OCTOBER 7-10 PHILADELPHIA, PENNSYLVANIA

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1 OMED 17 OCTOBER 7-10 PHILADELPHIA, PENNSYLVANIA 29.5 Category 1-A CME credits anticipated ACOFP / AOA s 122 nd Annual Osteopathic Medical Conference & Exposition ACOFP - The Heart of the Matter - An Evidence Based Approach to Common Cardiovascular Concerns: Primary Care Approach to Hypertension - Sorting Out the Latest Treatment Guideline Michael Levin, DO The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

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3 The Management of Hypertension in 2017 Targets and Therapies Michael Levin, D.O., FA.C.O.I. Chair: Division of Nephrology Philadelphia College of Osteopathic Medicine Metropolitan Nephrology Associates Objectives Review recent evidence affecting the diagnosis and management of patients with elevated blood pressure Discuss the therapeutics of various antihypertensive agents used in managing patients with hypertension Compare and contrast BP targets and first-line therapy options from various clinical practice hypertension guidelines ( e.g., JNC, ADA) 1

4 The Renal Continuum of Care Primary Care Physician Nephrologist At Risk Population Diabetes Hypertension Obesity CVD CKD ESRD 26,000,000+ People 500,000+ People ~375,000 Dialysis ~125,000 Transplant 2

5 Patient Background 60 y/o African American Male evaluated for challenging to control blood pressure issues Diagnosed during routine examination in Primary Care office 4 years prior and has been a challenge for the Medical team to control PMHx: HTN, CAD with stent, CKD stage 3, Obesity, DM x 4 years PSH: Cardiac PTCA with DES Circumflex Medications: Lisinopril 40 mg Daily, Coreg 25 mg Twice per day, Hydrochlorthiazide 25 mg per day FamHx: Father; deceased, MI at 50 SocHx: Smoker, 15 pack years; quit 10 years ago. Factory worker. Physical Exam BP: 168/94 HR: 84 BMI: 44 Neck: supple, no goiter, but circumference > 18 inches Heart: 84 per minute, no gallop or rub Lungs: clear Extremities: reduced pinprick b/l, no peripheral edema Eyes: dilated exam background retinopathy changes 3

6 Labs at Evaluation Hgb 14.8 Hct 36% Hgb A1C: 8.6% Na: 140 K: 5.5 Cl: 104 CO2: 26 BUN: 31 Cr: 2.2 egfr: 36 cc/min UA: 1+ protein, no RBC s 4

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9 Hypertension: A Brief Snapshot Most common modifiable CVD/Renal risk factor Contributed to > 50 % of adverse CVD outcomes BP Control Reduces Heart Failure by 50%; CVA by 40%; MI 25% 33 % of adults will be affected 60 % increase by 2025 US Renal Data System: Annual Data Report, US Department of Public Health and Human Services, NIH

10 Hypertension: A Brief Snapshot The Big Question remains: What is the Goal Blood Pressure, and what is Optimum NHANES % aware of Diagnosis 74.9 % on current treatment 52.5 % Controlled 47.5 % Uncontrolled Heart and Stroke Statistics Update AHA. Circulation 14;129;e28-e292 8

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13 Ambulatory Blood Pressure Monitoring (ABPM) Possibly more useful than clinic BP measurements 436 Italian CKD patients mean egfr 43 ml/min Elevated BP, non dippers, reverse dippers had increase risk for composite endpoints of death or ESRD Prognostic role of ABPM in patients with nondialysis CKD. Arch Int Med 171: ,

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16 Choice of Antihypertensive Agents Primary Prevention of CV complications Lowering BP to goal is more important than the choice of drug- assuming you achieve the goal Secondary CV Protection with underlying comorbid illnesses Not all agents provide the same benefit Assumption is that for the most part there are class effects: Ace-I, ARB s Less noted class effects perhaps for choice in CCB s, Thiazide Types, β Blockers Circulation 15;131: e435-e70 14

17 Thiazide (Type/Like) Diuretic Class HCTZ vs. Chlorthalidone(CTD) 15

18 Beta Blockade as Initial Therapy 16

19 Major Hypertension Trials 17

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21 Lifestyle modifications 19

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23 Systolic Blood Pressure Intervention Trial (SPRINT) Compare SBP <120 vs. 140mmHg in delaying CKD progression in HTN patients over age 50 SPRINT 9361 hypertensives with CV risk factor assigned to intensive vs standard BP (SBP 120 vs 140) At least 50 y/o; excluded DM, CVA, EF < 35%, >1gm proteinuria Trial stopped 3.5 into 5 years Intensive arm: significantly lower primary composite outcome (MI, ACS, cva, CHF, or death from CV cause) Intensive arm: significantly lower all cause mortality 21

24 SPRINT CKD Subgroup of 2646 CKD patients Again, no DM, no >1gm proteinuria No difference in egfr decrease 50% or ESRD. Too few events (15 in intensive group, 16 in standard group) GFR statistically significantly higher in intensive group But not clinically significant Risk of AKI in intensive group (HR 1.65) But most were stage 1 AKI, volume depletion, 90% recovered Risk of primary outcome (MI, ACS, cva, CHF, or death from CV cause) reduced but not statistically significant (HR 0.81) Risk of all cause mortality reduced, statistically significant (HR 0.72) Bottom line Guidelines say <140/90 There is evidence of benefit with tighter BP goals in proteinurics Tighter BP control won t slow CKD progression, but will improve mortality and prevent cardiovascular outcomes 22

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26 Risk Factors for CKD Progression HTN Proteinuric CKD (>300 mg/d) RAAS inhibition superior to other antihypertensive agents Systematic review 85 RCTs (nearly 22,000 patients) showed no benefit of combination of ACEI and ARB No benefit in preventing ESRD, progression of proteinuria (micro macro) Maione A, et al. ACEI ARB and combined therapy in patients with micro- and macroalbuminuria and other CV risk factors: systematic review of RCTs. Nephrol Dial Trans 26:

27 Effects of Intensive BP lowering on CV and Renal Outcomes 25

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