percentage of patients aged 18 years and < 60 ACEI, ARB older with a diagnosis of > 60coronary, ACEI, artery ARB,, BB disease or heart failure seen within a 12 month period who also have a prior, BBMI OR a current or prior LVEF <40% who ACEI, were ARB, prescribed beta blocker therapy Non black Black Diabetes Without CKD, BB, ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Metoprolol (Lopressor, Toprol) Atenolol (Tenormin) Bisoprolol (Zebeta) Esmolol (Brevibloc) Carvedilol (Coreg) Propranolol (Inderal) Labetalol (Trandate) Nadolol (Corgard) Nebivolol (Bystolic) JNC Non black Black Diabetes Without CKD, BB, JNC ASH/ISH < 60 ACEI, ARB > 60,, ESC/ESH, BB, BB ACEI, ARB CHEP ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9),

14 Terazosin (Hytrin) Prazosin (Minipress) Doxazosin (Cardura) Phentolamine (Regitine) JNC Non black Black Diabetes Without CKD, BB, JNC ASH/ISH < 60 ACEI, ARB > 60,, ESC/ESH, BB, BB ACEI, ARB CHEP ACEI, ARB (BB if < 60) ARB (BB if < 60), CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB Salvo, M. & White, C.M. (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Clonidine Methyldopa 14

15 Loop Diuretics Furosemide Torsemide Bumetanide Ethacrynic Acid Mineralcorticoid Antagonist Spironolactone Eplerenone Sodium Channel Blocker Amiloride Hydralazine Sodium Nitroprusside Minoxidil (Loniten) Diazoxide (Proglycem) Uncontrolled blood pressure despite the use of three optimized antihypertensive medications, of which one is a diuretic. Prevalence is unknown (Estimated 10 30%) D. A. Calhoun, D. Jones, S. Textor et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510 e

16 Poor adherence Provider inertia Inadequate doses Inappropriate combinations of meds Excess alcohol intake Obstructive Sleep Apnea D. A. Calhoun, D. Jones, S. Textor et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510 e526. P. A. Sarafidis and G. L. Bakris, (2008). Resistant hypertension. An overview of evaluation and treatment. Journal of the American College of Cardiology, 52(22), Thyroid Disease OSA Primary Hyperaldosteronism Renal Artery Stenosis Cushings Disease Coarctation of the Aorta Hyperparathyroidism Pheochromocytoma Faselis, C., Doumas, M. & Papademetriou, V. (2011). Common secondary causes of resistant hypertension and rational for treatment. International Journal of Hypertension,. 16

17 Increase diuretic dose Consider a loop if GFR< 30mL/min/1.73m 2 Add an alpha blocker Use a combined alpha/beta blocker: carvedilol, labetalol Add spironolactone, epleronone, OR amiloride Add hydralazine, clonidine, guanfacine, Consider using BOTH a nondihydropiradine AND a dihydropiradine Consider minoxidil REFER to A HYPERTENSION SPECIALIST: Viera, A.J. 7 Hinderlier, A.L. (2009). Evaluation and management of the patient with difficult to control or resistant hypertension. American Family Physician, 79(10), BP remains > 140/90 (>age ) despite 3 antihypertensives (1 being a diuretic) Review Lifestyle Factors & Coach patient Obesity, excess alcohol, high salt intake, DASH diet, physical activity Stop or Minimize interfering substances NSAIDS, OCPs, Alcohol, Ephedra, etc. Assess Adherence Review Home BP log SCREEN for SECONDARY causes of Hypertension Adjust Pharmacologic Treatment Maximize Diuretic include Spironolactone REFER to a SPECIALIST Cardiology Nephrology 17

18 NSAID use Belief System Medication Adherence Medication Affordability Home Blood Pressure Monitoring Self Titration Patient Selection BP Goals: < 140/90 Home BP monitoring Patient Centered Care Self Titration in select populations Facilitate healthy lifestyle modification 18

19 QUESTIONS?? Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. (2008). Treatment of hypertension in patients 80 years of age or older. NEJM;358(18): B. Benjamin et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2017 update: a report from the American Heart Association [published online ahead of print January 25, 2017]. Circulation. doi: /CIR Caboral Stevens, M. & Rosario Sim, M. (2014). Review of the Joint National Committee s recommendations in the management of hypertension. JPN, 10(5), Calhoun, D. A., Jones, D., Textor, S. et al., (2008). Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, 117(25), e510 e526. Chobanian AV. Bakris GL. Black HR, et al; (2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, 289(19), Chopra,. & Nanda, N. (). Textbook of Cardiology: A Clinical and Historical Perspective. New Delhi: Jaypee Brothers Medical Publishers. Cushman WC, Evans GW, Byington RP, et al; (2010). ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. NEJM;362(17): Eckel, RH, et al. (). AHA/ACC guideline on lifestyle management to reduce cardiovascular risk, Circulation. Salvo, M. & White CM (2014). Reconciling multiple hypertension guidelines to promote effective clinical practice. Annals of Pharmacotherapy, 48(9), Egan, B., Li, J., Hutchison, F. & Ferdinand, K. (2014). Hypertension in the United States : Progress toward Healthy People 2020 Goals. Circulation. Faselis, C., Doumas, M. & Papademetriou, V. (2011). Common secondary causes of resistant hypertension and rational for treatment. International Journal of Hypertension. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation. 2014; 129(3):e28 e292. Healthy People 2020 Heart Disease and Stroke. objectives/topic/heart disease and stroke/objectives. Accessed August 16, James, P. et al. (2014) Evidence based guideline management of high blood pressure in adults: Report from the panel members appointed to the eighth Joint National Committee (JNC8). JAMA, 311(5), Wright, JT, et al. (2015). A randomized trial of intensive versus standard blood pressure control. NEJM 373, Leung AA, et al. Hypertension Canada s 2016 CHEP Guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention and treatment of hypertension. Can J Cardiol. 2016; 32: National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; (2003). National High Blood Pressure Education Program Coordinating Committee The JNC 7 report. JAMA. 289(19):256O Sarafidis, P. A. and Bakris, G. L. (2008). Resistant hypertension. An overview of evaluation and treatment. Journal of the American College of Cardiology, 52(22), Viera, A.J. 7 Hinderlier, A.L. (2009). Evaluation and management of the patient with difficult to control or resistant hypertension. American Family Physician, 79(10), Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindholm, L.H., Kenerson, J.G.Harrap, S.B. (2014). Clinical practice guidelines for the management of hypertension in the community: A statement by the American Society of Hypertension and the International Society of Hypertension. Journal of Hypertension, 32: Whelton, P. et al. (2003). Primary prevention of hypertension. JAMA, 288(15),