Blood Pressure Management &
Cardiovascular Health
Mark Huffman, MD, MPH
Northwestern University Feinberg School of Medicine
Northwestern Memorial Hospital Healthy Transitions
21 November 2013
1
Blood Pressure Management &
Cardiovascular Health
• Normal vs. optimal blood pressure: does it
make a difference?
• Raised blood pressure (hypertension) rates:
Global, US, Cook County, and Chicago
• Diagnosis and evaluation of hypertension
• Management options: 2013 AHA/ACC/CDC
guidelines
2
Blood Pressure Management &
Cardiovascular Health
• Normal vs. optimal blood pressure: does it
make a difference?
• Raised blood pressure (hypertension) rates:
Global, US, Cook County, and Chicago
• Diagnosis and evaluation of hypertension
• Management options: 2013 AHA/ACC/CDC
guidelines
3
Normal vs. Optimal
Q1: What is a normal blood pressure?
Q2: What is an optimal blood pressure?
Q3: What was FDR’s blood pressure in
1945?
4
Normal vs. Optimal
Q1: What is a normal blood pressure?
“Normal” describes the bell-shaped
distribution of a continuous measure, such as
blood pressure within a population.
5
Blood Pressure Curves, US Women
(2001-2008)
6
Wright J, et al. NCHS 2011.
Average US Blood Pressure, Men
7
Wright J, et al. NCHS 2011.
Average US Blood Pressure, Women
8
Wright J, et al. NCHS 2011.
Observed SBP and Prevalence of
BP Lowering Therapy (UK)
Men
Women
Wills AK, et al. PLoS Med 8(6): e1000440.
Normal vs. Optimal
Q1: What is a normal blood pressure?
Q2: What is an optimal blood pressure?
Q3: What was FDR’s blood pressure in
1945?
10
Normal vs. Optimal
Q2: What is an optimal blood pressure?
“Optimal” describes the blood pressure that is
associated with the greatest health
outcomes, such as low rates of heart
disease, strokes, or heart failure.
(What is it? And over what time period?)
11
Optimal Blood Pressure ~115/75
12
Lewington S, et al. Lancet 2002;360: 1903–13.
Age-Dependent? U-shaped Curve
13
Denardo S, et al. Am J Med 2010;123:719–26.
Normal vs. Optimal
Q1: What is a normal blood pressure?
Q2: What is an optimal blood pressure?
Q3: What was FDR’s blood pressure in
1945?
14
Normal vs. Optimal
15
Signs and Symptoms of
Malignant Hypertension
Evidence of end-organ damage:
•
•
•
•
•
Blurred vision (eyes)
Headache (brain)
Chest pain (heart)
Shortness of breath, especially when lying down (heart)
Kidney damage (kidneys)
The rate of change in blood pressure tends to be more
important than the absolute level due to the body’s ability to
auto-regulate one’s blood pressure.
16
17
Blood Pressure Management &
Cardiovascular Health
• Normal vs. optimal blood pressure: does it
make a difference?
• Raised blood pressure (hypertension) rates:
Global, US, Cook County, and Chicago
• Diagnosis and evaluation of hypertension
• Management options: 2013 AHA/ACC/CDC
guidelines
18
Global Blood Pressure
2008 global average adult blood pressure
Men: 128.1 mmHg (126.7, 129.4)
Women: 124.4 mmHg (123.0, 125.9)
Between 1980 and 2008, the average blood pressure
decreased each decade by:
0.8 mmHg for men 1.0 mmHg for women
19
Danaei G, et al. Lancet 2011; 377: 568–77.
20
Danaei G, et al.
Lancet 2011; 377:
568–77.
US, Cook County, and Chicago
Estimates of Hypertension:
Institute for Health Metrics & Evaluation
Chicago Health Atlas
21
Blood Pressure Management &
Cardiovascular Health
• Normal vs. optimal blood pressure: does it
make a difference?
• Raised blood pressure (hypertension) rates:
Global, US, Cook County, and Chicago
• Diagnosis and evaluation of hypertension
• Management options: 2013 AHA/ACC/CDC
guidelines
22
How is Hypertension Diagnosed?
“The diagnosis of hypertension should be based on at least
3 different BP measurements, taken on 2 separate office
visits to account for the natural variability of BP and other
factors that can affect BP.
“To confirm the validity and reliability of the measurement,
at least 2 measurements should be obtained once the
patient is comfortable and settled for at least 5 minutes. BP
should be measured in the sitting position with the back
supported, feet on the floor, arm supported in the horizontal
position, and the BP cuff at heart level.”
23
Aronow WS, et al. Circulation 2011; 123:2434-2506.
How is Hypertension Diagnosed?
• Home blood pressure measurements are increasingly
preferred as adjuncts to those taken in the doctor’s office.
• Automatic sphygmomanometers work well; Omron, upper
arm cuffs are preferred ($45-$65 on amazon.com) and
are often covered by insurance.
24
myamericanheart.org
How is Hypertension Evaluated?
• Home blood pressure measurements are increasingly
preferred as adjuncts to those taken in the doctor’s office.
• Check your BP right after you get up in the morning
(consistency helps reduce the number of variables).
• On occasion, your doctor might ask you to wear a blood
pressure cuff throughout an entire 24 hour period
(ambulatory blood pressure monitoring) to check you
blood pressure throughout the day.
• You can enter via MyChart to share with your blood
pressure with your doctor.
25
How is Hypertension Evaluated?
26
Blood Pressure Management &
Cardiovascular Health
• Normal vs. optimal blood pressure: does it
make a difference?
• Raised blood pressure (hypertension) rates:
Global, US, Cook County, and Chicago
• Diagnosis of and evaluation hypertension
• Management options: 2013 AHA/ACC/CDC
guidelines
27
Meta-Analysis: SHEP, Syst-Eur, Syst-China
% Risk Reduction
20
0
All
CV
Mortality Mortality
CV
Events
Stroke
CHD
-32%
-37%
-25%
-20
-40
-60
-17%
-25%
...and 50% reduction in CHF in SHEP!
Staessen J, et al. Lancet 2000:355:865
NNT for 5 Years to Prevent 1 Event
(NNT=number needed to treat)
CV Event
Stroke
CHD
All patients
26
48
64
Men
18
34
44
Women
38
68
92
Age 60-69
39
99
89
Age 70+
19
32
50
Staessen J, et al. Lancet 2000:355:865
Hypertension in the Very Elderly Trial
(HYVET)
International multicenter trial; participants were ≥80 years
Baseline SBP 160 to 199 mm Hg; target BP <150/<80 mmHg
Randomized to indapamide 1.5 mg vs. placebo; could receive
perindopril (2 or 4 mg) or placebo
Primary outcome: Fatal or non-fatal stroke
Secondary outcomes: Total mortality, CVD death, cardiac
death, stroke death, fatal/NF heart failure
NEJM 2008; 358:1887
Hypertension in the Very Elderly Trial
(HYVET)
3845 participants; baseline blood pressure=173/91 mmHg
Mean age = 83 years (range 80-105); 61% women; 12% with
prior CVD
Mean duration of F/U: 2 years (0 to 6.5 years)
The trial was stopped early for significant reductions in primary
endpoint and all-cause mortality
NEJM 2008; 358:1887
Hypertension in the Very Elderly Trial
(HYVET)
BP  14.5/6.8
BP  29.5/12.5
NEJM 2008; 358:1887
Hypertension in the Very Elderly Trial
(HYVET)
17.7/1000 p-y
12.4/1000 p-y
30% RRR;
NNT 94
over 2 years
NEJM 2008; 358:1887
Hypertension in the Very Elderly Trial
(HYVET)
59.6/1000 p-y
47.2/1000 p-y
21% RRR;
NNT 40
over 2 years
NEJM 2008; 358:1887
2013 AHA/ACC/CDC Recommendations
35
Go AS, et al. J Am Coll Cardiol 2013; Nov 12.
2013 AHA/ACC/CDC Recommendations
Systems-level approach to hypertension control, including:
1.
2.
3.
4.
5.
Identifying all patients eligible for management
Monitoring at the practice/population level
Increasing patient and provider awareness
Providing an effective diagnosis and treatment guideline
Systematic follow-up of patients for initiation and intensification
of therapy
6. Clarifying roles of healthcare providers to implement a team
approach
7. Reducing barriers for patients to receive and adhere to
medications as well as to implementing lifestyle modifications
8. Leveraging the electronic medical record systems being
established throughout the US to support each of these steps
36
Go AS, et al. J Am Coll Cardiol 2013; Nov 12.
Kaiser Permanente (2001-2009)
37
Jafffe MG, et al. JAMA. 2013;310(7):699-705
Lifestyle: Foundation of Management
38
Go AS, et al. J Am Coll Cardiol 2013; Nov 12.
Hypertension
Treatment
Algorithm
39
Go AS, et al. J Am Coll Cardiol
2013; Nov 12.
40
Medications: Certain Circumstances
Especially for patients with multiple medical problems,
pill boxes help increase adherence to blood pressure
lowering medications by ~10%.
Only $5-$10 on amazon.com!
41
Go AS, et al. J Am Coll Cardiol 2013; Nov 12.
Aged under
55 years
Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
C2
A
A+
C2
Summary of
antihypertensive
drug treatment
Step 1
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
See slide notes for details of
footnotes 1-5
Take Home Points: Management
43
•
Home BP monitoring is preferred method of
diagnosis and evaluation of treatment.
• Use an automated BP machine (upper arm cuff)
• Sign up for MyChart BP log
•
Lifestyle modification, particularly diet, can have a
powerful effect on blood pressure.
• Check out dashdiet.org for tips
•
Combination pills are being increasingly used to
improve blood pressure control.
• Use a pillbox to make taking your meds easier
Blood Pressure Management &
Cardiovascular Health
Mark Huffman, MD, MPH
Northwestern University Feinberg School of Medicine
Northwestern Memorial Hospital Healthy Transitions
21 November 2013
44