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What Is Hypertension?,JNC 7 Definitions,Chobanian AV, et al. Hypertension 2003;42:1206-52,*Individuals aged 40-69 years, starting at blood pressure 115/75 mm Hg. CV, cardiovascular; DBP, diastolic blood pressure; SBP, systolic blood pressure. Chobanian AV et al. JAMA. 2003;289(19):2560-2572. Lewington S et al. Lancet. 2002;360(9349):1903-1913.,Cardiovascular Mortality Risk Doubles With Each 20-mm Hg SBP or 10-mmHg DBP Increment*,Cardiovascular mortality risk,2x,4x,8x,Non-Hispanic White,Non-Hispanic Black,Mexican American,Men (age, years),Hypertension* Prevalence (%),0,20,40,60,80,100,Women (age, years),0,20,40,60,80,100,Hypertension* Prevalence (%),*Hypertension defined as a BP of 140/90 mm Hg or reported use of antihypertensives. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Hajjar I, Kotchen TA. JAMA. 2003;290:199-206.,Prevalence of Hypertension Increases with Age: NHANES 1999-2000 Data,NHANES = National Health and Nutrition Examination Survey. Fields, LE et al. Hypertension. 2004;44:398-404.,Increasing Prevalence of Hypertension: Rise From 1988 to 2000 (NHANES),0,0.5,1,1.5,2,2.5,3,3.5,4,4.5,5,Non-Hispanic Whites,Non-Hispanic Blacks,Mexican Americans,% Increase (19881994 to 19992000),Ethnic/Racial Differences in Prevalence of Hypertension,Blacks have a higher prevalence and incidence of hypertension than whites. Most studies in the United Kingdom and the United States report a higher prevalence and lower awareness of hypertension in black people than in white people. In Mexican-Americans, the prevalence and incidence of hypertension is similar to or lower than in whites. NHANES III reported an age-adjusted prevalence of hypertension at 20.6% in Mexican-Americans and 23.3% in non-Hispanic whites.,Group HTN Prevalence White 21.2% Black/African-American 29.2% Hispanic/Latino 19.6% Asians 16.9% Native Hawaiian/other Pacific Islander 20.7% American Indians/Alaska Natives 25.4%,American Heart Association Heart Disease and Stroke Statistics 2007,Hypertension Prevalence by Ethnic/Minority Groups,Contributing Factors: Social, Environmental, or Genetic?,Environmental factors ultimately related to race (e.g. socioeconomic disadvantage, less access to health care) play roles in causing and sustaining hypertension 1, 2 Despite similar African heritage, Africans living in Africa or West Indies have much less hypertension than African Americans 3,4 In rural Africa, hypertension prevalence is very low and blood pressure does not rise with age as it does in all ethnic groups in US 3,1 Cooper RS, Rotimi CN, Ward R. The puzzle of hypertension in African-Americans. Sci Am. 1999;280:5662. 2 Geronimus AT, Bound J, Waidmann TA, et al. Excess mortality among blacks and whites in the United States. N Engl J Med. 1996;335(21):15521558. 3 Cooper R, Rotimi C, Ataman S, et al. The prevalence of hypertension in seven populations of west African origin. Am J Public Health. 1997;87:160168. 4 Ordunez-Garcia PO, Espinosa-Brito AD, Cooper RS, et al. Hypertension in Cuba: evidence of a narrow black-white difference. J Hum Hypertens. 1998;12:111116.,BP Reductions as Small as 2 mm Hg Reduce Risk of CV Events by Up to 10%,Meta-analysis of 61 prospective, observational studies 1 million adults 12.7 million person-years,Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.,2 mm Hg decrease in mean SBP,10% reduction in risk of stroke mortality,7% reduction in risk of CHD mortality,BPLTTC Meta-analysis: Stroke and CHD,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,JNC7 Algorithm for Treatment of Hypertension,Not at Goal BP 140/90 mm Hg for most 130/80 for those with diabetes or CKD,Initial Drug Choices,Drug(s) for compelling indications + BP meds as needed,Compelling Indications,Lifestyle Modifications,Stage 2 BP 160/100 2-drug combo for most (diuretic + ACEI, or ARB, or BB, or CCB),Stage 1 140-159/90-99 Diuretics for most; consider ACEI, ARB, B, CCB,No Compelling Indications,Not at Goal BP,Optimize dosages or add drugs until goal BP is achieved. Consider hypertension specialist consult.,Chobanian AV, et al. JAMA. 2003;289:2560-2572.,ACEI = ACE inhibitor CCB = calcium channel blocker ARB = angiotensin receptor blocker B = -blocker CKD = chronic kidney disease,JNC 7 Compelling Indications,Chobanian AV, et al. JAMA. 2003;289:2560-2572.,Heart failure Post-MI High CHD risk Diabetes Chronic kidney disease Recurrent stroke prevention, , ,B, ,ACEI, ,ARB, ,CCB, ,AA,Diuretic,AA = aldosterone antagonist,AHA Perspective/Hypertension Management and BP Goals Summary of Main Recommendations,adapted from Rosendorff C, et al. Circulation 2007;115:published online,Lose weight if overweight Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (ie, 24 oz 720 mL of beer, 10 oz 300 mL of wine, 2 oz 60 mL of 100-proof whiskey) per day or 0.5 (15 mL) ethanol per day for women and people of lighter weight Increase aerobic activity (30-45 min most days of the week) Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium) Maintain adequate intake of dietary potassium (approximately 90 mmol/d) Maintain adequate intake of dietary calcium and magnesium for general health Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health,JNC VII recommendations.Chobanian AV, et al. JAMA. 2003;289:2560-2572.,Lifestyle Modification,Lifestyle Modification,Hypertension Increases With Obesity in WomenEspecially After Age 45,Huang Z et al. Ann Intern Med. 1998;128:8188.,Multivariate RR* for Hypertension According to Weight Change,*Adjusted for age, BMI at age 18 years, height, family history of myocardial infarction, parity, oral contraceptive use, menopausal status, postmenopausal use of hormones, and smoking. 140/90 mmHg.,Age 45 Age 4554 Age 55,Loss 10,Loss 5.09.9,Loss 2.14.9,Change 2.1,Gain 2.14.9,Gain 5.09.9,Gain 1.019.9,Gain 20.024.9,Gain 25,Multivariate Relative Risk,7,6,5,4,3,2,1,0,Weight Change After 18 Years, kg,Reasons for Inadequate BP Control,Poor compliance to lifestyle modifications Acceptance of inadequate control by physician Difficulty achieving BP control with one agent/suboptimal regimens BP goals are more aggressive than in previous years Lack of compliance due to: perceived side effects of antihypertensive medication(s) frequency of dosing/multiple agents to attain control,(Adapted from JNC VI. Arch Intern Med. 1997),Prevalence of Nonbiomedical Expectations in African-Americans (N = 93),Yes,No,Cure of hypertension Take medications for life Take medications only with symptoms Having at least one non-biomedical expectation Having all three nonbiomedical expectations,Nonbiomedical Expectations,38% 48% 23% 65% 15%,51% 38% 67% 35% 85%,11% 14% 10% 0% 0%,Dont Know,Ogedegbe G. J Natl Med Assoc. 2004;96:442449.,*Computed by M. Wolz (unpublished data cited by Chobanian et al.) Adapted from Chobanian AV, et al. JAMA. 2003;289:2560-2572.,NHANES III 19911994,NHANES III 19881991,Adults, %,Patient Awareness,NHANES II 19761980,Treatment,Control,19992000*,51,73,68,31,55,54,10,29,27,70,59,34,0,10,20,30,40,50,60,70,80,The Gap Between Rates of Hypertension Awareness and Control,Age-Adjusted Blood Pressure Control Rates in Different Groups,Group HBP control 2003-04 Mexican-American men 31.1% Mexican-American women 24.6% Non-hispanic white men 34.8% Non-hispanic white women 41.8% Non-hispanic black men 26.8% Non-hispanic black women 30.3%,Monotherapy for Hypertension Is Inadequate in 4050% of Patients,Adapted from Materson BJ et al. Am J Hypertens. 1995;8:189192.,0,20,40,60,80,CCB (diltiazem),Beta Blocker (atenolol),Diuretic (HCTZ),Alpha1 Antagonist (prazosin),ACEI (captopril),Alpha2 Agonist (clonidine),50% response,*Response=diastolic blood pressure (DBP) 90 mmHg at the end of titration period and having maintained a DBP of 95 mmHg for 1 year without drug tolerance. Mean baseline blood pressure=152/99 mmHg.,Patients With Response*, %,Placebo,Blood Pressure Control Usually Requires Combination Therapy,Vicious Cycle of Therapeutic Failure,Inadequate Management of Blood Pressure in VA Hypertensive Population,Retrospective chart review of 800 hypertensive men followed over 2 years at 5 VA hospitals Mean age = 65, Ave duration of HTN = 12 yrs Approx 40% had BP 160/90 mm Hg Mean no of visits/year = 6.4 Antihypertensive meds were increased at 6.7% of the HTN visits More intensive therapy was associated with better BP control,Berlowitz DR NEJM 1998;339:1957,In Clinical Practice, Most Patients Undertreated,Lloyd-Jones DM et al. JAMA. 2005;294:466-72.,*Framingham Heart Study, N = 4919 treated patients,Suboptimal number of antihypertensive medications*,60,30,10,0,20,40,60,1,2,3,Patients (%),Antihypertensive medications (n),Cushman WC et al. Arch Intern Med. 2000;160:825831.,Treatment Success,* %,Outside the Stroke Belt Inside the Stroke Belt,100,80,60,40,20,0,Hydrochloro-thiazide,Atenolol,Captopril,Diltiazem Hydrochloride,Clonidine,Prazosin Hydrochloride,Antihypertensive Medications for African American Patients,65,47,58,39,57,21,81,77,66,41,42,49,100,80,60,40,20,0,Hydrochloro-thiazide,Atenolol,Captopril,Diltiazem Hydrochloride,Clonidine,Prazosin Hydrochloride,Antihypertensive Medications for White Patients,62,30,70,68,64,55,66,65,76,55,63,67,Treatment Success,* %,*One-year treatment success rates in controlling diastolic blood pressure.,Efficacy of Various Antihypertensive Medications in and Out of the Stroke Belt,ALLHAT: SBP Changes in African-Americans and Non-Black* Participants,Adapted from Wright JT Jr. et al. JAMA. 2005;293:15951608.,Black,Non-Black,Study Year:,2,4,Chlorthalidone,2,4,Amlodipine,2,4,Lisinopril,8.6,10.2,10.5,12.3,7.1,9.8,8.8,12.3,3.4,9.5,6.8,12.0,14,12,10,8,6,4,2,0,*White, Asian, Native American, and other (92% White).,Blood Pressure Response, mmHg,Relative Risk Reduction With Ramipril vs. Amlodipine Besylate: AASK,Ramipril Amlodipine besylate,Events per person-yr,GFR,ESRD,GFR, ESRD, or death,GFR, glomerular filtration rate; ESRD, end-stage renal disease. Agodoa LY et al. JAMA. 2001;285:2719-2728.,RRR=41% P=0.03,RRR=44% P=0.01,RRR=38% P=0.005,RAAS Activity in African-Americans an Apparent Paradox,African-American hypertensive patients have Plasma renin activity Salt-sensitivity Pressure natriuresis response But also have Activation of intrarenal RAAS Renovasoconstriction Impaired renal vascular response to Ang II and RAS blockage,Price DA, Fisher ND, Curr Hypertens Rep. 2003;5:225-230,Pulse Pressure and the Incidence of Cardiovascular Disease,A cross-sectional prospective study by Benetos et.al of 19,083 patients 40-69 yo, pulse pressure alone was shown to be an independent predictor of cardiac risks judged by degree of cardiac hypertrophy,Hypertension, vol. 30, p. 1410, 1997,VALUE: Outcome and SBP Differences at Specific Time Periods: Primary Endpoint,Time Interval,(months),Overall study,3648,2436,1224,612,03,Study end,Favors amlodipine,1.0,2.0,0.5,PRIMARY ENDPOINT Odds Ratios and 95% CIs,D,SBP,mmHg,1.4,1.6,1.8,2.0,3.8,1.7,2.2,36,2.3,Favors valsartan,4.0,Julius S et al. Lancet. June 2004;363.,Mortality From High Blood Pressure Higher in African-Americans,Overall Mortality Rates From Causes Related to Hypertension, 2003*,*High blood pressure listed as a primary or contributing cause of death. High blood pressure=systolic 140 mmHg or diastolic 90 mmHg, taking antihypertensive medicine, being told 2 times by a physician that you have high blood pressure.,Mortality Rate, %,African American,Female,Male,Female,20,10,30,40,50,49.7,14.9,40.8,14.5,0,60,Male,White,In hypertensive African-Americans, 30% and 20% of all deaths in men and women, respectively, may be due to high blood pressure.,Adapted from Thom T et al. Circulation. 2006;113:e85e151.,Complications Related to Hypertension in African-American Patients,Compared with the general population, African-Americans have a higher rate of: hypertension 40% heart disease mortality 50% obesity 70% stroke mortality 80% diabetes mellitus 100% ESRD 320%,ESRD, end-stage renal disease. American Heart Association. 2001 Heart and Stroke Statistical Update. Burt JL et al. Hypertension. 1995;25:305-313. JNC VI. Arch Intern Med. 1997;157:2413-2446.,Complications of Hypertension: Target-Organ Damage,CHD, coronary heart disease; CHF, congestive heart failure; LVH, left ventricular hypertrophy. JNC VI. Arch Intern Med. 1997;157:2413-2446.,Check fundi EKG or echocardiography Atherosclerotic plaque (x-ray or ultrasound evidence in carotid, iliac, or femoral arteries or aorta) Fasting blood sugar or 2-hr Post-prandial Hgb A1c Microalbumin:creatinine ratio serum creatinine,Hypertensive Target-Organ Disease: Assessment,Hypertensive Retinopathy,Causes of Resistant Hypertension,Pseudoresistance Poor compliance Drug Interactions Underdosing Improper combinations,Obesity Excess Alcohol Volume Overload Sleep Apnea Secondary Hypertension,Coarctation of aorta,Renal Artery Stenosis Renin tumor Glomerulonephritis DM nephrosclerosis Polycystic disease Collagen disease Chronic Pyelonephritis,Conns syndrome Pheochromacytoma Cushing syndrome Thyroid Disease Acromegaly Hyperparathyroidism,Drug Induced,Causes of Secondary Hypertension,Clues to Suggest Secondary Hypertension,Historical Clues Resistance to 4 drug therapy Young age of onset of HTN (teens, 20s) Sudden increase in BP Episodes of extreme BPs Low potassium & muscle cramps Women age 35-55 new onset Daytime sleepiness, snoring, poor sleep habits,Physical Exam Clues Abdominal bruit, reduced LE pulses Femoral bruit/ Renal bruit Unequal BP in extremities Reduced pulse in extremities Severe LE edema Wide pulse pressure & cardiac murmur Buffalo hump, striae, central obesity Enlarged thyroid,Managing Hypertension in African-Americans,Most will require combination therapy when initial therapy fails All antihypertensive classes, including RAAS agents, are associated with BP-lowering effects in African-Americans Be vigilant in pursuit of BP goals as stated in ISHIB Guidelines,RAAS=renin-angiotensin-aldosterone system Douglas JG et al. Arch Intern Med. 2003; 163:525-541,If BP 145/90 mm Hg, monotherapy or combination therapy including a RAS blocker,If BP 155/100 mm Hg, monotherapy,If BP 155/100 mm Hg, combination therapy,Add a 2nd agent from a different class or increase dose,Increase dose or add a 3rd agent from a different class,Uncomplicated hypertension Goal BP: 140/90 mm Hg,Not at BP goal? Intensify lifestyle changes AND,Consensus Statement: Management of High Blood Pressure in African-Americans,*Preferable BP goal for patients with renal disease with proteinuria 1 gm/24 h is 125/75 mm Hg. Initiate monotherapy at recommended starting dose with an agent from any of the following classes: diuretics, beta blockers, CCBs, ACE inhibitors, ARBs To achieve BP goals more expeditiously, initiate low-dose combination therapy with any of the following combinations: beta blocker/diuretic, ACE inhibitor/diuretic, ACE inhibitor/CCB, or ARB/diuretic. Consider specific clinical indications when selecting agents.,If BP 145/90 mm Hg, combination therapy including a RAS blocker,Add a 2nd agent from a different class or increase dose,Increase dose or add a 3rd agent from a different class,Diabetes/nondiabetic renal disease with proteinuria 1 g/24 h* Goal BP: 130/80 mm Hg,Not at BP goal? Intensify lifestyle changes AND,Patient with elevated BP,The majority of patien