Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
1. Paradigm Shifts in
Hypertension Management
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495
2. Paradigm Shifts in
Hypertension Management
1. Hypertension is an important global problem;
Controlling it is challenging; All have room for
improvement
2. Focus on BP goal attainment– sooner rather than
later
3. Resort to combination therapy readily
4. Prevent or reduce target organ damage
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3.
4. Global Burden of Hypertension
2025 Projection
Year 2000 Year 2025
• 26.4% of world adult • 29.2% of world adult population
population had hypertension will have hypertension
• Total of 972 million adults • Total of 1.56 billion adults
(60% ↑ overall; 24% ↑ in
developed nations, 80% ↑ in
developing nations)
• Highest prevalence will be in
• Highest prevalence is in
economically developing
established market
continents (eg, Asia, Africa)
economies (eg, North – will account for 75% of world’s
America, Europe) hypertensive patients
Kearney PM et al. Lancet. 2005;365:217-223.
7. Consensus Target BP Levels Since JNC 7 in the
Prevention and Management of
Ischemic Heart Disease
American Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention <140/90
High CAD risk* <130/80
Stable Angina <130/80
Unstable Angina/NSTEMI <130/80
STEMI <130/80
LV Dysfunction <120/80
*High CAD risk = diabetes mellitus, chronic kidney disease, known CAD,
CAD equivalent (carotid artery disease, peripheral artery disease, abdominal
aortic aneurysm), or 10-year Framingham risk score >10%
Rosendorff et al, Circulation,2007;115: 2761-2788
8. Inadequate Control of Hypertension
• New England VA Study
– 800 men; mean age, 66 years, many with comorbid
conditions
– Mean duration of HTN = 12.6 years
– Index visit BP: 146/84 mmHg
– Mean of 6.4 hypertension-related visits per year
• Followed for two 2 years
< 25% reached goal BP < 140/< 90 mm Hg
– 40% had BP ≥ 160/≥ 90 mm Hg
• Percentage of visits where therapy was increased:
– 11.2% overall
– 22%, if DBP ≤ 90 mm Hg and SBP ≥ 165 mm Hg
– 35% of time when DBP > 90 mmHg
Berlowitz et al. N Engl J Med. 1998;339:1957-1963.
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9. Inadequate Control of Hypertension
Clinical Inertia
• In 75% of visits documenting elevated blood
pressure, physicians failed to increase the dose
of antihypertensive medications or to try new
treatments.
• But clinicians did not ignore patients with
elevated blood pressure. Follow-up visits
occurred 2-3 weeks sooner for patients with
poorly controlled hypertension.
• Thus, although physicians closely monitored
elevated blood pressure, they repeatedly
delayed making changes to a patient’s regimen.
Berlowitz et al. N Engl J Med. 1998;339:1957-1963.
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10. Therapeutic (Clinical) Inertia?
Causes:
Satisfaction with current BP level
The failure of Elevated SBP more acceptable
health care
Use of “soft” reasons to avoid
providers to intensifying therapy
initiate or Time constraints (15 min visits)
intensify
Reluctance to use combination therapies
therapy when
Competing priorities
indicated
Phillips LS et al. Ann Intern Med. 2001;135:825–834.
11. Value: Early Onset of BP Effect
“The trial gives new insights into the clinical
importance of the rate of achieving BP
control:
BP goals need to be reached within a
relatively short time (weeks rather than
months), at least in patients with hypertension
who are at high cardiovascular risk.”
-VALUE Trial, 2004
Julius S, et al. Lancet. 2004;363(9426):2022-2031.
12.
13. BP Goal Attainment: JNC VII
Expert Roundtable Conclusions
“In addition to prescribing the right agent from the start, based
on the individual needs of the patient, physicians need to be
more aggressive in bringing their patients to goal”
-Michael A. Weber, MD; Founder & Past President of The
American Society of Hypertension
“We want them to attain BP goals while making sure they are
adhering to the therapy. The problem is that physicians stop
evaluating the patient’s progress toward the targeted BP level”
-Jan N. Basile, MD; Review Committee, JNC 7
Adapted from Weber et al., J Clin Hypertens 2004;6:699–705).
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14. The Practical Reality of Combination Therapy
Adding another drug provides greater blood
pressure reduction than can be achieved by
titrating the current drug to a higher dose
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19. Dietary modifications and exercise
Low calorie diets have modest effect on BP in
overweight individuals (avg. 5-6 mm Hg).
Aerobic exercise (brisk walking, jogging, or cycling)
for 30-60 min., 3-5 times/week, had small effect on
BP (2-3 mm Hg).
Relaxation therapies
These activities (stress management, meditation,
cognitive therapy, muscle relaxation) reduce by
average of 3-4 mm Hg.
20. Limit alcohol consumption
Excessive alcohol consumption is associated with
raised blood pressure, poorer CV and hepatic health.
Reducing alcohol can lower BP 3-4 mm Hg.
Limiting excessive consumption of
coffee/caffeine
Limit dietary sodium intake
< 6 g/day, modest reduction of 2-3 mm Hg.
Encourage smoking cessation
23. Offer antihypertensive drug treatment to people
aged under 80 years with Stage 1 hypertension
who have one or more of the following:
Target organ damage
Established cardiovascular disease
Renal disease
Diabetes
10-year CV risk equivalent to 20% or greater.
Offer antihypertensive drug treatment to people
of any age with stage 2 hypertension.
24. For people aged under 40 years with
stage 1 hypertension and no evidence of
target organ damage, CV disease, renal
disease or diabetes
Consider specialist evaluation of
secondary causes of
hypertension and more detailed
assessment of potential target
organ damage.
25.
26. The ABCDE algorithm
Young subjects (<55 yr) Older subjects (>55 yr)
A or B (if associated
Step I A and/or C
sympathetic hyperactivity)
Step 2 Add C or D or both Add D
A and C, and/or D, add B
Step 3 A or B, C and/or D, add E
or E
27. What is New in Indian Guidelines on
Hypertension - 2013
28. Due to health related toxic effects
of mercury, mercury
sphygmomanometers
are being replaced by aneroid and
digital sphygmomanometers.
29. Use of beta-blockers as first line
agents in hypertension has receded
and these are now recommended as
agents for use only in young
hypertensives with specific indications.
For routine patients these are no
longer recommended as first line
agents
30. Diuretics are now considered at par
with of ACEI’s or ARB’s and calcium
channel blockers and not as preferred
agents as in previous guidelines.
Chlorthalidone is now available and
shown to be better than
Hydrochlorothiazide and its usage is to
be preferred.
31. When blood pressure is high by
more than 20/10 mm of Hg systolic
and diastolic it is now
recommended to start with a
combination of drugs.
Monotherapy is not going to be
effective in achieving target blood
pressure.
32. Certain combinations have
been shown to be better
than others in recent trials.
Specially ACEI’s/ARB’s in
combination with CCB’s
forms a good combination.
33. J shaped curve exist specially for
non revascularised coronary artery
disease patients and caution has
been advocated in trying to lower
blood pressure to low target levels
specially in these patients.
34. A new form of non pharmacological,
interventional sympathetic
denervation therapy has become
recently available and is being
evaluated.
36. Either a thiazide-type diuretic, CCB,
ACEI/ARB will be recommended as initial
drug therapy for most patients.
Direct renin inhibitors will be recommended
as an additive
• Chlorthalidone or indapamide should be
highlighted as the evidence-based thiazide
type diuretic of choice
38. It makes less difference which antihypertensive
agent is used, unless the patient has a compelling
indication for a specific antihypertensive class
It matters more that BP is
appropriately reduced to
the chosen BP goal.
39. The current recommended BP goals in
those with Diabetes and CKD from the
ADA, NKF, and JNC 7 is
<130/80 mm Hg.
40. The initial drug chosen will be
broadened to include
Thiazide-diuretic,
ACEI/ARB, or CCB and may
include non-atenolol BB’s.
41. Most patients will require 2 or more
antihypertensive agents to get BP
effectively controlled which may be
best approached with initial combination
therapy, either as a fixed-dose
combination (FDC) or as 2 individual
initial agents
Editor's Notes
Emerging Treatment Challenges in Hypertension Epidemiologic trends and the guidelines provided by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7 can be summarized by a new focus on attaining goal BP, attainment of goal as early as possible, consistency over 24 hours, and goal achievement across both systolic and diastolic BP.
Inadequate Control of Hypertension In this study, the care of 800 hypertensive men was evaluated during a 2-year period at 5 VA medical centers in New England. Their average age was 65.5 (± 9.1) years; their average duration of hypertension was 12.6 (± 5.3) years; 92% were white; 33% were taking a single antihypertensive medication; 32% were taking 2 medications; and 27% were taking 3 or more medications. In addition, many had significant comorbidities, including diabetes mellitus (34%), hyperlipidemia (26%), coronary artery disease (37%), and cerebrovascular disease (11%). At the end of the study, patients had been seen an average of 6 times per year in hypertension-related office visits, yet 40% had a blood pressure 160/90 mm Hg, and medications had been increased only 6.7% of the time. (An increase in therapy was either an increase in dose of the existing regimen or addition of new medications.) Fewer than 25% of the patients had what would be considered well-controlled BP (ie, BP <140/90 mm Hg). The presence of coronary artery disease among patients with a BP <165/90 mm Hg was associated with decisions to increase antihypertensive therapy, presumably because many antihypertensive medications serve a dual function and are also used to treat manifestations of coronary disease. Most of the visits were with staff attending physicians; only 19% were with residents. Overall, management of HTN was inadequate despite the availability of easy access to health care and the availability of medications either at no cost or low cost to the patient. The authors concluded, “Many physicians are not aggressive enough in their approach to hypertension.” 1 Reference 1. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med . 1998;339:1957-1963. Slide 4
CVF-300044 Healthcare providers often do not initiate or intensify antihypertensive therapy appropriately—despite a better understanding of the prevalence of hypertension, evidence for increased cardiovascular morbidity and mortality associated with uncontrolled hypertension, clear treatment guidelines for diagnosing and reducing high blood pressure, and widespread availability of safe and effective antihypertensive medications. Therapeutic inertia is separate from the patient-related issue of adherence and access to care; it is primarily a problem of the healthcare professional and the healthcare system. Overestimating adherence to guidelines; a perception that control is improving, or it is not improving due to patient non-adherence to non-therapeutic components of the treatment plan (ie, lifestyle changes); concerns about potential drug interactions and side effects despite clinical trial data; lack of education, training, and practice organization on the benefits of treating to therapeutic targets, the practical complexity and need for polypharmacy in treating to target, and the need to structure routine practice to facilitate identification of therapeutic problems are all factors that contribute to therapeutic inertia. Reference: Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825-834.
Clinical Support for Early Onset of BP Effect Results of the recent landmark clinical study, the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial, have indicated that achievement of BP goal early in therapy—in weeks—positively impacts the long-term health of patients. The VALUE trial compared the effects of the calcium channel blocker Norvasc (amlodipine; AMLO) with the angiotensin II receptor blocker (ARB) Diovan (valsartan; VAL) in 15,245 hypertensive patients at risk for cardiovascular complications. The study sought to prove that, at equivalent levels of BP control, a VAL-based regimen would offer superior cardioprotection to an AMLO-based regimen in patients with hypertension. Methods: Patients were randomized to treatment with either VAL 80 mg/d or AMLO 5 mg/d, with a BP goal of <140/90 mm Hg. If needed, patients were titrated up to VAL 160 mg/d or AMLO 10 mg/d. If patients still did not meet goal, hydrochlorothiazide (HCTZ) was added, first at 12.5 mg/d, then at 25 mg/d to both patient groups. Endpoints: The primary endpoint of the study was time to first cardiac event (cardiac mortality or morbidity). Secondary end points included fatal and nonfatal myocardial infarction (MI), fatal and nonfatal stroke, all-cause mortality, and new-onset diabetes. Conclusions: The hypothesis was not proven; no statistically significant difference in cardioprotection was shown between VAL and AMLO. However, AMLO-based therapy was proven to be significantly more effective in reducing BP, especially during the early phase of treatment at the time of first measurement (Month 1). The difference was initially 4.0/2.1 mm Hg at 1 month. The AMLO-based regimen got more patients to the BP goal of <140/90 mm Hg (62%) than the VAL-based regimen (56%).
Thus, the Syst-Eur extension demonstrated that it was not simply the final blood pressure that determined clinical outcome, but the speed with which this control was obtained . The investigators determined that the significant reductions in relative risk achieved at the end of the Syst-Eur extension were entirely due to the early benefit in the patients who received prompt active treatment (treated immediately, compared with those who received active treatment only after the initial trial was unblinded, a median follow-up of 2.0 years). 1 The investigators interpreted these results as supporting the necessity of starting therapy soon after diagnosis of hypertension. More to the point, these results underscore the importance of lowering blood pressure early on . 1. Staessen JA, Thijisq L, Fagard R, et al. Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial. J Hypertens. 2004;22:847–857.
The Treatment of Hypertension in Today's Managed Care Environment
AZOR: A CCB/ARB Fixed Combination for the Treatment of Hypertension DSCS07000125 To further support this conclusion, this slide shows the major studies in hypertension that demonstrated that combination therapy improves blood pressure control. The trend line indicates a greater decrease in diastolic blood pressure is demonstrated as the number of antihypertensive agents increases. These studies show that approximately 2-4 antihypertensive agents may be needed to see DBP reductions in the 20-30 mm Hg range. 1. Elliott WJ. Combination drug treatment of hypertension: Have we come full circle? Curr Hypertens Rep. 2002;4:278–285 .