Mr Patrick Gladding. Specialist General Cardiology and Internal Medicine Auckland

Transcription

1 Mr Patrick Gladding Specialist General Cardiology and Internal Medicine Auckland 16:30-17:25 WS #60: Individualising Hypertension Treatment - Intensive or Not? 17:35-18:30 WS #72: Individualising Hypertension Treatment - Intensive or Not? (Repeated)

2 Individualising Hypertension Treatment: Intensive or not? Dr. Patrick Gladding, MBChB, FRACP, PhD Ascot Cardiology

3 Hypertension update Outline New Guidelines Definitions and treatment thresholds Global risk, investigations (Pulse wave velocity) and monitoring (mhealth) Targets SPRINT trial Lifestyle interventions (Functional Foods) Genomics and Personalised Care

4 Secondary causes of Hypertension Aortic coarctation Cushings syndrome

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8 Office BP White coat hypertension Ambulatory 24-hr BP (ABPM) Masked hypertension Home blood pressure monitoring Increased granularity White coat hypertension Feedback Dietary/Lifestyle and drug n=1 trials Adherence Personal control JAMA. 2014;312(8): patients 9mmHg SBP reduction with self-mx

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12 2 emerging techniques in echo to improve detection of end-organ damage: 1) LV strain; Deformation of the LV vs EF 2) LV mass

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14 Hypertension update 76 yr old man Supine HTN orthostatic hypotension (~50mmHg) Arterial stiffness indicates lower central BP 14

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16 JNC 8 Goal for people > 60 yrs should be a SBP < 150, DBP < 90

17 1466 older men and women For fit elderly patients, a high DBP (>90 mm Hg) was associated with a 50% increase in mortality The ultimate goal is personalized treatment so that we can avoid overtreatment of the frail, and undertreatment of the fit. By contrast, for frail elderly patients, a low DBP was associated with a 50% increased risk of dying during 15 year follow-up period

18 9361 patients (age, 50) with SBP of 130 to 180 mm Hg and high cardiovascular (CV) risk One or more: CV disease, CKD EGFR ml/minute/1.73 m2, 10-year Framingham CV risk 15%, or age 75 Patients with diabetes and stroke were excluded. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively) The trial was terminated early after median follow-up of 3.3 years The primary composite outcome (MACE) occurred in 5.2% of intensivetreatment patients and 6.8% of standard-treatment patients (P<0.001)

19 First, the results should not be considered a mandate for people to run out and get treated so their blood pressures are below 120. Second, the potential benefits of lowering blood pressure must be weighed against harms. Third, we need more information about the balance of risks and benefits for each person so that the choice can be personalized.

20 The ideal blood pressure for most people is likely to be below 120 mmhg systolic and 75 mmhg diastolic. The 2017 AHA/ACC guideline s recommended treatment goal is to reach office BP levels of less than 130mmHg (systolic) and less than 80 mmhg (diastolic) if pharmacotherapy is commenced.

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22 Personalised Hypertension Management 80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations. Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od. She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/l. Creatinine 82 umol/l, caucasian, nonsmoker. Is she well treated? Should treatment be intensified? Is the SPRINT trial relevant? Is there an app for that????

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24 Insert title of presentation here ABPM shows average BP 135/80 with a precipitous drop at around 1400 (see attached) to BP 105/66, when she often feels unwell. Diastolic BP <65mmHg is BAD

25 Personalised Hypertension Management 80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations. Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od. She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/l. Creatinine 82 umol/l, caucasian, nonsmoker. Is she well treated? NO. She is overtreated. Should treatment be intensified? NO Is the SPRINT trial relevant? YES and NO SPRINT score calculator NNT 267, NNH 30.

26 Personalised Hypertension Management 80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations. Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od. She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/l. Creatinine 82 umol/l, caucasian, nonsmoker. Inhibace + is halved I m a different person!

27 ios Android

28 Guidelines take with a grain of salt Increased risk of CV events with very low salt intake Guidelines based on averaging population N Engl J Med

29 Renal denervation therapy SYMPLICITY-3: Renal denervation therapy doesn t work, for unselected patients with HTN Renal artery stenosis

30 Age directed vs Renin directed Rx Individualise Rx based on other comorbidities Spironolactone for Resistant HTN

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32 J Clin Pharmacol 1994;34:

33 Gladding et al. Personalized Medicine Journal. June 2015,Vol. 12, No. 3, Pages

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35 Personalised Medicine in practice 35

36 Era of Mobile Health 36

37 Advanced ECG WiFi based ECG Ultraportable, $3,500 Deconvolutes ECG components Advanced pattern recognition, artificial intelligence ECG biological age 37

38 Advanced ECG for general practice Sensitive, high sampling frequency, accurate.

39 Case 43 year old man with dyspnoea, BP 220/140

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41 British Journal of General Practice 2007; 57: BMJ 1996;312:222 41

42 A-ECG LVSD Sensitivity 93-95%, Specificity 95% Southern X reimbursed

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44 Conclusion Hypertension is common, often called the Silent Killer Requires personalised Care taking into account Global risk Age and comordities Guidelines not always applicable to the individual patient Emerging technologies for investigation of end-organ disease Lifestyle, diet, prevention paramount Functional foods Feedback, mhealth, Internet of Things (IoT) Limited new drug treatments, or procedures though these will be targeted Emerging role of genomics (not yet fully advocated)

45 Interactive Session: Hypertension and Personalised Care Dr. Patrick Gladding, MBChB, FRACP, PhD

46 Case: 26 year old with HTN on home BP monitor Ubiquitous home BP monitoring Checked BP on friend s mother s home BP machine Measurement high ABPM 169/101 No other PMHx Maternal Grandparents had HTN, Gfather had ESRF and HD Normal diet, no illicit drugs Mother did not have pre-eclampsia Normal FBC, Cr, TSH. 46

47 Case: 26 year old with HTN on home BP monitor What investigations would you order? 1. Urinalysis sediment, microalbumin/cr ratio 2. Renin/Aldosterone levels 3. Echocardiogram 4. Renal artery USS 5. All of the above 47

48 Case: 26 year old with HTN on home BP monitor What investigations would you order? 1. Urinalysis sediment, microalbumin/cr ratio 2. Renin/Aldosterone levels 3. Echocardiogram 4. Renal artery USS 5. All of the above 48

49 Case: 26 year old with HTN on home BP monitor Differential diagnosis for his age Secondary hypertension much more likely from structural reasons e.g. coarctation, PCKD, but acute renal injury, nephritis but also endocrine (hyperaldosteronism) FHx PCKD? Hereditary HTN 49

50 Case: Value of ubiquitous home BP monitoring Checked BP on friend s mother s home BP machine Measurement high ABPM 169/101 USS right renal hydronephrosis ACEi -?nephrectomy 50

51 Case: 56 year old man with longstanding hypertension 56 year old man with longstanding hypertension GORD, dyslipidaemia, TIA 2014?, abnormal LFTs - 3-4L beer/day Palmar desquamation reaction to indapamide ABPM average BP 145/87, whilst on Candesartan 16mg od Renal USS no renal artery stenosis, post void residual 80mls Echocardiogram: Mild basal septal hypertrophy Renin 744 (4 46), Aldosterone 134 (60 1,000) on ARB

52 Case: 56 year old man with longstanding hypertension

53 Case: 56 year old man How would you manage him? 1. Renin directed Rx - Bb 2. Add bendrofluazide 3. Add amlodipine 4. Counsel regarding EtOH 5. 1 or 3, and 4 Spironolactone for Resistant 53 HTN

54 Case: 56 year old man How would you manage him? 1. Renin directed Rx - Bb 2. Add bendrofluazide 3. Add amlodipine 4. Counsel regarding EtOH 5. 1 or 3, and 4 54 Spironolactone for Resistant HTN

55 Case: 56 year old man with longstanding hypertension Renin is a red herring, cannot be relied upon whilst taking antihtn meds, especially RAAS blockers Renin is also elevated in chronic EtOH Indapamide is a thiazide-like diuretic, as is bendrofluazide?class effect with desquamation Age on the cusp of the NICE guidelines so could get ACEi (<55yrs) or CCHB (>55yrs) however the big problem is in the ABPM

56 Case: Value of 24hr ABPM and diurnal measures Focus on alcohol Worrying diastolic nadir 40mmHg

57 Case: 56 year old man abstaining from alcohol

58 Case: 61 year old GP 61 year old GP, Hx of HTN on Rx 12L ECG normal AECG abnormal/cad and biological age Coronary angiogram mild-moderate CAD 58 Journal of Hypertension 2014, 32:

59 Case 61 year old GP What are the red arrows pointing to? 1.Acute coffee intake 2.Conn syndrome 3.Work stress 4.Normal diurnal variation 5.Phaeochromocytoma

60 Case: 61 year old GP What are the red arrows pointing to? 1.Acute coffee intake 2.Conn syndrome 3.Work stress 4.Normal diurnal variation 5.Phaeochromocytoma

61 Case 61 year old GP Work stress is associated with HTN Concurrent CAD Rx to lower target? Manage causes of stress, mindfulness 61 Journal of Hypertension 2014, 32:

62 Case: 56 year old wife of GP Emotional stress ABPM BP 166/97 (Grade II HTN) Was on Amlodipine 5mg Drug withheld 2 weeks: Renin 22, Aldo N Green mussel extract, celery extract J Clin Hypertens (Greenwich) Jan; 16(1): Journal of Hypertension 2014, 32:

63 Case: 56 year old wife of GP What is the next course of action? 1.Increase dose of CCHB 2.Bb 3.ACEi or ARB 4.Diuretic 5.Spirinolactone 63 Spironolactone for Resistant HTN

64 Case: 56 year old wife of GP What is the next course of action? 1.Increase dose of CCHB 2.Bb 3.ACEi or ARB 4.Diuretic 5.Spirinolactone 64 Spironolactone for Resistant HTN

65 Case 56 year old wife of GP Emotional stress Was on Amlodipine 5mg ABPM BP 166/97 Renin 22, Aldo N Green mussel extract, celery extract Px Chlorthalidone 12.5mg od Pranayama Pranayama J Clin Hypertens (Greenwich) Jan; 16(1): Journal of Hypertension 2014, 32:

66 Case: 48 year old woman 48 year old woman with depression on Venlafaxine 225mg Mild dyslipidaemia Prior Hx of right sided breast cancer, partial mastectomy FHx of premature stroke Office BP 145/99 Normal Cr, ECG, renin/aldosterone ratio 66

67 Case: 48 year old woman How would you better define risk in view of BP? Advanced lipids Lp(a) CIMT CAC ETT CTCA 67

68 Case: 48 year old woman How would you better define risk in view of BP? Advanced lipids Lp(a) CIMT CAC ETT CTCA 68

69 Case: 48 year old woman What is the cause of her mild hypertension? 69

70 Case: Drug induced HTN 48 year old woman with depression started Venlafaxine, BP 145/99 Genomics indicated ADE WiFi BP max 133/95 70

71 Case:29 year old woman 29 year old woman, otherwise well, father adopted Normal weight, no EtOH No added salt, good sleep quality Office BP 140/90 on OCP 71 Journal of Hypertension 2009, 27:

72 What would you do next? 1. Stop the OCP, alternative Rx and retest her BP hr ABPM 3. Renin/Aldosterone 4. Renal USS 5. Renal denervation therapy

73 What would you do next? 1. Stop the OCP, alternative Rx and retest her BP hr ABPM 3. Renin/Aldosterone 4. Renal USS 5. Renal denervation therapy

74 Case: Incidental genomics 29 year old woman, otherwise well, father adopted Office BP 140/90 on OCP ABPM 132/85 deltaf508 carrier Genetic counselling Prenatal screening 3-4 cups of coffee per day associated with increased risk of MI and HTN in poor metabolisers Journal of Hypertension 2009, 27:

75 Case 54 year old man 54 year old man presents with MI HTN with known hypertensive retinopathy, mild-mod LVH on Echo BP 217/119 in 2014, started on Felodipine 10mg od Smoker Occasional methaphetamine user BP 170/90 on chlorthalidone 12.5mg od Moderate CAD on coronary angiography ASA/Ticagrelor/Statin/Bb/Chlorthalidone

76 Case 54 year old man - Potassium Renin <2 (4 46), Aldosterone 600 (60 1,000) Felodipine 10mg od Losartan + Thiazide 3.5 MI 3.4 F/up clinic Chlorthalidone stopped Atypical CP, dyspnoea Admitted to hospital TnI <15 K supp Atypical CP, dyspnoea Admitted to hospital Dx GORD Spironolactone Took P went to ED 2.9

77 Case: 54 year old man What is the diagnosis? 1.Acute coffee intake 2.Surreptitious thiazide use 3.Conn syndrome 4.Methaphetamine related hypokalaemia 5.Phaeochromocytoma

78 Case: Conn Syndrome What is the diagnosis? 1.Acute coffee intake 2.Surreptitious thiazide use 3.Conn syndrome Saline suppression test Renal vein sampling 4.Methaphetamine related hypokalaemia 5.Phaeochromocytoma

79 Thank you