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
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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
Factors responsible for worse HTN control among Hispanics
• Limited access to care
• Communications barriers
– Patient teaching in Spanish improves health behaviors
– Preference for direct management in PC rather than referrals
• Less leisure time physical activity
• Dietary patternsPerez. Clin Nurs Res 2011; 20: 347
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
Factors responsible for worse HTN control among Hispanics
• Limited access to care
• Communications barriers
• Less leisure time physical activity
• Dietary patterns
– Excess salt intake
– “Salt titration”
– Cultural issues related to food sharing
Perez. Clin Nurs Res 2011; 20: 347
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)
JNC8. JAMA 2013: epub ahead of print Dec 18
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)
JNC8. JAMA 2013: epub ahead of print Dec 18
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