Case Studies in Managing

g g
Hypertension: Defining the Barriers
to Control

David Feldman, MD, PhD, FACC, FAHA

Director of Heart Failure and Cardiac
Transplantation
The Ohio State University

Learning Objectives
ƒ Aggressively screen for and manage hypertension, using
evidence-based guidelines to help you and your patients
set treatment goals
g

ƒ Target interventions (lifestyle changes and pharmacologic

agents) to prevent disease progression and reduce
morbidity and premature mortality

ƒ Recognize and remove important barriers to improving

blood pressure control
ƒ Explore therapeutic combinations that can prevent
disease progression and improve morbidity and mortality

ƒ Identify one change you can make to your practice that

will support ongoing implementation of these lessons

1
 Significance of Hypertension
•In the United States, hypertension affects approximately 50 million
individuals, and accounts for 35 million office visits per year. Worldwide,
about 1 billion people have hypertension.

•Only 33% of people who are receiving treatment for hypertension have
their blood pressure under control.

•Relationship between blood pressure (BP) and risk of cardiovascular

disease (CVD) is continuous, consistent, and independent of other risk
factors.

•Individuals who are normotensive at 55 years of age have a 90% lifetime

risk of developing HTN (Framingham).

•For those between 40 and 70 years of age whose BP is between 115/75

to 185/115, each increase of 20 mmHg in systolic BP or 10 mmHg in
diastolic BP doubles the risk of CVD.

JNC 7

ƒ Men age 55 and woman age 65 have a 90% risk

of developing hypertension.
ƒ 2004 direct costs = $55.5 billion
ƒ If co-morbidities are added (end-stage renal
disease, coronary artery disease, congestive
heart failure
failure, diabetes mellitus
mellitus, cerebrovascular
accident), cost is $108 billion.

2
 JNC 7: Are You Surprised?
ƒ 30% of adults do not know they have
hypertension.
hypertension
ƒ 40% of those who are hypertensive are not being
treated.
ƒ 66% of those who are being treated have a blood
pressure greater than 140/90 mmHg.

Benefits of Lowering Blood Pressure

Anti-hypertensive therapy associated with:

• 35% – 40% mean decrease in stroke

• 20% – 25% decrease in MI
• More than 50% decrease in heart failure

Patients who have stage 1 hypertension/additional risk

factors:

• Achieving a sustained 12 mmHg decrease in systolic

BP for 10 years will prevent 1 death for every 11 pts
treated

3
 JNC 7: Treatment Algorithm for Hypertension
Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)

(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

Without compelling indications With compelling indications

Stage 1 hypertension Stage 2 hypertension Drugs for compelling indications

(SBP 140–159 or DBP 90–99 mm Hg) (SBP ≥160 or DBP ≥100 mm Hg) Other antihypertensive drugs
Thiazide-type diuretic for most. Two-drug combination for most (diuretic, ACEI, ARB, BB, CCB) as
May consider ACEI, ARB, BB, CCB, (usually thiazide-type diuretic and needed.
or combination. ACEI or ARB or BB or CCB).

Not at goal blood pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin-

converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=β-blocker;
CCB=calcium channel blocker
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure - Complete Report. National Heart, Lung and Blood Institute. Bethesda, 2004.

JNC 7: The Fine Print

ƒ Cracking open the door beyond diuretics for first line in a

patient without co-morbid conditions
p
− Along with promoting a thiazide diuretic for Stage 1
HTN, the committee added this surprising sentence:
“May consider ACE-I, ARB, BB, CCB.”

ƒ The ‘Compelling Indication’ Category - JNC put emphasis

on evidence showing benefits with specific
antihypertensive agents for certain medical conditions.
Again, taking a small sidestep from the NHLBI dictum of
diuretics first.

4
 Case Presentation #1

Vicki Struthers
ƒ 36 y/o white female

ƒ PMH
− Recently returned to work
10 weeks after the birth of
first child
− Total cholesterol: 160
mg/dL
− HDL: 66 mg/dL
/
− LDL: 120 mg/dL
− Family history of diabetes
− No history of smoking

*Hypothetical case based on a typical patient expected to present in clinical practice

5
 Vicki Struthers – by the numbers
Tests Ordered Before Your
Visit Today
ƒ ECG-normal
ECG l

Labs
ƒ Cr: 0.9 mg/dL; Na: 135 mmol/L;
glucose: 97 mg/dL; HCT: 35;
TSH: 2.1; K: 4.2 mmol/L

Vit l
Vitals
ƒ HR: 88 bpm, BP: 138/89mm/Hg,
BMI: 23
ƒ No Rx, NKDA

Treatment Alternatives
What do you recommend now?

A. Diet and lifestyle modification

B. Begin drug therapy
C. Ask her to come back for a BP recheck in one
week.
D. All of the above.
E. A & C

6
 Treatment Alternatives
Correct Answer
What do you recommend now?

A. Diet and lifestyle modification

B. Begin drug therapy
C. Ask her to come back for a BP recheck in one
week.
D. All of the above.
E. A & C

1-week Follow-up
Vicki returns in a week. She’s begun a daily
exercise program and her BP on return is
138/88 mm H Hg. Wh
Whatt iis th
the correctt di
diagnosis?
i ?

A. Normal BP
B. Prehypertension
C. Stage 1 hypertension
D. Not sure

7
 1-week Follow-up
Correct Answer
Vicki returns in a week. She’s begun a daily
exercise program and her BP on return is
138/88 mm H Hg. Wh
Whatt iis th
the correctt di
diagnosis?
i ?

A. Normal BP
B. Prehypertension
C. Stage 1 hypertension
D. Not sure

Treatment Alternatives

What is the best treatment for Vicki at this point?

A. Diet and lifestyle modification, and regular

follow-up of her BP
B. Drug therapy
C. Both of the above
D. Have her fill out her “bucket list” and enjoy the
last year of her life.

8
 Treatment Alternatives
Correct Answer

What is the best treatment for Vicki at this point?

A. Diet and lifestyle modification, and regular

follow-up of her BP
B. Drug therapy
C. Both of the above
D. Have her fill out her “bucket list” and enjoy the
last year of her life.

Vicki Struthers @ 1 & 12 Years Later

ƒ At 1 yr: “I take my medicine”,

structured exercise program

ƒ Low-salt, low-fat diet

ƒ At 12 yrs: Running 10Ks,

daughter in middle school.

ƒ BP: 118/70

9
 Clinical Practice Recommendation

Exercise may be beneficial in lowering blood

pressure and reducing cardiovascular risk.

Strength of Evidence:
Three reviews of 50 observational studies found the risk of CV
disease was lowered in those who were physically active.
Conversely, a review of 43 epidemiological studies found that
physical inactivity was associated with a doubling of cardiovascular
disease.

Evidence Based Source:

Bandolier

Website of Supporting Evidence:

http://www.jr2.ox.ac.uk/bandolier/booth/hliving/ExcerCVDis.html

JNC 7: Classification and Management

of Blood Pressure for Adults
Initial Drug Therapy
Without With
BP SBP* DBP* Lifestyle
Lif t l C
Compelling
lli Compelling
C lli
Classification (mm Hg) (mm Hg) Modification Indications Indications
Normal <120 and <80 Encourage
No antihypertensive Drug(s) for compelling
Prehypertension 120–139 or 80–89 Yes drug indicated. indications.
Thiazide-type diuretic Drug(s) for compelling
Stage 1 for most. May consider indications.
140–159 or 90–99 Yes
hypertension ACEI, ARB, BB, CCB,
or combination.
Two-drug combination
for most (usually yp
Other antihypertensive
Stage 2
≥160 or ≥100 Yes thiazide-type diuretic drugs (diuretic, ACEI,
hypertension
and ACEI or ARB or ARB, BB, CCB) as
BB or CCB). needed.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure - Complete Report. National Heart, Lung and Blood Institute. Bethesda, 2004.

10
 Case Presentation #2

Nate Biddleson
55 y/o African-American male presents for
follow-up after an Executive Physical.

Past Medical History

− Blood pressure on initial presentation
was 157/95, now 146/94
− Non-smoker, no known CAD
− Fasting glucose 140 mg/dL (repeated
f
from previous
i visit,
i it when
h it was 142
mg/dL); A1C: 8.2%
− Initial therapy: Diet modification,
increased exercise, took “some
vacation”, and started 25 mg of HCTZ

11
 When the First Drug Doesn’t Work
ƒ JNC 7 advocates for rapid progression to combination
therapy before fully exploring mono-therapy.

ƒ This approach is not an issue for those with Stage 2, but for
Stage 1. Different mechanisms may cause HTN in different
patients; and heterogeneous mechanisms from multiple class
of agents may be necessary.

ƒ Alternative approach: if there is a partial response, then

increase the dose or add a second agent. If there is no
response at all, try an alternate class. The goal here being to
find the simplest way to control blood pressure.

What Should We Do Next?

A. Continue dietary modification and exercise

recommendations
B. Begin therapy with an ACEi, ARB, or CCB
C. Refer to dietitian for diet counseling
D. Begin metformin
E. All of the above
F. A & B only

12
 What Should We Do Next?
Correct Answer

A. Continue dietary modification and exercise

recommendations
B. Begin therapy with an ACEi, ARB, or CCB
C. Refer to dietitian for diet counseling
D. Begin metformin
E. All of the above
F. A & B only

2-Week Follow-Up

Mr. Biddleson returns, having visited with the dietitian and is

y g to implement his recommendations. He has started
trying
walking daily. His BP at this visit is 136/84; 2hr postprandial
glucose is 126 mg/dL. What should we consider next?

A. Increase the dose of the ACEi/ARB or CCB

B. Consider additional up-titration or new medications
g BP or cholesterol as needed.
for diabetes, High
C. Initiate a dose of aspirin, if not already started
D. All of the above

13
 2-Week Follow-Up
Correct Answer
Mr. Biddleson returns, having visited with the dietitian and is
trying
y g to implement his recommendations. He has started
walking daily. His BP at this visit is 136/84; 2hr postprandial
glucose is 126 mg/dL. What should we consider next?

A. Increase the dose of the ACEi/ARB or CCB

B. Consider additional up-titration or new medications
g BP or cholesterol as needed.
for diabetes, High
C. Initiate a dose of aspirin, if not already started
D. All of the above

1-Month Follow-Up

Mr. Biddleson returns for follow-up. His BMI is

29; 2hr postprandial glucose is 92 mg/dL;
HgA1c is 6.8% and his BP is 120/78.

14
High-Risk Hypertensive Patients Require
Multiple Agents to Get to Goal
Achieved
Systolic BP
AASK1 (134 mm Hg)

ABCD2,3
23 (132 mm Hg)

ALLHAT4 (135 mm Hg)

HOT2,5 (141 mm Hg)

IDNT6 (140 mm Hg)

RENAAL7 (140 mm Hg)

UKPDS2,8 (144 mm Hg)

1 2 3 4
Number of BP Medications
AASK=African-American Study of Kidney Disease and Hypertension; ABCD=Appropriate Blood Pressure Control in
Diabetes; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trials; HOT=Hypertensive
Optimal Treatment; IDNT=Irbesartan Diabetic Nephropathy Trial; RENAAL=Reduction of Endpoints in Non-Insulin Diabetes
Mellitus with the Angiotensin II Antagonist Losartin; UKPDS=United Kingdom Prospective Diabetes Study.
1Wright JT et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147.
3Estacio RO et al. N Engl J Med. 1998;338:645-652. 4The ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997.
5Hansson L et al. Lancet. 1998;351:1755-1762. 6Lewis EJ et al. N Engl J Med. 2001;345:851-860. 7Bakris GL et al. Arch

Intern Med. 2003;163:1555-1565. 8UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.

Compelling Indications for Consideration

of One Drug Class vs. Another
Heart Failure: Thiazide/loop, BB, ACEi, ARB,
Aldosterone antagonist
Post- MI: BB, ACE, Aldosterone antagonist

High CVD risk: Thiazide, BB, ACEi, ARB

DM: Thiazide, BB, ACEi, ARB, CCB

CRF: ACEi, ARB. For creatinine 2-3 try

Cr > 1.5 in men loop diuretic
Cr > 1.3 in
women

15
 ACC/AHA Practice Guidelines
Pyramid Approach to HF Stages

R f
Refractory
t
End-Stage HF
Marked symptoms at rest
D despite maximal
medical therapy*
HF with Current or Prior Symptoms
Known structural heart disease
C Shortness of breath and fatigue
Reduced exercise tolerance
Structural Heart Disease
Previous
P i MI
B LV systolic dysfunction
Asymptomatic valvular disease
High Risk for Developing HF
Hypertension

A CAD
Diabetes mellitus
Family history of cardiomyopathy

Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43

Case Presentation #3

16
 Clark Galloway
42 y/o white male

Past medical history

• “borderline” hypertension
• “…too busy to exercise”
• Total cholesterol: 223 mg/dL
• HDL: 24 mg/dL
• Parents
P t deceased
d d related
l t d tto
“some heart failure thing”
• +TOB (smoker)

*Hypothetical case based on a typical patient expected to present in clinical practice

Clark Galloway – by the numbers

Tests Ordered Before Visit Today
ƒ ECG: normal sinus rhythm (NSR), No Q wave, an intra-
ventricular
t i l conduction
d ti d delay
l and
d voltage
lt c/w
/ lleft
ft
ventricular hypertrophy.
ƒ Echo: next slide
Labs
ƒ Total cholesterol 223 mg/dL, HDL-C 24 mg/dL, SCr:
1.1mg/dL; Na: 140 mmol/L, fasting glucose: 140 mg/dL;
HCT: 44; TSH: 1.1; fasting glucose taken on two
separate days 128 mg/DL and 138 mg/DL
Vitals
ƒ Heart Rate: 82 bpm; BP: 142/86 mmHg; BMI: 26
ƒ No prescription medicine (Rx), NKDA

17
Clark Galloway –Parasternal Long
Axis Echo

What Do You Recommend?

A. Begin an ACEi or ARB
B St
B. Strongly
l recommend d dietary
di t and
d lifestyle
lif t l
modification, including low Na, low-fat diet and a
daily exercise program
C. Begin a statin and aspirin
D. Return visit in 2 weeks with recheck of fasting
blood glucose and blood pressure and consider
a BB at this juncture as an additional
medication.
E. All of the above

18
 What Do You Recommend?
Correct Answer
A. Begin an ACEi or ARB
B St
B. Strongly
l recommend d dietary
di t and
d lifestyle
lif t l
modification, including low Na, low-fat diet and a
daily exercise program
C. Begin a statin and aspirin
D. Return visit in 2 weeks with recheck of fasting
blood glucose and blood pressure and consider
a BB at this juncture as an additional
medication.
E. All of the above

Clark Galloway 1 Year Later

ƒ At 1 yr: “I was too busy to

exercise and I don’t like
medicine… I felt fine”

ƒ BP is 156/98, HR93 bpm.

His BMI is 26. His fasting
blood glucose is 130
mg/dL. His total
cholesterol is 240.

19
 What Are Appropriate Actions
At This Visit?
A. Discuss the potential outcomes and risks of uncontrolled
hypertension with other factors such as elevated blood
glucose
l and
dddyslipidemia
li id i
B. Re-prescribe medications mentioned earlier
C. Cautiously add a prescription for metformin and a
nonspecific-BB in a short period of time.
D. Admit to the hospital
E. Choices A and B
F. Choices A, B and C

What Are Appropriate Actions

At This Visit? Correct Answer
A. Discuss the potential outcomes and risks of uncontrolled
hypertension with other factors such as elevated blood
glucose
l and
dddyslipidemia
li id i
B. Re-prescribe medications mentioned earlier
C. Cautiously add a prescription for metformin and a
nonspecific-BB in a short period of time.
D. Admit to the hospital
E. Choices A and B
F. Choices A, B and C

20
 Clark Galloway 5 Years Later

ƒ In the past 5 years he

has received a major
promotion, gained 15lbs
and joined a cigar club.

ƒ Today his BP is
162/100 He is angry
162/100.
and significantly short of
breath at rest.

After leaving your office and rebuking your

suggestions, Clark presents in the emergency room
after two additional hours of symptoms

ƒ Now with unremitting chest pain for 2 hours.

ƒ His EKG and cardiac enzymes confirm ACS.
ƒ At his heart cath, he is found to have 2-
vessel disease, and two stents are placed in
one artery.
ƒ His LEVF is
Hi i 40-45%,
40 45% BP iis 148/100 and
d hi
his
HbA1C is 12.0%.

21
 Post-Discharge

ƒ He is discharged on several medications, including a

beta-blocker,, an ACE inhibitor,, aspirin,
p , clopidogrel,
p g ,a
statin and diabetic regimen (including low dose insulin
and an oral agent(s).

ƒ He is advised to cease tobacco immediately.

ƒ He is scheduled to see a dietitian, a diabetes educator,

andd start
t t cardiac
di rehab
h b (f
(four weeks
k after
ft d/c).
d/ ) He
H iis
instructed to return to your office in one week, and
follow-up with the cardiologist that was established in
the hospital.

What’s Your Advice To Clark Today?

A. If he does not follow his recommended regimen, his risk

of recurrent MI is almost certain, only the exact timing is
uncertain.
t i
B. Of all the actions that he can take to lower his risk, the
most important are to control his blood pressure and
take his clopidogrel/aspirin combination.
C. Dietary and lifestyle modification are important in
preventing further cardiovascular disease
D. All of the above
E. A & C only

22
What’s Your Advice To Clark Today?
Correct Answer
A. If he does not follow his recommended regimen, his risk
of recurrent MI is almost certain, only the exact timing is
uncertain.
t i
B. Of all the actions that he can take to lower his risk, the
most important are to control his blood pressure and
take his clopidogrel/aspirin combination.
C. Dietary and lifestyle modification are important in
preventing further cardiovascular disease
D. All of the above
E. A & C only

Clark Galloway 12 Years Later

ƒ Shortness of breath at rest and
PND for the past 3 weeks.
ƒ Recurrent substernal chest pain
2-3 times daily with limited
activity.
ƒ He has had a 9 kg. weight gain.
ƒ Significant
g jjugular
g venous
distension, bi-basilar rales, a
prominent S3 and S4 and 3+
pitting lower extremity edema.
ƒ His BP is 105/50 and HR 95.
LVEF is <20% and VO2 max 11.

23
 Your Best Action Would Be To:

A. Start an ACE inhibitor and low-dose beta-

blocker
B. Admit to the hospital to start an ACE inhibitor
AND low dose beta-blocker
C. Admit to the hospital to re-start an ACE inhibitor
ASA/clopidogrel and low dose beta-blocker and
obtain cardiology consultation
D. Send him to the ED ASAP

Your Best Action Would Be To:

Correct Answer
A. Start an ACE inhibitor and low-dose beta-
blocker
B. Admit to the hospital to start an ACE inhibitor
AND low dose beta-blocker
C. Admit to the hospital to re-start an ACE
inhibitor ASA/clopidogrel and low dose beta-
blocker and obtain cardiology consultation
D. Send him to the ED ASAP

24
 ACC/AHA Practice Guidelines
Pyramid Approach to HF Stages

R f
Refractory
t
End-Stage HF
Marked symptoms at rest
D despite maximal
medical therapy*
HF with Current or Prior Symptoms
Known structural heart disease
C Shortness of breath and fatigue
Reduced exercise tolerance
Structural Heart Disease
Previous
P i MI
B LV systolic dysfunction
Asymptomatic valvular disease
High Risk for Developing HF
Hypertension

A CAD
Diabetes mellitus
Family history of cardiomyopathy

Hunt et al., Journal of American College of Cardiology. 2005;38:1116-43

Hypertension in Patients With High-

Risk Conditions

ƒ ~3/4 of adults with diabetes have BP ≥130/80

mmHg or use prescription medications for HTN1
ƒ ~2/3 of patients with HF have a past or current
history of HTN2
ƒ More than 50%–75% of patients with chronic
kidney disease have BP >140/90 mmHg3

1. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics. Bethesda, MD: US
Department of Health and Human Services, NIH, 2005. Available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm.
Accessed Oct. 2006. 2. Hunt SA et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart
Failure in the Adult. Available at http://www.acc.org/qualityandscience/clinical/guidelines/failure/update/index.pdf. Accessed Oct.
2006. 3. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines on
Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Available at
http://www.kidney.org/professionals/KDOQI/guidelines_bp/guide_1.htm. Accessed Oct. 2006.

25
 Chronic Kidney Disease

Goals: 1) Slow deterioration of renal function

2) Prevent CVD

Often need 3 or more drugs

Target < 130/80

Drugs: ACE inhibitors/ARBs—favorable effects on progression

-- Increase in creatinine of 35% is acceptable

Advanced Renal Disease:

•GFR < 30, CR 2.5 – 3.0 mg/dL
•Increased dose of loop diuretics usually needed in combo with
other drugs

Incidence of Coronary Heart Disease (CHD)

Events in Patients With and Without Diabetes
P<.001
50
Nondiabetics with no prior MI 45.0
Nondiabetics with p
prior MI
40
Diabetics with no prior MI
7-Year Follow-up* (%)
Incidence During

Diabetics with prior MI

30
P<.001
18.8 20.2
20

10
3.5

0
n=69 n=1,304 n=169 n=890

Events per 3.0 0.5 7.8 3.2

100 Person-years
*Among 1373 nondiabetic subjects and 1059 diabetic subjects, from a Finnish population-based study.
Haffner SM et al. N Engl J Med. 1998;339:229-234.

26
 Causes of Death in Persons With
Diabetes, Based on US Studies
Cardiac Disease

Cerebrovascular
Disease

Diabetes

Malignant Neoplasms

Pneumonia/Influenza

All Other

0 10 20 30 40 50 60
Deaths (%)
1990 US death certificates with mention of diabetes, all ages.
1990 US death certificates with mention of diabetes, age at death ≥45 years.
Moss SE et al. Am J Public Health. 1991;81:1158-1162. Ochi JW et al. Diabetes Care. 1985;8:224-229. Kleinman JC et
al. Am J Epidemiol.1998;128:389-401. Bender AP et al. Diabetes Care.1986;9:343-350.

The Diabetic Hypertensive Patient Is at

Especially High Risk…
ƒ For cardiovascular disease (CVD)
− “Two thirds to three fourths of people with diabetes
mellitus die off some form
f off heart or blood vessel
disease”1
ƒ For myocardial infarction (MI)
− Patients with diabetes without a previous MI have
as high a risk of MI as patients without diabetes
with a p
previous MI2
ƒ For congestive heart failure (CHF)
− In the DIGAMI trial, 66% of total mortality among
patients with diabetes was due to HF3
DIGAMI=Diabetes Insulin-Glucose Infusion in Acute MI.
American Heart Association. Heart and Stroke Statistical—2004 Update. Dallas, TX: AHA; 2003; 2Haffner SM et al. N Engl J
Med. 1998;339:229-234; 3Malmberg K et al. Eur Heart J. 1996;17:1337-1344.

27
 UKPDS: Blood Pressure Control Study in
Type 2 Diabetes Effect of Intensive BP Lowering on Micro-
and Macrovascular Complications Risk
Any
Diabetes- Diabetes-
related related Renal Vision
MI Endpoint Death Retinopathy Failure Stroke Deterioration HF
0

-10
Risk Reduction (%)

-20
−21
-30 P=.13 −24
P=.0046
−32 −34
-40 P=.019
P=.0038
−42
-50 P 29
P=.29 −44
44
P=.013 −47
P=.0036
-60 −56
P=.0043
Benefits of 144/82 vs 154/87
-70

1,148 hypertensive patients with type 2 diabetes were allocated to tight (144/82 mm Hg, n=758) or less tight
(154/87 mm Hg, n=390) and followed for a median of 8.4 years.
UKPDS Group. UKPDS 38. BMJ. 1998;317:703-713.

UKPDS: Benefits of Glycemic vs BP

Control With ACEi’s or β-Blockers

20
HF Stroke MI Diabetic Death
Risk of Event (%)

0
+7

-9 -8
-12
-20
-21

-32
-40
40

-44
Glycemic control
-60 -56
ACEi or β-Blocker

ACEi=Angiotensin-converting enzyme inhibitor. UKPDS Group. BMJ. 1998;317:703-713. Lancet. 1998;352:837-853.

28
 Clinician Input

When we first encountered Clark, what are

the things we could have done that would
have made a difference?

Clinical Practice Recommendation

Treating high blood pressure to JNC-7 GOALS with

anti-hypertensive
anti hypertensive medications reduces the risk of
cardiovascular disease and death.

Strength of Evidence:
A Recommendation; There is robust evidence to recommend a
pattern of care.

Evidence Based Source:

National Guideline Clearinghouse

Website of Supporting Evidence:

http://www.guideline.gov/summary/summary.aspx?doc_id=5635&
nbr=003796&string=hypertension#s23

29
 Importance of Patient Education
ƒ 50% of patients discontinue their anti-
hypertensive within one year of initiating
t t
treatment.
t

ƒ DASH diet for hypertension:

− limit sodium
− increase fruits and vegetables (8-10/day)
− increase low fat dairy (3
(3-4/day)
4/day)

ƒ Focus on diet history for hypertensive patients

Key Diet History Questions

for Patients with HTN
ƒ Do you use a salt shaker?
ƒ Do you taste your food before you add salt?
ƒ How often do you eat salty foods, such as chips, pretzels,
salted nuts, canned and smoked foods?
ƒ Do you read labels for sodium content?
ƒ How many servings of fruits and vegetables do you eat everyday?
ƒ How often do you eat or drink dairy products? What kind?
ƒ How often do you eat out? What kinds of restaurants?
ƒ Do you like to drink alcohol? How much?
ƒ How often do you exercise, including walking?

30
 Lack of Adherence
• Causes 125,000 deaths a year - twice the
mortality rate from MVAs
• Direct cause of 30% of hospital admissions for
people over the age of 65
• Half of all prescriptions are taken incorrectly,
contributing to prolonged or additional illnesses.
• Increases with the number of meds and doses
per day; at 4 times a day, only 40% of patients
get it right.

Selected Factors that Influence

Dissemination and Implementation
ƒ Systems of Care ƒ Patients
• Access to care • Beliefs about disease
• Coverage • Relationships with health
• Marketing influences care providers and
systems
ƒ Providers • Preferences
• Understanding of disease
• Limited visit time to
(inextricably connected to
address a patient’s
beliefs)
multiple issues (CVD,
di b t
diabetes, smoking)
ki )
• Office design oriented
toward acute, rather than
chronic care
• Innovation bias
• Lack of knowledge

31
 Differences Between More and Less
Successful Providers

More Successful Less Successful

ƒInvolved patients in decision
decision-making.
making ƒReferenced technical aspects of drug
ƒUsed med changes to educate / benefits.
engage. ƒLess information sharing – “only if
ƒPatient-maintained record card to asked”.
monitor compliance. ƒFelt time constraint did not permit
ƒProgressively introduce effective dose discussing adverse effects of meds.
and number of meds. ƒFelt knowledge of side effects would
ƒAwareness of patient ability to afford / hinder compliance.
p
role of formulary (e.g., VA)
ƒLeast expensive appropriate med when
possible.
ƒGreater attention to gender,
comorbidities, age when prescribing.

Shared Traits of More and Less

Successful Providers
ƒ Several BP readings to confirm hypertension, multiple visits.
− Unless BP very high or comorbidities present.

ƒ High awareness of national BP guidelines.

ƒ Concurrence on hypertension treatment goals, especially for

comorbidities, e.g., diabetes, etc.
ƒ Likely to begin hypertension treatment with 2-3 months of lifestyle
management.
− Not sufficient to attain desired BP

ƒ Difficulty / reluctance in treating older patients to JNC standards.

− Questioned value of aggressively treating older (80+ years) patients
with other severe problems

ƒ Would look at any BP reduction as partial success

32
 Causes of Resistant Hypertension
Improper Measurement
Volume Overload
Excess Sodium
Volume retention from Renal Disease
Inadequate Diuretic Therapy
Drug-Induced/Other Causes
Noncompliance Licorice
Inadequate Doses Ephedra
Inappropriate Combos ma haung
NSAIDS; COX 2 inhibitors Bitter Orange
Cocaine, amphetamines, other illicits Obesity
Sympathomimetics (decongestants etc.) EtOH Sleep Apnea
OCPs Steroids
Cyclosporine and tacrolimus Erythropoietin
Secondary Causes
Renal Artery Stenosis
Phenyl Chromocytoma

Additional Challenge in Treatment of

Hypertension: Medication Adherence
ƒ Adherence to a drug regimen is an important component
of BP control
− Approximately 50% of patients with poor BP control
have adherence problems (defined by taking <80% of
medication)
ƒ Several drug-related factors can influence medication
adherence, including:
− Adverse events
• Frequency of adverse events has been inversely
correlated with adherence rates
− Dosing frequency
• Reduction in dose frequency can lead to improved
adherence
Feldman R et al. Can J Public Health. 1998;89:I-16–I-18.

33
 Strategies to Improve Management
of Patients With Hypertension and Diabetes

In-hospital Increasing
ACC/AHA HF Outpatient
Guidelines1 I iti ti 2,3
Initiation23
Compliance2,3

I IIa IIb III

• Clinical trial • Implement evidence-based • Improve quality of

evidence care and therapies
care and outcomes
incorporated into • Majority of patients eligible
recommendations for treatment
for patient care • Early benefit of therapy not
missed
• Higher persistence rates
post discharge
1. Hunt SA et al. Circulation. 2005;112:1825–1852. 2. Fonarow GC. Rev Cardiovasc Med. 2002;3:S2–S10. 3. Gattis W et al. J
Am Coll Cardiol. 2004;43:1534–1541.

Improved Adherence Has Been

Associated With Improved Outcomes
ƒ In the BHAT trial, patients who took ≤75% of their
prescribed β-blocker regimen were 2.6 times more likely
to die within the first year of follow-up
follow-up, compared with
more compliant patients 1

ƒ In the COMPASS study, patients treated with oral nitrates

had better efficacy with once-daily dosing2
− Mean weekly number of chest pain episodes:
• 94% decrease in once-daily group
• 30% decrease in twice-daily group (P<.0001 compared to
once-daily group)

Beta-Blocker Heart Attack Trial (BHAT): multicenter, randomized, double-blind trial comparing propranolol vs placebo in 3837 patients
aged 30–69 years surviving acute MI. Patients 5–21 days post-MI were randomized to propranolol or placebo and were followed for an
average of 25 months. Adherence data were available for 2175 patients (1081 randomized to propranolol).
Compliance With Oral Mononitrates in Angina Pectoris Study (COMPASS): open, nonblinded, randomized, parallel-group study in 101
patients aged 40–75 years; compared patient compliance (using electronic measurement) and treatment effectiveness in patients with
stable angina pectoris treated with oral nitrates administered once daily vs twice daily.
1. Horwitz R et al. Lancet. 1990;336:542–545. 2. Kardas P et al. Am J Cardiol. 2004;94:213–216.

34
 Summary

ƒ Every patient will be screened for hypertension.

ƒ Hypertension is a significant risk factor for
cardiovascular disease.
ƒ Every patient should be treated to goal to
decrease the risk of premature death due to
cardiovascular disease.
ƒ Treatment plans should always include helping
patients adhere to lifestyle and medication
changes.

70

References
• ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in
the Adult—Summary Article. A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines
for the Evaluation and Management of Heart Failure): Developed in Collaboration With the
A
American
i C
College
ll off Ch
Chestt Physicians
Ph i i and
d the
th IInternational
t ti lSSociety
i t ffor H
Heartt and
dLLung
Transplantation: Endorsed by the Heart Rhythm Society. Circulation 2005;112:1825-1852.
• American Academy of Family Physicians Home Study Self-assessment Program. Hypertension
monograph #305. FP Essentials, 2004. AAFP; Kansas City, Mo.
• American Heart Association. Heart Disease and Stroke Statistics — 2004 Update. Dallas, Tex.:
American Heart Association; 2003.
• Bakris GL, Weir MR, Shanifar S, Zhang Z, Douglas J, van Dijk DJ, Brenner BM; RENAAL Study
Group. Effects of blood pressure level on progression of diabetic nephropathy: results from the
RENAAL study. Arch Intern Med 2003 Jul 14;163(13):1555-65.
• Bakris GL. Maximizing Cardiorenal Benefit in the Management of Hypertension: Achieve Blood
Pressure Goals. J Clin Hypertens (Greenwich). 1999 Oct;1(2):141-147.
• Bender AP, Sprafka JM, Jagger HG, Muckala KH, Martin CP, Edwards TR. Incidence, prevalence,
and mortality of diabetes mellitus in Wadena, Marshall, and Grand Rapids, Minnesota: the Three-
Three
City Study. Diabetes Care 1986;9:343-350.
• Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh
Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72.
• Domenic A Sica MD (2007) Distinctions in Class: Considerations for the Use of β-Blockers in
Cardiovascular Disease. J Clin Hypertens 2007;9 (s4);2-3.
• Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW. The effect of nisoldipine
as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent
diabetes and hypertension. N Engl J Med 1998 Mar 5;338(10):645-52.
• Feldman R, Bacher M, Campbell N, Drover A, Chockalingam A. Adherence to pharmacologic
management of hypertension. Can J Pub Health 1998;89:I-16-I-18.

35
 71

References, cont.
• Fonarow GC, Gawlinski A, Watson K. In-hospital Initiation of Cardiovascular Protective Therapies
to Improve Treatment Rates and Clinical Outcomes: The University of California-Los Angeles,
Cardiovascular Hospitalization Atherosclerosis Management Program. Crit Path Cardiol
2003;2(2):61-703.
• H ff
Haffner SM,
SM Lehto
L ht S,S Rönnemaa
Rö T
T, P
Pyörälä
ö älä K
K, L
Laakso
k M M. MMortality
t lit ffrom coronary h
heartt di
disease iin
subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial
infarction. N Engl J Med 1998 Jul 23;339(4):229-34.
• Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in
subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial
infarction. N Engl J Med 1998 Jul 23;339(4):229-34.
• Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood pressure lowering and
low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal
Treatment (HOT) randomized trial. Lancet 1998;351:1755-1762.
• Herzog E, Varley C, Kukin M. Pathway for the Management of Acute Heart Failure. Crit Path
Cardiol 2005;4(1):37-42.
• Horwitz RI, Viscoli CM, Berkman L, et al. Treatment adherence and risk of death after a
myocardial infarction. Lancet 1990;336:542
1990;336:542–545.
545.
• Hunt SA et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic
heart failure in the adult—Summary Article: A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to
update the 2001 guidelines for the evaluation and management of heart failure). J Am Coll Cardiol
2005 Sep 20; 46:1116-43.

72

References, cont.
• Khan O. Hypertension with updated guidelines from AAFP & JNC VII; 2006. University of
Pittsburgh School of Public Health; Pittsburgh, Penn.
http://www.publichealth.pitt.edu/supercourse/SupercoursePPT/22011-23001/22501.ppt accessed
April 13, 2008.
• Kl i
Kleinman JC
JC, Donahue
D h RP,
RP Harris
H i MI,
MI FiFinucane FF
FF, M
Madans
d JH
JH, BBrock
k DB
DB. M
Mortality
t lit among
diabetics in a national sample Am J Epidemiol 1988.128: 389-401.
• Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al; Collaborative Study Group.
Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with
nephropathy due to type 2 diabetes. N Engl J Med 2001 Sep 20;345(12):851-60.
• Malmberg K, Rydén L, Hamstent A, Herlitz J, Waldenström A, Wedel H.; the DIGAMI study group.
Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients
with acute myocardial infarction. Eur Heart J 1996;17:1337-1344.
• Moss SE, Klein R, Klein BE. Cause-specific mortality in a population-based study of diabetes. Am
J Public Health 1991;81:1158-1162.
• National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics.
Bethesda, MD: US Department of Health and Human Services, NIH, 2005. Available at
http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed April 13, 2008.

36
 73

References, cont.
• National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical
Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease.
Available at http://www.kidney.org/professionals/KDOQI/guidelines_bp/guide_1.htm. Accessed
April 13, 2008.
• O hi JW
Ochi JW, Melton
M lt LJ,LJ P
Palumbo
l b PJ PJ, Ch
Chu CP
CP. A population-based
l ti b d study
t d off di
diabetes
b t mortality.
t lit
Diabetes Care 1985;8:224-229.
• The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major
Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme
Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981-2997.
• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure - Complete Report. National Heart, Lung and Blood Institute.
Bethesda, 2004.
• UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular
and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998 Sep
12;317(7160):703-13.
• Weber MA. The JNC 7 Report: Challenges and Dilemmas in Writing Guidelines. J Clin Hypertens
2003;5(4):282–286.
• Wright JT Jr, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, et al. Effect of blood
pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease:
results from the AASK trial. JAMA 2002 Nov 20;288(19):2421-31.

37