A Community Approach to Controlling High Blood Pressure

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A Community Approach to Controlling High Blood
Pressure

• Thomas Pickering MD, D Phil
• Behavioral Cardiovascular Health and Hypertension
  Program
• Columbia Presbyterian Medical Center

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HYPERTENSION

• The
• Silent Killer
• or...

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The InvisibleDisease?
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Hypertension Is.

• Common60 million Americans
• Lifelong
• Major risk factor for heart attack stroke,
  leading causes of death disability
• Treatable20-50 reduction in morbidity
• Commonest reason for visiting a physician

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Deaths Worldwide in 2000
Blood Pressure
Tobacco
Cholesterol
Underweight
Unsafe sex
Fruit and vegetable intake
High body mass index
Physical inactivity
Alcohol
Unsafe water, sanitation, and hygiene
0
1000
2000
3000
4000
5000
6000
7000
8000
Number of Deaths (000s)
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Prevalence of Hypertension in North America and
Europe(Wolf-Maier et al JAMA 2003289 2363)

• Country Prevalence on Meds
• US 27.8 52.5
• Canada 27.4 36.3
• Italy 37.7 32.0
• Sweden 38.4 26.2
• England 41.7 24.8
• Spain 46.8 26.8
• Finland 48.7 25.0
• Germany 55.3 26.0

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CV Mortality Risk Doubles withEach 20/10 (mm Hg)
BP Increment
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7
6
5
4
CV Mortality Risk
3
2
1
0
115/75
135/85
155/95
175/105
SBP/DBP (mm Hg)
Individuals aged 40-70 years, starting at BP
115/75 (mm Hg). CV, cardiovascular SBP, systolic
blood pressure DBP, diastolic blood
pressure Lewington S, et al. Lancet. 2002
601903-1913. JNC 7. JAMA. 20032892560-2572.
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Benefits of Lowering BP
Average Percent Reduction Stroke incidence
3540 Myocardial infarction 2025
Heart failure 50
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Hypertension Awareness, Treatment and Control
US 1976 to 2000
80
73
68
69
Awareness
70
58
55
54
60
Treatment
51
50
40
() Adults
31
34
29
27
Control
30
20
JNC VI
JNC 7
JNC V
JNC IV
10
10
0
NHANES III (Phase 2) 1991-1994
NHANES II 1976-1980
NHANES III (Phase 1) 1988-1991
NHANES 1999-2000
Burt et al. Hypertension. 199525305-313 Hyman
et al. N Engl J Med. 2001345479-486 National
Center for Health Statistics. NHANES 1999-2000
(CD-ROM) NIH. The Sixth Report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure
1997. NIH publication 98-4080.
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Hypertension Control Rates () Around the World
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Why is Blood Pressure Control so Poor?

• 1. Blame the patient
• 2. Blame the doctor
• 3. Blame the system

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Why is Blood Pressure Control so Poor?

• 1. Blame the patient
• Patients dont follow advice
• They forget to take their pills
• Pills cause side effects

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Reasons for Patient Inertia

• Lack of social support
• Depression
• Complexity of treatment regimen
• Economic Factors
• Family
• Healthcare provider

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Non-adherence with Aspirin is predicted by
depression in post-MI patients
(Rieckmann et al, unpublished)
p .03
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Effects of Electronic Pill monitoring in
Resistant Hypertension (Burnier et al, J
Hypertens 2001 19335)
Pre-Monitoring Monitoring
SBP mmHg
Months of treatment
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Why is Blood Pressure Control so Poor?

• 2. Blame the doctor
• Hypertension control is not high priority
• Doctors BP readings are unreliable
• Finding the right drug isnt easy

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Conditions Associated with Poor Response to
Antihypertensive Drugs

• Older age
• Obesity
• Diabetes

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Characteristics of Patients with Uncontrolled
Hypertension in the US NHANES (Hyman et al,
NEJM 2001 345 479)

• Predictors of Uncontrolled Hypertension
• HTN Undiagnosed HTN Diagnosed
• Factor Rel Risk Attrib Risk Rel
  Risk Attrib Risk
• Age gt65 7.69 0.46
  2.08 0.32
• Male sex 1.58 0.22 1.30
  0.12
• Black race 1.45 0.05
  - -
• MD visits 1.40 0.09
  1.89 0.08

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Therapeutic Inertia of Physicians Predicts BP
Control (Okonofua et al, Hypertens 2006 47345)
of patients with BP lt140/90
Quintiles of Therapeutic Inertia Score (Failure
to increase Rx when BP high)
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Therapeutic Inertia of Physicians Predicts BP
Control (Okonofua et al, Hypertens 2006 47345)
of patients with BP lt140/90
87 of visits when BP was gt140/90 resulted in no
change of medications
Quintiles of Therapeutic Inertia Score (Failure
to increase Rx when BP high)
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Why is Blood Pressure Control so Poor?

• 3. Blame the system
• Poor access to medical care
• Inconvenience of multiple clinic visits
• Drugs are expensive

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Achieving Blood Pressure Goals Globally Five Key
Actions for Healthcare Professionals

• Steering Committee Independent Experts
• George Bakris MD Henry Black MD
• Martha Hill RN, PhD Tom Pickering MD, D
  Phil
• Guiseppe Mancia MD Luis Ruilope MD
• Krisela Steyn MD
• Professional Associations
• American Society of Hypertension
• Asian-Pacific Society of Hypertension
• European Society of Hypertension
• Inter-American Society of Hypertension
• International Council of Nurses
• World Hypertension League
• WONCA
• World Heart Foundation

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Five Core Actions to get to Hypertension Goals
1. Detect High Blood Pressure Risk 2. Assess
Total Cardiovascular Risk 3. Create an Active
Partnership with the Patient 4. Treat
Hypertension to Goal 5. Create a Supportive
Environment
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Goal 1. Detect High Blood Pressure

• Promote community awareness of hypertension as a
  serious CV risk factor
• Measure blood pressure at every office visit
• Use accurate technique
• Follow-up on elevated readings
• Follow current guidelines on hypertension
  detection

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Goal 1. Detect High Blood Pressure

• Promote community awareness of hypertension as a
  serious CV risk factor
• Measure blood pressure at every office visit
• Use accurate technique
• Follow-up on elevated readings
• Follow current guidelines on hypertension
  detection

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A Typical Clinic Visit in 2000

• Time spent travelling waiting- 2 hours
• Time spent with doctor- 8 minutes

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Mercury Sphygmomanometer
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Mercury Sphygmomanometer
150/90
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Home (Self) Monitoring
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Home (Self) Monitoring
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Patients Self- Monitored BP
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Comparison of Home, Clinic, and Ambulatory
Pressures

• Clinic ABPM Home
• Predicts outcome Yes Yes Yes
• Diagnostic use Yes Yes Yes
• Normal lt140/90 lt135/85(D) lt135/85
• Evaluation of Rx Yes Limited Yes
• Diurnal Rhythm No Yes No
• Cost Low High Low

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JNC 7 Self-Measurement of BP

• Provides information on
• Response to antihypertensive therapy
• Improving adherence with therapy
• Evaluating white-coat HTN
• Home measurement of gt135/85 mmHg is generally
  considered to be hypertensive.
• Home measurement devices should be checked
  regularly.

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Call to Action on Use and Reimbursement for Home
Blood Pressure Monitoring.A joint statement by
the American Heart Association, American
Diabetes Association, American Society of
Hypertension, Preventive Cardiovascular Nurses
Association.

• Thomas G Pickering MD, D Phil,
  Nancy Houston Miller RN, BSN,
  Gbenga Ogedegbe MD, MPH,
  Lawrence R Krakoff MD,
  Nancy T. Artinian
  PhD, RN, David Goff MD, PhD,.

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Goal 2.Assess Total Cardiovascular Risk

• Assess other CV risk factors (lipids, glucose,
  smoking, obesity)
• Check family history
• Match interventions to total CV risk- the higher
  the risk, the more aggressive the therapy
• Follow current guidelines on risk assessment

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Goal 2.Assess Total Cardiovascular Risk

• Assess other CV risk factors (lipids, glucose,
  smoking, obesity)
• Check family history
• Match interventions to total CV risk- the higher
  the risk, the more aggressive the therapy
• Follow current guidelines on risk assessment

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NCEP Risk Stratification
AGE
TC
SMOKER
HDL

SBP
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Obesity and Cardiovascular Disease

• The Challenge
• Obesity is a major risk factor for cardiovascular
  morbidity
• Its prevalence is increasing
• It is treatable by behavioral, pharmacological,
  and surgical means
• While nominally recognizing its importance,
  cardiologists generally adopt a nihilistic
  approach to its treatment

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Classification of Obesity by BMI

• Obesity class BMI
• Underweight lt18.5
• Normal 18.5-24.9
• Overweight 25.0-29.9
• Obesity grade I 30.0-34.9
• II 35.0-39.9
• Extreme obesity III gt40

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Body Mass Index and Mortality1,184,657
participants in the Cancer Prevention
Study(Calle et al, NEJM 1999 341 1097)
CVD
Relative Risk of Death
Other
Cancer
Women- non-smokers no previous disease
Body-Mass Index
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Overlap of Four Common Conditions
Obesity
Hypertension
Diabetes
Sleep Disordered Breathing
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BMI Risk of Cardiovascular Disease Diabetes
Nurses Health Study(Willett NEJM 1999341427)
Type 2 Diabetes
Relative Risk
Hypertension
CHD
Body-Mass Index
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Relationship Between Tight Glucose Control and
Blood Pressure Control on Cardiovascular
Outcomes in the UKPDS
UKPDS 38, BMJ, 1998317703-713 UKPDS 39
BMJ317713
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JNC VI Recommendations

• Risk Stratification and Treatment
• Risk Group A Risk Group B RiskGroup C
• Risk Factors None 1 or more, Diabetes,with
• other than or without diabetes
  others
• Target Organ Damage No No Yes
• Blood Pressure Treatment
• 130-35/85-89 Lifestyle Lifestyle Lifestyle/Drug
• 140-159/90-99 Lifestyle (1 yr) Lifestyle/Drug Dru
  g
• Above 160/100 Drug Drug Drug

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Goal 3.Create an active partnership with the
Patient

• Motivate patient and healthcare professional
• Agree on the blood pressure goal
• Agree on strategies for reaching goal
• Establish a patient support system (patient,
  family, healthcare professionals, local groups)

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Goal 3.Create an active partnership with the
Patient

• Motivate patient and healthcare professional
• Agree on the blood pressure goal
• Agree on strategies for reaching goal
• Establish a patient support system (patient,
  family, healthcare professionals, local groups)

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Blood Pressure Goals

• Uncomplicated Hypertension
• 140/90
• Diabetes
• 130/80
• Kidney Disease
• 130/80

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Know Your Numbers

• Blood Pressure less than 140/90
• Cholesterol less than 240 (total) and 160 (LDL)
  for anyone
• less than 200 (total) and 130 (LDL) if you have
  high blood pressure or diabetes
• Weight BMI less than 25 30 minutes
  of exercise 4 days/week 5 servings of veg
  fruit/day

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Passport to Your Health
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Meta-Analysis of Home Monitoring for Improving BP
Control (Cappuccio et al,
BMJ 2004 329,145)
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Goal 4.Treat Hypertension to Goal

• Unambiguously recommend lifestyle modifications
• Select the appropriate antihypertensive drugs
• Early and aggressive therapy for hypertensive
  patients in keeping with guidelines
• Monitor progress regularly and maintain good
  patient records
• Aim to bring patients rapidly to blood pressure
  goals and when goals are reached, maintain them
• Support patient participation/compliance
• Follow current hypertension guidelines

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Goal 4.Treat Hypertension to Goal

• Unambiguously recommend lifestyle modifications
• Select the appropriate antihypertensive drugs
• Early and aggressive therapy for hypertensive
  patients in keeping with guidelines
• Monitor progress regularly and maintain good
  patient records
• Aim to bring patients rapidly to blood pressure
  goals and when goals are reached, maintain them
• Support patient participation/compliance
• Follow current hypertension guidelines

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DASH Sodium Trial(Sacks et al, NEJM, 344 3,
2001)
-2.1
-4.6
-5.9
Control
Systolic Pressure mmHg
-5.0
-1.3
-1.0
-2.2
DASH
Sodium Intake
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What if there was a treatment that did all of the
following?
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• Reduce risk of hypertension
• Reduce risk of diabetes
• Reduce risk of MI
• Reduce risk of stroke
• Reduce risk of osteoporosis
• Improve pain immobility of arthritis
• Reduce chances of ER visits hospitalization

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• Reduce risk of hypertension
• Reduce risk of diabetes
• Reduce risk of MI
• Reduce risk of stroke
• Reduce risk of osteoporosis
• Improve pain immobility of arthritis
• Reduce chances of ER visits hospitalization

What pills could do all of these?
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Its free!
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There is

• Its Called Walking

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Walking lowers risk of developing type 2 diabetes
(Hu et al, JAMA 19992821433)
Risk of Diabetes
BMIgt25
BMIlt25
Quintile of Physical Activity
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Walking lowers risk of developing type 2 diabetes
(Hu et al, JAMA 19992821433)
30 reduction of diabetes
Risk of Diabetes
BMIgt25
BMIlt25
Quintile of Physical Activity
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Walking to Work Lowers the Risk of Developing
Hypertension in Japanese Men (Hayashi et al, Ann
Int Med 1999 13021)
Odds Ratio of developing HTN over 10 years
10 minutes or less
11-20 minutes
21 minutes or more
Time spent walking to work
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Walking to Work Lowers the Risk of Developing
Hypertension in Japanese Men (Hayashi et al, Ann
Int Med 1999 13021)
29 reduction of hypertension
Odds Ratio of developing HTN over 10 years
10 minutes or less
11-20 minutes
21 minutes or more
Time spent walking to work
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Goal 4.Treat Hypertension to Goal

• Unambiguously recommend lifestyle modifications
• Select the appropriate antihypertensive drugs
• Early and aggressive therapy for hypertensive
  patients in keeping with guidelines
• Monitor progress regularly and maintain good
  patient records
• Aim to bring patients rapidly to blood pressure
  goals and when goals are reached, maintain them
• Support patient participation/compliance
• Follow current hypertension guidelines

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Limited Efficacy of Monotherapy in Treating
Hypertension (Materson NEJM 1993 328 914)
Patients Responding
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy One Increase Dose
Reduction of SBP mmHg
Half Standard
Double
Dose of individual drugs
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy One Increase Dose
Reduction of SBP mmHg
Half Standard
Double
Dose of individual drugs
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy One Increase Dose
Reduction of SBP mmHg
Half Standard
Double
Dose of individual drugs
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy Two add another drug
Reduction of SBP mmHg
One Two
Three
Number of Drugs
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy Two add another drug
Reduction of SBP mmHg
One Two
Three
Number of Drugs
80
Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy Two add another drug
Reduction of SBP mmHg
One Two
Three
Number of Drugs
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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Reduction of SBP mmHg
Dose Half Standard
Double Drugs One
Two Three

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Value of Low Dose Combination Drugs (Law et al,
BMJ 20033261427)
Strategy One Increase Dose
Reduction of SBP mmHg
Side effects
Half Standard
Double
Dose of individual drugs
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Goal 5.Create a Supportive Environment

• Refer patient to community organizations
• Seek support from local community
  leaders/institutions
• Provide culturally sensitive educational material
• Support patient activism
• Advocate health policies that reduce barriers to
  treatment

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Effectiveness of VA Hypertension
Clinics-1980Predictors of successful treatment

• Patient Characteristics
• White race
• Longer time in clinic
• More intense treatment regimens
• More compications of hypertension

(Stason et al, Med Care 1994 321197)
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Effectiveness of VA Hypertension
Clinics-1980Predictors of successful treatment

• Clinic Characteristics
• Schedule more frequent visits
• Reminders after missed appointments
• Regular staff meetings
• Satisfied clinic directors
• Higher workloads

(Stason et al, Med Care 1994 321197)
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Hypertension Mangement Traditional Model
Patient
BP Reading
Office Visit
Physician
1 2
3
Month
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Hypertension Mangement The Virtual
Hypertension Clinic
Monitor
Averaged BP Readings
Server
Office Visit
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