2014 Update on Hypertension

transcript

2014 Update on HypertensionFocus on the Hispanic Patient

Aldo J. Peixoto, MDProfessor of Medicine (Nephrology)Associate Chair for Ambulatory Services, Dept. of MedicineClinical Chief, Section of Nephrology

Educational Objectives

• To review the burden of HTN in the US with a focus on the Hispanic population

• To review the approach to treatment of hypertension in 2014

Hypertension Facts

• >1 billion people worldwide

• 30-45% of adults in developed countries

• Responsible for 13.5% of overall world deaths

– 12.9% low-income countries

– 17.6% high-income countries

• Responsible for 6% of overall world lost years due to disability from stroke or MI

Lawes et al. Lancet 2008

Each 20/10 mmHg increase in BP is associated with doubling of risk of death

Meta-analysis of 61 observational studies>1,000,000 subjects12.7 million person-years

Lewington et al. Lancet 2002

Prevalence of HTN in the US according to age, sex and ethnicity

CDC, 2012 Report. MMWR 2012; 61: 703-9

There are differences in HTN rates among Hispanics according to country of origin

• US-born Hispanics:

– Mexicans: 19%

– Puerto-Ricans: 16%

– Cubans: 9%

– Central & South American (pooled): 9%

• Foreign-born Hispanics:

– Mexicans: 13%

– Puerto-Ricans: 32%

– Cubans: 29%

– Central & South American (pooled): 13%

Hypertension-related mortality (per 100,000) among different Hispanic subpopulations

From CDC. MMWR 2006; 55: 177

Awareness, Treatment and Control rates are lower among Hispanics in the US (NHANES 2003-2010)

Mexican Americans

Whites (NH)

Blacks (NH)

Awareness 69% 79% 81%

Treatment 59% 71% 72%

Control 36% 49% 43%

Stage 2 HTN (BP >160/100)

19% 12% 18%

CDC 2013 Report. MMWR 2013; 62: 351-5

Factors responsible for worse HTN control among Hispanics

• Limited access to care

• Communications barriers

• Less leisure time physical activity

• Dietary patterns

Perez. Clin Nurs Res 2011; 20: 347

Healthcare access and rates of awareness, treatment and control of HTN among Hispanics

Mexican Americans

Whites (NH)

Blacks (NH)

Health care coverage

65% 92% 83%

Routine place for health care

81% 95% 95%

> 2 times receiving health care in the past year

67% 82% 81%

CDC 2013 Report. MMWR 2013; 62: 351-5

Control is achievable when care is accessibleLessons from Hispanics in clinical trials

• BP Control in ALLHAT:

– 72% Hispanic Whites

– 69% Hispanic Blacks

– 67% Non-Hispanic Whites

– 59% Non-Hispanic Blacks

• BP Control in women in INVEST:

– 75% Hispanics (all)

– 68% Non-Hispanic Whites (P <0.001)

Guzman. Am J Cardiovasc Drugs 2012; 12: 165

– Patient teaching in Spanish improves health behaviors

– Preference for direct management in PC rather than referrals

• Dietary patternsPerez. Clin Nurs Res 2011; 20: 347

– Excess salt intake

– “Salt titration”

– Cultural issues related to food sharing

Summary #1

• HTN is less common among Hispanics than other groups

• Treatment and control rates are lower in Hispanics

• Limited access to care is a major issue

• Modifiable social/cultural factors need attention – important role of Hispanic healthcare providers

Management of Hypertension

What’s new in 2014?

Basic Clinical Evaluation of HTN

• Clinical history• Focused exam• Accurate BP• Focused laboratory testing:

– Basic metabolic panel– Ca– CBC– Urinalysis– EKG

Home BP Monitoring

• Identifies risk better than office BP• Improves treatment adherence• Improves BP control rates• Technique:

– Twice a day (AM and PM)– Duplicate readings– 7 days at a time

• Target: <130/85

Niiranen. Hypertension 2013; 61: 27ESH Practice Guidelines. J Hum Hypertens 2010; 24: 779

2013 JNC8 TargetsGeneral Population

• Age >60:

– BP <150/90 mmHg (A)

• Age <60:

– Diastolic BP <90 mmHg (A for ages 30-59; E for ages 18-29)

– Systolic BP <140 mmHg (E)

JNC8. JAMA 2013: epub ahead of print Dec 18

2013 JNC8 TargetsSpecial Groups

• Diabetes

– 140/90 mmHg (E)

• Chronic Kidney Disease

– 140/90 mmHg (E)

Lifestyle Modification

Modification Approximate SBP reduction(range)

Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

2013 JNC8Initial Drug Recommendations

• Non-Black, including DM:

– ACEi or ARB or Thiazide Diuretic or Calcium Channel Blocker (B)

• Black, including DM:

– Thiazide Diuretic or Calcium Channel Blocker (B for all, C for DM)

• CKD, regardless of race or DM status:

– ACEi or ARB (B)

Summary #2

• Out-of-office BP is an essential part of the management of HTN

• New BP targets are less strict, 140/90 mmHg for most, 150/90 mmHg acceptable for older patients

• Lifestyle changes and drug treatment remain the cornerstones of therapy

• Initial drug choices include ACEi, ARB, CCB and diuretics, not beta-blockers

2014 Update on Hypertension

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