Disclosures. Funding: CIHR, HSF, AIHS, UHF. Research: Novo Nordisk, CVRx, Valencia. Consulting: Valeant

Transcription

1 Hypertension Update Raj Padwal Associate Professor General Internal Medicine and Clinical Pharmacology Director, Hypertension Clinic University of Alberta

2 Disclosures Funding: CIHR, HSF, AIHS, UHF Research: Novo Nordisk, CVRx, Valencia Consulting: Valeant Speaking and other Honoraria: Mylan, Servier, Merck

3 Objectives 1. Discuss the new CHEP diagnostic algorithm for hypertension. 2. Other updates: a. Smoking cessation b. Atherosclerotic renal artery stenosis c. Thresholds and targets in stage I uncomplicated HTN, diabetes, and the very elderly

4 European Society of Hypertension Classification of Blood Pressure Category Systolic Diastolic Optimal <120 and / or <80 Normal <130 and / or <85 High-Normal and / or Grade 1 (mild hypertension ) and / or Grade 2 (moderate hypertension) and / or Grade 3 (severe hypertension) 180 and / or 110 Isolated Systolic Hypertension (ISH) 140 and <90 The category pertains to the highest risk blood pressure *ISH=Isolated Systolic Hypertension. J Hypertens 2007;25:

5 Burden of disease attributable to 20 leading risk factors in 2010, expressed as a percentage of global disability-adjusted life-years

6 Hypertension In Canada Hypertension awareness, treatment, and control changes over time Joffres MR, Hamet P, MacLean DR, L italien GJ, Fodor G. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hypertens. 2001;14(11): Leenen FHH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K, Lum Kwong MM, Fodor G. Results of the Ontario Survey on the Prevalence and Control of Hypertension. CMAJ. 2008;178(11): Wilkins K, Campbell NRC, Joffres MR, McAlister FA, Nichol M, Quach S, Johansen HL, Tremblay MS. Blood pressure in Canadian adults. Health Reports. 2010;21(1): Statistics Canada. Blood pressure of Canadian adults, 2009 to Ottawa, ON: Statistics Canada, x/ /article/11714 eng.pdf.

7 Hypertension In Canada: Latest Update

8 Question 55 y.o. female with hypertension and diabetes on three drugs. BP in the office is 165/95 mmhg. BP at home 120/72. Feels well. Next action: 1.Increase drug doses or add another agent 2.Trust home BP no changes 3.Get ABPM 4.2 or 3

9 What s new? CHEP 2015 Recommendations Clinic blood pressures should be using electronic (oscillometric) monitors The diagnosis of hypertension should be based on out ofoffice measurements The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment supporting smoking cessation Treatment of atherosclerotic renal artery stenosis is primarily medical 2015

10 BP measurement methods Office (attended, OBPM) Auscultatory (mercury, aneroid) Oscillometric (electronic) Office Automated (unattended, AOBP) Oscillometric (electronic) Ambulatory (ABPM) Home (HBPM) For information on blood pressure measurement devices: monitors/bp monitors/ 2015

11 BP measurement methods Office (attended, OBPM) Auscultatory (mercury, aneroid) Oscillometric (electronic) monitors/bp monitors/ 2015

12 Recommended automated blood pressure monitors for home blood pressure measurement Please refer to for a complete list of devices endorsed by Hypertension Canada.

13 New 2015 Recommendation: BP Measurement Office BP measurement (OBPM): Measurement using electronic (oscillometric) upper arm devices is preferred to auscultatory devices (Grade C). 2015

14 Blood Pressure Assessment: Patient preparation and posture Standardized Preparation: Patient 1. No acute anxiety, stress or pain. 2. No caffeine, smoking or nicotine in the preceding 30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. No tight clothing on arm or forearm. 6. Quiet room with comfortable temperature 7. Rest for at least 5 minutes before measurement 8. Patient should stay silent prior and during the procedure Canadian Hypertension Education Program Recommendations 14

15 Manual OBPM is inaccurate Up to 20 studies in the past 4 decades have studied the errors observed in routine office auscultatory measurement, both in nurses and physicians, due to issues concerning the observer the preparation of the patient the technique and the device used Leads to misclassification of BP Armstrong RS, et al. Int J Nursing Practice 2002;8: Gillespie A and Curzio J. Nursing Standard 1998;12:35-7 Gleichmann SI, et al. J Hypertens 1989;7(S3):S99-S102 Villegas I, et al. Hypertension 1995;26: Dreveniiorn E, et al. J Clinical Nursing 2001;10: McKay DW, et al. Medical Education 1992;26: McKay DW, et al. J Hum Hypertens 1990;4: Kemp F, et al. Professional Nurse 1994;9:521-4 Campbell NC, et al. AJH 2005;18:1522-7

16 Auscultatory OBPM is inaccurate In the real world, the accuracy of auscultatory OBPM can be adversely affected by provider, patient and device factors such as: too rapid deflation of the cuff digit preference with rounding off of readings to 0 or 5 also, mercury sphygmomanometers are being phased out and aneroid devices are less likely to remain calibrated Consequence: Routine auscultatory OBPMs are 9/6 mm Hg higher than standardized research BPs (primarily using oscillometric devices) Myers MG, et al. Can Fam Physician 2014;60:

17 Keys to accurate OBPM Use standardized measurement techniques and validated equipment Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation The first reading should be discarded and the latter two averaged. 2015

18 Out-of-office Assessment is the Preferred Means of Diagnosing Hypertension Elevated BP Reading(s) office, home or pharmacy Hypertension Visit 1 History, Physical Examination and Diagnostic Tests BP 180/110 Hypertension AOBP 135/85 OBPM 140/90 Yes No No Hypertension (Annual BP Measurement Recommended) Out-of-Office Assessment ABPM (preferred) HBPM Diagnostic Series Clinic BP as alternate method (If ABPM or HBPM is not available)

19 Normal Values ABPM 130/80 overall 135/85 daytime 120/70 nighttime HBPM 135/

20 Out of office BP measurements are more highly correlated with BP related risk SBP DBP Mule et al. J Cardiovasc Risk 2002;9:

21 ABPM predicts CV risk better than OBPM For every 10-mmHg increase in 24h ABPM SBP, adjusted HR for daytime 1.12 ( ) and 1.21 ( ) for night-time For every 5-mmHg increase in 24h ABPM DBP, adjusted HR for daytime 1.02 ( ) and 1.09 ( ) for night-time Dolan E, et al. Hypertension 2005;46: Adjusted for clinic BP

22 HBPM predicts CV risk better than OBPM Niiranen T J et al. Hypertension. 2010;55: Asayama K, et al. (Ohasama) Eur Heart J 2005;26: Ohkubo T, et al. (Ohasama) J Hypertens 1998;16:971-5 Bobrie G, et al. Arch Intern Med 2001;161:

23 Only relying on office pressures misses out on white coat and masked hypertension 200 Ambulatory BP mmhg Masked Hypertension Normotension True Hypertension White Coat Hypertension Manual Office BP mmhg From Pickering et al. Hypertension 2002;40:

24 The prognosis of white coat and masked hypertension CV events per 1000 patient year 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;

25 Characteristics of ABPM and HBPM ABPM HBPM Cost Relatively high Relative low Reporting bias + Patient training Minimal + Wide availability + Diagnostic ability + + White coat phenomena and + + Masked HTN BP variability Short term Day to day Nocturnal BP + Prognostic ability + + Repeatability/long term follow up Low High (treatment adjustment and f/u) Improves long term adherence to drug therapy and hypertension control rates

26 Summary of evidence Out of office is needed to identify white coat hypertension (and to rule out masked hypertension) ABPM has better predictive ability than OBPM HBPM has better predictive ability than OBPM 2015

27 A standardised approach should be used for ABPM (Grade D) The appropriate sized cuff should be applied to the non dominant arm unless the SBP difference between arms is >10 mm Hg, in which case the arm with the highest value obtained should be used The device should be set to record for a duration of at least 24 hours with the measurement frequency set at a minimum of 20 minute intervals during the day and 30 minutes at night A patient reported diary to define daytime (awake), night time (sleep), activities, symptoms and medication administration is useful for study interpretation. Daytime and night time should preferentially be defined using the patient s diary. Alternatively, pre defined thresholds can be used (e.g. 08:00 to 22:00 for daytime and 22:00 to 8:00 for night time). The ABPM report should include all of the individual BP readings (both numerically and graphically), the percentage of successful readings, the averages for each time frame (daytime, night time, 24 hours) and the dipping percentage (the percentage the average BP changed from daytime to night time). Criteria for a successful ABPM study are: At least 70% of the readings are successful AND At least 20 daytime readings and 7 night time readings are successful

28 VII. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension Home blood pressure values should be based on: Duplicate measures, Morning and evening, For an initial 7-day period. First day home BP values should not be considered. The following six days blood pressure readings should be averaged Average BP equal to or over 135/85 mmhg should be considered elevated (for those patients whose clinic BP target is less than 140/90 mmhg).

29 Home BP Telemonitoring Omboni and Ferrari. Curr Hypertens Rep 2015

30 CHEP 2015 Recommendations What s new? Assess clinic blood pressures using electronic (oscillometric) monitors The diagnosis of hypertension should be based on out ofoffice measurements The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment for smoking cessation Treatment of atherosclerotic renal artery stenosis is primarily medical. 2015

31 New 2015 Recommendation: Vascular Protection Tobacco use status of all patients should be updated on a regular basis and health care providers should clearly advise patients to quit smoking. 2015

32 Effect of advice on smoking cessation rates Cochrane Database Syst Rev May 31;5:CD doi: / CD pub

33 New 2015 Recommendation: Vascular Protection Advice in combination with pharmacotherapy (e.g., varenicline, bupropion, nicotine replacement therapy) should be offered to all smokers with a goal of smoking cessation. 2015

34 Cochrane network meta analysis 2014 Kate Cahill et al Nicotine replacement therapy (NRT), antidepressant bupropion, and nicotine receptor partial agonist varenicline Impact on long term abstinence 6 months or longer Synthesis of 12 Cochrane reviews 267 studies Over 10,000 participants 2015

35 Network meta analysis of smoking cessation pharmacotherapies studies Cochrane Database Syst Rev May 31;5:CD doi: / CD pub4 2015

36 Smoking Cessation

37 What s new? CHEP 2015 Recommendations Clinic blood pressures should be using electronic (oscillometric) monitors The diagnosis of hypertension should be based on out ofoffice measurements The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment supporting smoking cessation Treatment of atherosclerotic renal artery stenosis is primarily medical 2015

38 CHEP Recommendations 2015: Therapy Patients with hypertension attributable to atherosclerotic renal artery stenosis (RAS) should be primarily medically managed because renal angioplasty and stenting offer no benefits over optimal medical therapy alone. 2015

39 Whats Old but Still Important? Treatment Thresholds and Targets

40 Question 83 y.o. female with hypertension,diabetes and CKD. Which is the best answer: 1.SBP target is <130 2.SBP target is <140 3.SBP target is <150 4.It depends.

41 Question 33 y.o. female elevated BP average is 150/93. Otherwise well. Which is the best answer: 1.Drugs should be started now 2.Drugs should be started if BP >160/100 3.Drugs should be started in 6 months if BP still at this level

42 Treat the Patient not Just the Number It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. Sir William Osler ( )

43 Usual blood pressure threshold values for initiation of pharmacological treatment Population SBP > DBP > Diabetes High risk (TOD or CV risk factors) Low risk (no TOD or CV risk factors) Very elderly* ( 80 yrs.) 160 NA TOD=target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk benefit analysis. 2015

44 Recommended Treatment Targets Treatment consists of health behaviour ±pharmacological management Population SBP < DBP < Diabetes All others < 80 yrs. (including CKD) Very elderly ( 80 yrs.) 150 NA In patients with coronary artery disease be cautious when lowering blood pressure if diastolic blood pressures are < 60mmHg 2015

45 BP is a continuous risk factor Stroke IHD Prospective Studies Collaboration. Lancet 2002

46 BP Lowering Benefits and Baseline Risk 11 trials; 51,917 patients Blood Pressure Treatment Trialists Collaboration. Lancet 2014.

47 BP Lowering Benefits and Baseline Risk 11 trials; 51,917 patients NNT varies from 70 (<11%) to 26 (>21%) Blood Pressure Treatment Trialists Collaboration. Lancet 2014.

48 Canadian Hypertension Education Program Thresholds For Initiating Drug Therapy in Non Very Elderly, Non DM Patients 1. Prescribe for DBP 100 or SBP 160 if no TOD or risk factors (Grade A). 2. Strongly consider for DBP 90 and TOD or other CV risk factors (Grade A). 3. Strongly consider for SBP and TOD (Grade C).

49 II. Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment Population SBP DBP Diabetes High risk (TOD or CV risk factors) Low risk (no TOD or CV risk factors) Very elderly 160 NA TOD=target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis. 2014

50 Treatment of Grade 1 HTN 10 studies; subjects Sundstrom et al. Ann Intern Med 2015

51 II. Indications for Pharmacotherapy after diagnosis of hypertension (1) Patients at low risk with stage 1 hypertension ( /90-99 mmhg) lifestyle modification can be the sole therapy. Patients with target organ damage (e.g. left ventricular hypertrophy) ( /90-99 mmhg) Treat with pharmacotherapy Patients with chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 140/90 mmhg Patients with diabetes should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmhg

52 II. Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment Population SBP DBP Diabetes High risk (TOD or CV risk factors) Low risk (no TOD or CV risk factors) Very elderly 160 NA TOD=target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis. 2014

53 II. Indications for Pharmacotherapy Recommended Treatment Targets Treatment consists of health behaviour ±pharmacological management Population SBP DBP Diabetes <130 <80 All others < 80 y.a. (including CKD) <140 <90 Very elderly ( 80 years) <150* NA *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk benefit analysis. 2014

54 HYVET Trial Beckett et al. NEJM 2007

55 HYVET Trial Beckett et al. NEJM 2007

56 HYVET Trial Beckett et al. NEJM 2007

57 Diabetes

58 II. Indications for Pharmacotherapy Recommended Treatment Targets Treatment consists of non pharmacological ± pharmacological management Population SBP DBP Diabetes Grade C <130 <80 Very elderly ( 80 years) <150* <90 All others (including CKD) <140 <90 Grade A *This higher treatment threshold for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk benefit analysis.

59 HOT: Study Design and Treatment Arms Hansson. Lancet 1998

60 HOT: Results in DM2 Subgroup NNT 80 Hansson. Lancet 1998

61 ACCORD. NEJM. 2010

62 ACCORD 4733 patients with DM2 Standard BP (140 systolic) versus intensive (120) Factorial design also testing the efficacy of fibrates 4.7 years mean follow-up

63 ACCORD: BP Through Follow-up ACCORD. NEJM 2010

64 ACCORD: Results ACCORD. NEJM 2010

65 More Intensive Control in DM 13 trials; 37,736 patients Bangalore et al. Circulation 2011 NNT approx 185 over about 4y

66 More Intensive Control in DM 13 trials; 37,736 patients Bangalore et al. Circulation 2011 NNT approx 185 over about 4y

67 II. Indications for Pharmacotherapy Recommended Treatment Targets Treatment consists of non pharmacological ± pharmacological management Population SBP DBP Diabetes Grade C <130 <80 Very elderly ( 80 years) <150* <90 All others (including CKD) <140 <90 Grade A *This higher treatment threshold for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk benefit analysis.

68 Bottom Line: Thresholds and Targets These are our best guess in terms of thresholds and targets for most patients You should exercise your clinical judgment and tailor to individual patients 2015

69 hypertension.ca For patients: free access to the latest information and resources For professionals: Access an accredited 15.5 hour interdisciplinary training program Sign up for free monthly news updates, featured research and educational resources Become a member for special privileges and savings 2015