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Hypertension Overview


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Given at Primary Care Winter Refresher conference, February 2010

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Hypertension Overview

  1. 1. Hypertension: There’s Nothing “Uncomplicated” About It<br />Jon Zlabek MD, FACP<br />
  2. 2. Learning Objectives<br />Confront the cold hard truth<br />Understand the dangers of “Therapeutic Inertia”<br />Review the basics of hypertension management<br />Understand the approach to resistant hypertension<br />
  3. 3. The Problem<br />
  4. 4. The Cold Hard Truth<br />As health care providers, we stink at managing hypertension, and our patients die needlessly because of it.<br />
  5. 5. Hypertension<br />Affects ~31% of U.S. adults<br />Most common primary diagnosis <br />Incidence is increasing<br />Control is poor:<br />Only 53% are on therapy<br />Only 31% are controlled<br />Hypertension 2006;47:345-51Stroke 2006;37:577-617<br />
  6. 6. Why Should I Care?<br />It’s just a number, right?<br />
  7. 7. Target Organ Damage<br />Brain<br />Stroke or transient ischemic attack<br />Heart<br />Left ventricular hypertrophy<br />Coronary artery disease<br />Heart failure<br />Peripheral arterial disease<br />Kidney<br />Chronic kidney disease<br />Eye<br />Hypertensive retinopathy<br />
  8. 8. Hypertension<br />About 60% of all strokes are attributable to hypertension<br />That’s 468,000 strokes per year in USA <br />Blood pressure control decreases initial stroke rate by 35-40%<br />CHF decreased by &gt;50%<br />MI decreased by 20-25%<br />JNC-7 NHLBI<br />
  9. 9. We Missed the News Flash!<br />Stroke & heart disease death rises linearly from 115/75 mmHg<br />JNC-7 NHLBI<br />
  10. 10. We Missed the News Flash!<br />
  11. 11.
  12. 12.
  13. 13. We Missed the News Flash!<br />Stroke & heart disease death rises linearly from 115/75 mmHg<br />141/88 should take on a new meaning with this tidbit<br />Get them off the bubble and into the “safe zone”<br />JNC-7 NHLBI<br />
  14. 14. The Dangers of “Therapeutic Inertia”<br />
  15. 15. Therapeutic Inertia?<br /> Definition <br /> Healthcare providers’ failure to increase therapy when treatment goals are unmet<br />Hypertension 2006;47:345-51<br />
  16. 16. Therapeutic Inertia?<br />Blood pressure control rates haven’t changed much in the last 15 years<br />Lots of reasons given:<br />Patient compliance<br />Access to care<br />Cost<br />Hypertension 2006;47:345-51<br />
  17. 17. Therapeutic Inertia<br />7253 patients with hypertension seen by 168 physicians at 40 sites in the southeast US <br />Seen in the clinic  4 times in 2003<br />Recorded the last BP taken while sitting<br />At least one visit with BP  140/90<br />Hypertension 2006;47:345-51<br />
  18. 18. Therapeutic Inertia<br />A visit with “therapeutic inertia” was defined as one where an elevated blood pressure was recorded, but there was no increase in dose or number of antihypertensive medications<br />Hypertension 2006;47:345-51<br />
  19. 19. Therapeutic Inertia<br />Medications were changed at only 13.1% of visits with an elevated blood pressure<br />Hypertension 2006;47:345-51<br />
  20. 20. Therapeutic Inertia<br />Overall, patients’ BP improved from the first to the final visit<br />39.5% controlled at first visit<br />45.1% controlled at final visit<br />Patient were placed into quintiles based on the therapeutic inertia they experienced<br />Hypertension 2006;47:345-51<br />
  21. 21. Therapeutic Inertia<br />Quintile 1 patients experienced low therapeutic inertia<br />Their physicians were “doers”<br />Quintile 5 patients experiencedhigh therapeutic inertia <br />Their physicians were “watchers”<br />Hypertension 2006;47:345-51<br />
  22. 22. Therapeutic Inertia<br />“Doer” group:<br />SBP decreased by 6.8 mmHg<br />Increased control rate<br />53.0% to 75.5%<br />“Watcher” group<br />SBP increased by 1.8 mmHg<br />Worse control rate<br />22.2% to 7.7%<br />Hypertension 2006;47:345-51<br />
  23. 23. “Watchers”<br />“Doers”<br />
  24. 24. Therapeutic Inertia<br />Patients in the “doer doctor” group were 33 timesmore likely to have achieved blood pressure control at the last visit than those in the “watcher doctor” group<br />Hypertension 2006;47:345-51<br />
  25. 25. Therapeutic Inertia<br />If medication changes were made at 30% of the visits, instead of 13% . . .<br />BP control would increase from 45% to 66%<br />Cardiovascular and all-cause mortality in this group would be reduced ~10-15%<br />Hypertension 2006;47:345-51<br />
  26. 26. What Causes Therapeutic Inertia?<br />We think we’re better than we really are<br />Physician self-reported care is overestimated when compared to actual care<br />Annals of Internal Medicine 2001;135(9):825-34<br />
  27. 27. What Causes Therapeutic Inertia?<br />Use of “soft” reasons to avoid intensification of therapy<br />Perception that control was improving<br />Patient aversion to medication therapy<br />Annals of Internal Medicine 2001;135(9):825-34<br />
  28. 28. What Causes Therapeutic Inertia?<br />Lack of training/education<br />Not understanding the need for multiple medications at maximal doses<br />Lack of practice organization focused on therapeutic goals<br />Poor or no quality initiatives<br />Lack of electronic aids (flowsheets, etc)<br />Annals of Internal Medicine 2001;135(9):825-34<br />
  29. 29. How to Fix Therapeutic Inertia???<br />Be aware that we as humans “drift” toward this<br />Continually remind yourself and your patients of the devastation that comes with stroke and heart disease<br />
  30. 30. How to Fix Therapeutic Inertia???<br />Some providers may need to be more “industrious” during clinic visits<br />It’s much easier to “see you in 6 months” than to prescribe a medication<br />“Watching” 141/88 takes on a new light when we realize that risk of death goes up linearly from 115/75 <br />
  31. 31. Tips Compiled from GL’s Best HTN Providers<br />Intense focus on rechecking the BP and getting it into the CWS<br />Theme of patients sitting and relaxing for a while before taking/retaking BP<br />Provider rechecks it and gives it to MA to enter<br />MA rechecks it after the provider leaves<br />
  32. 32. Tips Compiled from GL’s Best HTN Providers<br />Repeated, intense follow up every month until patient is at goal<br />Theme of not hesitating to consult a hypertension specialist<br />
  33. 33. Tips Compiled from GL’s Best HTN Providers<br />Up-front and repeated speech about the “evils” of hypertension<br />Scare them with reality<br />Talk about end organ effects<br />“What you can’t feel can kill you”<br />“Can’t enjoy retirement with a stroke”<br />
  34. 34. Tips Compiled from GL’s Best HTN Providers<br />Use medications before or as they change their lifestyle, then take them away if/when they change<br />Don’t fall into the “I’ll try harder from now on” trap<br />Push BP down to the “safe zone”, not just barely to goal levels<br />
  35. 35. Tips Compiled from GL’s Best HTN Providers<br />Remind patients: <br />Importance of lifestyle changes<br />It will take at least 3 medicines to get to goal<br />Importance of their engagement in this<br />Involve them in treatment decisions<br />Make sure they are clear on BP goal number<br />Get a home BP monitor<br />
  36. 36. Tips Compiled from GL’s Best HTN Providers<br />More tips:<br />Use medications combinations to save money and improve compliance<br />Offer nurse-only (free) BP checks<br />Monthly audits by MA to find patient that are missing things or needs appt<br />Very strong theme of a close working relationship with their MAs<br />
  37. 37. Other Tips To Improve . . .<br />Make sure patients take their BP medications the morning of the appointment even if they are fasting<br />Make sure your MA/RN does not “round off” to zeros or fives<br />140 mmHg counts as not controlled; 139 mmHg counts as controlled<br />
  38. 38. Other Tips To Improve . . .<br />RE-CHECK and RE-RECORD<br />At the end of your history – You<br />Write it on a sticker and give to your nurse/MA to enter in CWS<br />If it is not entered discretely in CWS, it doesn’t count<br />After you are long gone – Your nurse/MA<br />Minimizes “white coat” effect<br />
  39. 39. The Basics of Hypertension Management<br />
  40. 40. New Guidelines Coming!<br />JNC 7 released in 2003<br />JNC 8 upcoming Summer 2010<br />Data presented here from JNC 7 with my predictions of JNC 8 in red italics<br />
  41. 41. Basics of Measurement<br />Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level.<br />Use an appropriate sized cuff<br />Small cuff = falsely high readings<br />
  42. 42. Initial Strategy<br />Make the diagnosis<br />At least 3 visits over weeks-months, assuming no end organ damage or BP less than 180/110<br />Define the goal blood pressure level<br />Use history, exam and tests to:<br />Seek out easily correctable causes<br />Assess target organ damage<br />Remember the vascular milieu<br />TREAT AND REPEAT!<br />
  43. 43. Goal Blood Pressure Levels<br />&lt;130/80 for:<br />Diabetes<br />Chronic kidney disease<br />CAD or CAD equivalent: <br />Carotid disease<br />PAD<br />AAA<br />10 year cardiovascular risk ≥ 10%<br />&lt;140/90 mmHg for others<br />JNC-7 NHLBICirculation 2007;115:2761-2788<br />
  44. 44. Initial Tests<br />Creatinine<br />Urinalysis<br />Potassium and Sodium<br />Calcium<br />TSH<br />Hemoglobin or Hematocrit<br />Glucose<br />Fasting Lipid Panel<br />EKG<br />
  45. 45. What to Tell Patients Now, and Reinforce at Each Visit<br />“We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure”<br />“Most patients eventually need 3-4 medications to achieve goal blood pressure levels”<br />
  46. 46. What to Tell Patients Now, and Reinforce at Each Visit<br />“I will be seeing you for brief 5 minute appointments with lab tests every month until your blood pressure goal is reached”<br />Tip: Double book these patients – they are quick<br />Very high yield “bread and butter” E&M code for the time spent<br />
  47. 47. Coding a 5 minute uncontrolled HTN follow up<br />S: Mr. Smith returns for a blood pressure follow up. It has been running 160/85 at home. He has no hyper- or hypotensive side effects on his meds.<br />O: BP 159/87. He appears well.<br />A: Uncontrolled hypertension<br />P: Increase lisinopril to 40 mg a day. Check potassium and creatinine. F/U in 1 month.<br />2<br />1<br />2<br />99213 = 0.97 RVU and $143 <br />
  48. 48. Treatment – First 3 Drugs<br />Thiazide diuretic<br />Triamterene/HCTZ 37.5/25 in AM<br />Using a thiazide alone makes a lot of extra work chasing K levels<br />F/U one month with Na, K, Creatinine<br />Option for dihydropyridine calcium channel blocker, e.g. amlodipine or ACE-I/ARB<br />JNC-7 NHLBINEJM 2009;361:878-87<br />
  49. 49. Treatment – First 3 Drugs<br />2. Add a low dose ACE-I<br />e.g. lisinopril 10 mg daily<br />Stop Triamterene/HCTZ and replace with Chlorthalidone (best) or HCTZ 25 mg daily<br />Change to ARB if cough develops<br />F/U one month with K, Creatinine<br />JNC-7 NHLBI<br />
  50. 50. Treatment – First 3 Drugs<br />2. Titrate ACE-I<br />Increase to lisinopril 20 mg<br />F/U one month with K, Creatinine<br />Increase to lisinopril 40 mg<br />F/U one month with K, Creatinine<br />A bump of up to 35% in creatinine with ACE-I is acceptable<br />JNC-7 NHLBI<br />
  51. 51. Treatment – First 3 Drugs<br />3. Add a dihydropyridine calcium channel blocker<br />e.g. amlodipine 5 mg daily<br />Warning – don’t add non-dihydropyridine here (diltiazem), as decreases in pulse limit your future beta blocker use<br />F/U one month – no lab needed<br />Titrate amlodipine to 10 mg daily<br />JNC-7 NHLBI<br />
  52. 52. Don’t Forget Lifestyle!<br />
  53. 53. Don’t Forget Lifestyle<br />Proven approaches:<br />Weight reduction (5-20 mmHg/10 kg)<br />DASH eating plan (8-14 mmHg)<br />Dietary Approaches to Stop Hypertension<br /><br />Sodium restriction (2-8 mmHg)<br />Physical activity (4-9 mmHg)<br />Moderation of alcohol (2-4 mmHg)<br />JNC-7 NHLBI<br />
  54. 54. Still Not At Goal?<br />If you’ve come this far and still haven’t reached your goal, you officially have “resistant hypertension”<br />Don’t throw in the towel!<br />This is a good time to consider a consult with a hypertension specialist<br />
  55. 55. The Approach to Resistant Hypertension<br />
  56. 56. Resistant Hypertension<br />Blood pressure of ≥140/90 or ≥130/80 with diabetes or renal disease, despite full doses of 3 medications, including a diuretic<br />What is the PRIMARY reason for uncontrolled resistant hypertension?<br />NEJM 2006;355:385-92<br />
  57. 57. Resistant Hypertension<br />“A suboptimal medical regimen has been shown to be the primary cause of resistant hypertension . . .”<br />NEJM 2006;355:385-92<br />
  58. 58. Other Causes<br />Medications/drugs (&lt;2%)<br />NSAIDS<br />Stimulants<br />Herbals (ginseng and yohimbine)<br />Appetite suppressants<br />Steroids<br />Adherence to therapy<br />NEJM 2006;355:385-92<br />
  59. 59. Other Causes<br />Inadequate diuresis<br />High sodium intake (&gt;150 mmol/day)<br />Alcohol (&gt;3-4 drinks/day)<br />Obesity<br />JNC-7 NHLBINEJM 2006;355:385-92<br />
  60. 60. “Secondary” Causes<br />Affects 10% of all patients with resistant hypertension<br />Affects 18% of those over age 60 with resistant hypertension<br />NEJM 2006;355:385-92<br />
  61. 61. “Secondary” Causes<br />Renal parenchymal disease (1-8%)<br />Renovascular disease (3-4%)<br />Aldosteronism (1.5-15%)<br />Thyroid disease (1-3%)<br />Cushing’s syndrome (&lt;0.5%)<br />Pheochromocytoma (&lt;0.5%)<br />Coarctation of the aorta (&lt;1%)<br />Sleep apnea (unknown)<br />NEJM 2006;355:385-92<br />
  62. 62. Treatment – After the First 3<br />4. Add a beta blocker<br />e.g. metoprolol 25 mg twice a day<br />F/U one month<br />Titrate to a pulse around 60 <br />
  63. 63. Treatment – After the First 3<br />5/6. Add a direct renin inhibitor<br />Aliskiren (Tekturna) 150 mg daily<br />F/U one month with K, Creatinine<br />Titrate to 300 mg daily in a month<br />
  64. 64. Treatment – After the First 3<br />5/6. Add an alpha blocker<br />e.g. doxazosin 1 mg daily<br />Warn of orthostatic hypotension/lightheadedness<br />F/U one month<br />Titrate to 2 mg, 4 mg and 8 mg at monthly F/U visits<br />
  65. 65. Treatment – Drug 7 and Beyond<br />Spironolactone (aldosterone blocker)<br />Watch K carefully<br />Hydralazine (direct vasodilator)<br />Must be beta-blocked and diuresed<br />Nitrate if coronary disease and angina<br />
  66. 66. Treatment – Drug 7 and Beyond<br />Avoid centrally acting drugs due to poor side effect profile<br />Clonidine<br />Reserpine<br />Guanfacine<br />
  67. 67. Resistant Hypertension<br />Consider consultation with a “hypertension specialist” per JNC-7<br />That’s us in Vascular Medicine!<br /> We love these patients!<br />JNC-7 NHLBINEJM 2006;355:385-92<br />
  68. 68. Take Home Points<br />“We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure”<br />Stroke and heart disease death rises linearly from 115/75 mmHg<br />Get them off the bubble and into the “safe zone”<br />
  69. 69. Take Home Points<br />Be diligent in management and follow up<br />5 minute monthly appts until controlled<br />Avoid “Therapeutic Inertia”<br />RE-CHECK and RE-RECORD in CWS<br />Consult a HTN specialist if control is difficult or for secondary evaluation<br />
  70. 70. Thanks!<br />