Controlling Hypertension in Primary Care: Hitting a moving target?

Controlling Hypertension in Primary Care: Hitting a moving target? David J. Hyman, MD,MPH Professor of Medicine and Family & Community Medicine Chief, Section General Medicine Baylor College of Medicine No Conflicts of Interest

Controlling Hypertension in Primary Care: Hitting a moving target? Objectives Review why hypertension is the most important topic in medicine and the great job that primary care is doing Be familiar with the shifting and conflicting guidelines: JNC 7, JNC 8 now AHA/ACC 2017 vs AAFP/ACP 2017 vs. other international groups vs NCQA (clinical quality) metrics Appreciate the critical role of how the blood pressure is measured in interpreting the guidelines Be relieved by the lack of controversy in drug regimens Recognize and intervene on resistant hypertension

Hypertension is the most important topic in medicine.

Prevalence of Hypertension in the United States* 100% Hypertension Prevalence 80% 60% 40% 20% 6% 16% 31% 48% 65% 78% 0% Age 18-34 35-44 45-54 55-64 65-74 75+ *Based on NHANES 1999 2000 data. Hypertension is defined as blood pressure 140/90 mmhg or antihypertensive treatment. Low reliability due to large relative error. Fields et al. Hypertension. 2004:44;398-404.

Benefits of Lowering BP Average Percent Reduction Stroke incidence 35 40% Myocardial infarction 20 25% Heart failure 50%

Global Disability Adjusted Life Years (DAYLs) Attributable to the 25 Leading Risk Factors 2010 Risk Factor 2010 Rank DALYs (95% UI) in thousands High blood pressure 1 173,556 (155.939-189.025 Tobacco smoking, including exposure to secondhand smoke 2 156,838 (136,543-173.057) Household air pollution from solid fuels 3 108,084 (84,891-132,983) Diet low in fruit 4 104,095 (81,833-124,169) Alcohol use 5 97,237 (87,087-107.658) High body-mass index 6 93,609 (77,107-110,600) High fasting plasma glucose level 7 89,012 (77,743-101,390) Childhood underweight 8 77,316 (64,497-91,943) Expo sure to amblent particulate-matter pollution 9 76,163 (68,086-85,171) Physical inactivity or low level of activity 10 69,318 (58,646-80,182) Murray, Christopher J, et. al, New England Journal of Medicine, 2013

Diabetes: Tight Glucose vs Tight BP Control and CV Outcomes in UKPDS % Reduction In Relative Risk 0-10 -20-30 -40-50 Stroke 5% 44% * Any Diabetic Endpoint 12% 24% * DM Deaths 10% Tight Glucose Control (Goal <6.0 mmol/l or 108 mg/dl) 32% Microvascular Complications 32% *P <0.05 compared to tight glucose control * 37% * Tight BP Control (Average 144/82 mmhg) Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661. Reprinted by permission, Harcourt Inc. www.hypertensiononline.org

Hypertension Control Horrible-Isn t it? Less than ½ of persons with hypertension are controlled 70% of people who start BP drugs stop within 5 years..

Blood Pressure Control Over Time Chobanian, N Engl J Med 2009;361:878-87.

The percentages are shown (mean and 95% confidence intervals) for hypertension prevalence, awareness, treatment, control, and proportion of treated patients controlled (control/treated) among adults 18 years of age in NHANES 1999 to 2012 at 2-year increments. Egan B M et al. Circulation. 2014;130:1692-1699 Copyright American Heart Association, Inc. All rights reserved.

Another database showing Hypertensives are mostly adherent 625,000 patients with prescription refill records available from insurer Adherent (>80%) 74.6% Moderate (60-79%) 15.3% Poor (<60%) 9.9% Pittman DG, et al Am J Managed Care 2010

Harris Health October 2018

Controlling Hypertension in Primary Care: Hitting a moving target? - Be familiar with the shifting and conflicting guidelines: JNC 7, JNC 8 now AHA/ACC 2017 vs AAFP/ACP 2017 vs. other international groups vs NCQA (clinical quality) metrics

Hypertension Treatment Effect Mirrors Observational Data Incidence of cardiovascular disease 12 10 8 6 4 2 0 120 140 160 180 200 220 Systolic blood pressure (mmhg) www.hypertensiononline.org

National Heart, Lung, and Blood Institute National High Blood Pressure Education Program U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

JNC BP Classifications: DBP 130 125 Stage 4 DBP (mm Hg) 120 115 110 105 100 95 Hypertensive Consider therapy Severe Severe Severe Moderate Moderate Moderate Mild Mild Mild Stage 3 Stage 3 Stage 2 Stage 2 Stage 1 Stage 1 Stage 2 Stage 1 90 85 80 Normal Normal Normal Normal Optimal Optimal Highnormal Highnormal Highnormal Highnormal Prehypertension Normal JNC I JNC II JNC III JNC IV JNC V JNC VI JNC 7 JNC I. JAMA. 1977;237:255-261. JNC II. Arch Intern Med. 1980;140:1280-1285. JNC III. Arch Intern Med. 1984;144:1045-1057. JNC IV. Arch Intern Med. 1988;148:1023-1038. JNC V. Arch Intern Med. 1993;153:154-183. JNC VI. Arch Intern Med. 1997;157:2413-2446. Chobanian AV et al. JAMA. 2003;289:2560-2572.

Hypertension. 1999;34:386-387

JNC BP Classifications: SBP SBP (mm Hg) 220 210 200 190 180 170 160 150 140 130 120 110 No recommendations for SBP in JNC I or JNC II ISH Border - line ISH Border - line Normal Stage 2 Stage 1 Stage 4 Stage 3 Stage 3 Stage 2 Stage 2 Stage 1 Stage 1 Highnormal Highnormal Normal Normal Optimal Optimal Prehypertension Normal JNC I JNC II JNC III JNC IV JNC V JNC VI JNC 7 JNC I. JAMA. 1977;237:255-261. JNC II. Arch Intern Med. 1980;140:1280-1285. JNC III. Arch Intern Med. 1984;144:1045-1057. JNC IV. Arch Intern Med. 1988;148:1023-1038. JNC V. Arch Intern Med. 1993;153:154-183. JNC VI. Arch Intern Med. 1997;157:2413-2446. Chobanian AV et al. JAMA. 2003;289:2560-2572.

Goals of Therapy 2013. JNC 8 majority report: over age 60: DM, cad, Ckd 150/90 mm/hg 140/90 mm/hg JNC 8 minority report: over age 60: 140/90 mm/hg

2010 Accord BP Diabetics 120mmHg vs. 140mmHg Negative 2013 SPS3 Post subcortical <130 mmhg vs < 140 mmhg Negative stroke 2015 SPRINT high risk 120mmHG vs. 140mmHG Stopped early!! not DM or CVA Benefit

Sprint Trial Major inclusion criteria Age > 50 SBP 130-180 (tx or un tx) At least one of : Clinical CVD except CVA CKD egfr 20-50 Framingham 10yr CVD risk > 15% Age >75 Major exclusion criteria Stroke DM CHF(sx or EF<35%) proteinuria >1 g/d CKD egfr <20 ADHERENCE CONCERNS SBP achieved: 121.5 mmhg NNT event 61 NNT to Prevent one death 90

AHA/ACC 2017 vs everyone else

AHA 2017

Changes in BP Categories from JNC 7 to the 2017 ACC/AHA HTN Guideline SBP DBP JNC7 2017 ACC/AHA <120 and <80 Normal BP Normal BP 120 129 and <80 Prehypertension Elevated BP 130 139 or 80 89 Prehypertension Stage 1 hypertension 140 159 or 90-99 Stage 1 hypertension Stage 2 hypertension 160 or 100 Stage 2 hypertension Stage 2 hypertension The 2017 ACC/AHA guideline definition of hypertension: SBP 130 mm Hg or DBP 80 mm Hg

If same patient was 60WF 10 yr risk 4.8% If 40 WM 10 yr risk 1.8% If 40 BM 10 yr risk 10.0% If 60 WM,BM,BF 10 yr risk >10% You have to use the calculator, guesstimates difficult

Prevalence of Hypertension 2017 ACC/AHA and JNC 7 Guidelines Prevalence of hypertension, % Number of US adults with hypertension, millions 13.7% 31.1, M Muntner et. al., Journal of the American College of Cardiology 2017, Nov 6 Muntner, et. al., Circulation 2017 Nov 13

JNC 8 AHA/ACC 2017 ESC/ESH 2018 ACP/AAFP 2017 Threshold for starting by age >60 150/90 < 60 140/90 all ages 140/90 130/80 High risk < 80 140/90 >80 160/90 >60 150/no rec strong >60 CVA/TIA consider 140 (weak) >60 high risk consider 140 (weak Target for on treatment BP >60 150/90 <60 140/90 <130/80 18-65 to 130 but not <120 >65 130-140 >60 < 150 >60 CVA/TIA consider 140mmHG (weak) >60 High risk consider 140 mmhg (weak)

Hitting the target How do you measure the BP you are acting on?

BP Measurement Techniques Method In-office Brief Description Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Ambulatory BP monitoring Indicated for evaluation of white-coat HTN. Absence of 10 20% BP decrease during sleep may indicate increased CVD risk. Self-measurement In Office automated unobserved May help improve adherence to therapy and evaluate white-coat HTN. Pt alone in room

If mean office visit SBP 140mmHG control about 50% frequency 68% 95% 99.7% -3-2 -1 mean +1 +2 +3 120 130 140 150 160 Number of standard deviations either side of mean

AHA 2017

Sprint Maybe much ado about nothing? 1) Sprint used unobserved Automated Office BP (AOBP) - pt seated alone in room for 5 minutes - only after 5 minutes of rest, would take 3 measurement 1 minute apart unobserved AOBP averages SBP 16mmHG lower than regular office BP often similar to day ABPM 2) Intervention achieved SBP 121.5 mmhg 121.5 + 16= 137.5 about current 140 3) Control group had target of 140mmHG, could have baseline medications reduced to get there actual SBP controls 134.6 mmhg 134.6 + 16 = 151.1 if individual at 140, 140 +16 = 166 Kjeldsen & Mancia European Heart J 2016

What BPs are we being graded on?

Definition of Hypertension Control in Clinical Practice NCQA/ HEDIS Enrolled for 1 year or more Have a hypertension code in 1st 6 months of year Age 45-84 BP at last visit in chart used Control: < 140 and < 90 mmhg at sampled visit Sennett C, Managed Care 2000

NCQA HEDIS 2019 < 140/90 on last visit in evaluation period or remote BP devices electronically submitted HEDIS 2015-2018 18-59 140/90 60-85 w dm 140/90 60-84 w/o dm 150/90

BP Drugs now the easy part - It will likely take more than one drug, tell patients this right from start - If it is really high start 2 drugs - Multidrug combination pills maybe good - If the blood pressure is high on subsequent visits- titrate the medication!!!! Clinical Inertia: not lack of access or non-adherence is biggest reason for lack of control

Order of BP medication use: 1 st (Ace or ARB) or CCB or Diuretic For DM (Ace or ARB ) For African Origin no DM: CCB or Diuretic 2 nd (Ace or ARB) and CCB or (ACE or ARB) and Diuretic 3 rd (Ace or ARB) and CCB and Diuretic 4 th spironolactone Only then, the other classes Sometimes other classes needed for other conditions or contraindications

NO ENALAPRIL Use Lisinopril Few B blockers NO Atenolol The REAL Dose of HCTZ is 50mg Chlorthalidone may be coming to Harris Health

What if the patient s Blood Pressure does not respond? RESISTANT HYPERTENSION

Definitions Resistant Hypertension: office blood pressure that remains elevated despite optimal doses of 3 classes of medication including diuretic if tolerated or controlled on 4 medicines Pseudo-resistant Hypertension: seems to meet definition but on further evaluation pt is -Non-adherent - Controlled on 24 hour ABPM - not really on optimal medications, - only uncontrolled on poor office measurement True resistant: not pseudo- resistant Apparent Resistant Hypertension: seems to meet definition but pseudo-resistant not ruled out

Apparent Resistant Hypertension Drilling down on the medical regimen: Source Result Persell NHANES 2003-8 Any diuretic 86% 2011 Study BP, drug names loop 30% not dosage thiazide like 59%(HCTZ 93%) 539 patients uncontrolled > 3 aldo antagonists 3.0% or controlled > 4 drugs Hanselin Drug insurance data base 2008-9 Any diuretic 93% 2011 drug names, dose, No BPs loop 19% 140,000/5million hypertensives on thiazide like 80% (HCTZ 94%) > 4 drugs Chlorthalidone 3%, aldo antagonist 5.9% HCTZ mean dose 21.1 mg Fontil National Ambulatory Medical Care Survey Any diuretic 77% 2013 2006-10 drug names, no dosages, office BP loop 23 % 1567 pts w uncontrolled > 3 or controlled thiazide like 56% (HCTZ 96%) > 4 drugs Chlorthalidone 1.2% aldo antagonists 3.9% Grigoryan Primary care patients 2006-7 uncontrolled Any Diuretic 91% 2013 > 3 drugs, n=34 loop 15% Drug names, doses, ABPM, thiazide like 84% (HCTZ electronic adherence monitor Chlorthalidone 0% aldo antagonists 0% > ½ max dose ace/arb/ccb HCTZ 24/26 at 25mg QD

Resistant Hypertension Uncommon if Appropriate Drugs used In a network of 200 practices across the Southeast with 468,000 treated hypertensives those uncontrolled on 3 or more drugs at acceptable dose: 4.7% Egan B, Zhao Y, Li J et al

Houston TX On a very detailed drill down using ABPM and electronic bottle cap monitoring: of Apparent resistant hypertenvsives (N=69) 22% normal ABPM 29% non adherent Essentially no one optimally treated, mostly HCTZ 25,no Chlorthalidone, no spironolactone Grigoryan L, Pavlik VN, Hyman DJ J Am Soc Hypertens 2013

Patients with severe BP elevations referred to resistant hypertension clinics or for device therapy have very high levels of non-adherence when measured by blood or urine samples

Diuretics are the key to controlling difficult to control hypertension The dose of HCTZ is 50mg!!!!!! Chlorthalidone if you can get it- 25 mg Spironolactone 25 to 50 mg is 4 th drug Eplerenone is alternative

What is real prevalence of resistant hypertension? A network of 200 practices across the Southeast 468,000 treated hypertensives - uncontrolled on 3 or more drugs at acceptable dose Semi Apparent Resistant Hypertension 4.7% Egan B, Zhao Y, Li J et al

Diuretics are the key to controlling difficult to control hypertension The dose of HCTZ is 50mg!!!!!! Chlorthalidone if you can get it- 25 mg Spironolactone 25 to 50 mg is 4 th drug Eplerenone is alternative

Conclusions Hypertension is the most important topic in Medicine! You don t have to accept the 2017 AHA/ACC guideline A well measured in office 140/90 is good criteria for starting 130/80 maybe indicated is some high risk patients 130/80 maybe reasonable target if well tolerated It is very fair that we will still be graded on 140/90 If someone actually fits SPRINT criteria, and wants to do it- go for it! but remember it is an average SBP 121mm, not always less than 120mmHG

Conclusions continued.. Measurement counts- follow the literature -follow your office practicethe closer to Automated Office BP method the better Do drugs! ACE(ARB) CCB diuretics Hctz 50 aldactone 4 th Resistant hypertension: check adherence. Rare referral for 2 nd hypertension

Hypertension is the most important topic in medicine!!! Please do not let any differences in guidelines lead us to nihilism and inaction!!!