Prevention, Treatment, Control and Sodium Reduction Policy

1
Prevention, Treatment, Control and Sodium
Reduction Policy

• Mary G. George MD, MSPH, Medical Officer
• Janelle Gunn MPH, RD, Policy Lead
• Division for Heart Disease and Stroke Prevention

2
Overview of this Module

• Hypertension and the impact on population health
• Assessment of hypertension
• Challenges in hypertension control
• JNC-VII treatment guidelines
• System-based initiatives to improve control
• Hypertension and sodium connection
• Community and population based changes to promote
  prevention

3
Discrepancy Between Health Determinants and
Spending of 1.7 Trillion, 2007

• Source Prevention Institute. 2007. Reducing
  Healthcare Costs Through Prevention. Available at
  http//www.preventioninstitute.org/documents/HE_He
  althCareReformPolicyDraft_091507.pdf

4
Epidemiology
5
(No Transcript)
6
Hypertension Mortality Rates

• http//apps.nccd.cdc.gov/DHDSPAtlas/reports.aspx

7
The Magnitude of the Problem

• Hypertension is the single largest risk factor
  for cardiovascular disease mortality, accounting
  for 45 of all CVD deaths1
• INTERSTROKE Study concluded that hypertension
  provides 34.6 of the population-attributable
  risk (PAR) for stroke2, while INTERHEART found it
  provides 17.9 of the PAR for myocardial
  infarction3
• The PAR is the reduction in incidence that would
  be observed if the population were entirely
  unexposed (did not have hypertension).

• 1. IOM (Institute of Medicine). 2010. A
  Population-Based Policy and Systems Change
  Approach to Prevent and Control Hypertension.
• 2. ODonnell MJ, Xavier D, Liu L et al. Risk
  factors for ischaemic and intracerebral
  haemorrhagic stroke in 22 countries (the
  INTERSTROKE
• study) a casecontrol study. The Lancet 2010
  37611223
• 3. Salim Yusuf, Steven Hawken, Stephanie Ôunpuu,
  Tony Dans, Alvaro Avezum, Fernando Lanas, Matthew
  McQueen, Andrzej Budaj, Prem
• Pais, John Varigos, Liu Lisheng, on behalf of the
  INTERHEART Study Investigators, Effect of
  potentially modifiable risk factors associated
  with
• myocardial infarction in 52 countries (the
  INTERHEART study) case-control study, The
  Lancet, 2004 9438, 1117.

8
Comprehensive Approach to Hypertension Control

• Focused clinical interventions for those at high
  risk
• Lifestyle advice
• Population-based strategies

9
Stages of CVD Intervention

• Primordial Before risk factors develop
• Primary Treatment of risk factors
• Secondary After a CVD event occurs

10
Primordial Prevention Preventing Risk Factors
from Developing

• In 1978, Strasser introduced the concept of
  primordial prevention. Once a risk factor has
  developed, it can be difficult to reduce the risk
  it contributes to overall health
• Medications and lifestyle interventions cannot
  reduce CVD event rates to levels seen in those
  who maintain optimal risk factor profiles (ideal
  cardiovascular health) into middle and older
  ages.

• Lloyd-Jones DM. Improving the cardiovascular
  health of the US population. JAMA. 12 1314
  -1316 .

11
Population Strategy

• WHO, Prevention of cardiovascular disease
  guidelines for assessment and management of total
  cardiovascular risk., 2007

12
Major Shifts in Population Risks and Expanded
Treatment, U.S.
Change in numbers of deaths

Risk Factors worse 17 Obesity (increase)
7 Diabetes (increase) 10 Risk Factors
better -65 Population BP fall -20
Smoking -12 Cholesterol (diet) -24 Physical
activity -5 Treatments -47 AMI
treatments -10 Secondary prevention -11 Heart
failure -9 Angina CABG PTCA -5 Hypertension
therapies -7 Statins (primary prevention) -5
  
0
341,745 fewer deaths in 2000

-
2000
1980
Ford, ES et.al. Explaining the decrease in U.S.
deaths from coronary disease, 1980-2000. NEJM
2007 356 2388.
13
What Can You Do to Make a Difference?

• Approximately 68 million U.S. adults (1 in 3)
  have hypertension
• Only 46 of adults with hypertension had
  adequately controlled blood pressure. The
  Million Hearts initiative has set a goal of 65
  control by 2017 overall, and 70 in the clinical
  setting

• Valderrama A, et al. Million Hearts Strategies
  to Reduce the Prevalence of Leading
  Cardiovascular Disease Risk Factors. MMWR. 2011
  60(36)1248-1251.

14
Patient Level Strategy

• A 10mmHg lower systolic blood pressure (SBP) or
  5mmHg lower diastolic blood pressure (DBP) is
  associated with an approximately 2025 lower
  risk of coronary heart disease (CHD) and an
  approximately 40 lower risk of stroke

1. Stamler J, Stamler R, Neaton JD, Blood pressure,
   systolic and diastolic, and cardiovascular risks.
   US population data, Arch Intern Med,
   1993153598615.
2. Asia Pacific Cohort Studies Collaboration, Blood
   pressure and cardiovascular disease in the Asia
   Pacific region, J Hypertens, 20032170716.
3. MacMahon S, Peto R, Cutler J, et al., Blood
   pressure, stroke and coronary heart disease. Part
   I, prolonged differences in blood pressure
   prospective observational studies corrected for
   the regression dilution bias, Lancet,
   199033576574.
4. http//www.touchbriefings.com/pdf/2988/giampaoli.p
   df

15
JNC VII Treatment Guidelines
16
Assessment

• Assess for major cardiovascular risk factors
• Assess for identifiable causes of hypertension
• Sleep apnea
• Drug induced/related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Cushings syndrome or steroid therapy
• Pheochromocytoma
• Coarctation of aorta
• Thyroid/parathyroid disease

• Greenland P. 2010 ACCF/AHA Guideline for
  Assessment of Cardiovascular Risk in Asymptomatic
  Adults
• Executive Summary. JACC. Vol. 56, No. 25, 2010.

17
Lifestyle interventions

• JNC VII recommends therapeutic lifestyle change
  only for most people with pre-hypertension
• Weight reduction
• DASH diet
• Dietary sodium reduction
• Physical Activity
• Moderate alcohol consumption

• http//www.nhlbi.nih.gov/guidelines/hypertension/

18
JNC VII Medication Recommendations

• Pre-hypertension
• Lifestyle interventions
• Stage 1 Hypertension
• (SBP 140159 or DBP 9099 mmHg) Thiazide-type
  diuretics for most. May consider ACEI, ARB, BB,
  CCB, or combination
• Stage 2 Hypertension
• (SBP 160 or DBP 100 mmHg) 2-drug combination
  for most (usually thiazide-type diuretic and
  ACEI, or ARB, or BB, or CCB)

ACEI ace inhibitors ARB angiotensin
receptor blockers BB beta blockers CCB
calcium channel blockers

• JNC-VII includes chlorthalidone among
  thiazide-type diuretics.

19
Medication Adherence

• Clinician empathy increases patient trust and
  motivation
• Physicians should consider their patients
  cultural beliefs and individual attitudes in
  formulating therapy
• Team-based care (pharmacy medication therapy
  management, physician assistants, nurse
  practitioners, etc.)
• Consider the Morisky Medication Adherence
  questionnaire for your hypertensive patients

20
Challenges in Hypertension Control
21
Special Populations

• Minorities
• Blacks have an increased rate of conversion from
  pre-hypertension to hypertension
• Median age-adjusted conversion time when 50 of
  patients converted from pre-hypertension to
  hypertension was 2.7 years in whites and 1.7
  years in blacks
• Over age 80
• Significant benefits from treatment
• May be more sensitive to medication side effects
  or drug interactions due to an increased number
  of medications taken

• Selassie A, et al. Progression is accelerated
  from prehypertension to hypertension in blacks.
  Hypertension. 2011
• 58579-587.

22
Resistant Hypertension

• Hypertension not controlled using a combination
  of 3 antihypertensive drug classes, including a
  diuretic
• Non-compliance/adherence with medication
• Fluid imbalance renal failure
• Hormonal imbalance

23
Incidence of Resistant Hypertension

• Study from Colorado Kaiser Permanente, found that
  1.9 of patients (1 in every 50 patients) with
  incident hypertension who were begun on treatment
  developed resistant hypertension within a median
  of 1.5 years from initial treatment
• They found 16 of patients on 3 or more drugs
  continued to have resistant hypertension

• Daugherty SL, et al. Incidence and prognosis of
  resistant hypertension in hypertensive patients.
  Circulation. February 29, 2012.
• Epub ahead of print

24
What Happens if Hypertension isnt Controlled?

• Left ventricular hypertrophy (LVH)
• Heart failure
• Chronic kidney failure
• Stroke (cerebral hemorrhage)
• Vascular dementia
• Retinopathy

25
Incidence of ESRD by Systolic Blood Pressure
Multiple Risk Factor Intervention Trial
White Men (n 300,645) Black Men (n 20,222)
83.1
Incidence of ESRD per 100,000 Person-Years
37.2
32.4
27.3
26.2
15.8
14.2
9.1
5.4
5.4
lt117
117-123
124-130
131-140
gt140
Systolic Blood Pressure (mm Hg)
The original cohort of 332,544 men included
11,677 men in other ethnic groups whose data are
excluded from this comparison. ESRD end-stage
renal disease
Klag MJ, et al. End-stage renal disease in
African-American and white men. 16-year MRFIT
findings. JAMA. 19972771293-1298.
26
Effects of Systolic and Diastolic BloodPressures
on CHD Mortality MRFIT
48.3
CHD Death Rate Per 10,000 Person-Years
80.6
37.4
34.7
43.8
31.0
38.1
25.5
23.8
24.6
25.3
16.9
25.2
20.6
13.9
24.9
12.8
10.3
160
12.6
11.8
11.8
8.8
100
140-159
8.5
90-99
Diastolic Blood Pressure(mm Hg)
9.2
80-89
120-139
75-79
Systolic Blood Pressure(mm Hg)
70-74
lt120
lt70
Data shown only for 316,099 white men 35 to 57
years of age who were followed for a mean of 12
years. CHD coronary heart disease MRFIT
Multiple Risk Factor Intervention Trial
Neaton JD, et al. Serum cholesterol, blood
pressure, cigarette smoking, and death from
coronary heart disease overall findings and
differences by age for 316,099 white men. Arch
Intern Med. 199215256-64.
27
Risk of Stroke Death According to Blood Pressure
(mm Hg) MRFIT

Systolic Blood Pressure (SBP) Diastolic Blood
Pressure (DBP)
Relative Risk of Stroke Death









10
1
2
3
4
5
6
7
8
9
Decile
(Highest 10)
(Lowest 10)
15198
142?92?
lt112lt71
112?71?
118?76?
121?79?
125?81?
129?84?
132?86?
137?89?
SBP
DBP
MRFIT Multiple Risk Factor Intervention Trial
P lt 0.01 P lt 0.001.
Stamler J, et al. Arch Intern Med.
1993153598-615 He J, Whelton PK. Am Heart J.
1999138(Pt 2)211-219.
28
System-based Initiatives to Improve Control
29
Meaningful Use and Pay-for-Performance

• PQRS Measure 317 Preventive Care and Screening
  Screening for High Blood Pressure
• Percentage of patients aged 18 and older who are
  screened for high blood pressure.
• PQRS Measure 236 (NQF 0018) Hypertension
  Controlling High Blood Pressure
• Percentage of patients aged 18 through 85 years
  of age who had a diagnosis of hypertension and
  whose blood pressure was adequately controlled
  (lt140/lt90) during the measurement year.

30
Team-based care the Role of the Pharmacist

• The Asheville Project is a community-based,
  pharmacist-directed, medication therapy
  management (MTM) program provided for several
  employers in the Asheville, NC area
• Patients with hypertension receiving education
  and long-term medication therapy management
  services achieved significant clinical
  improvements that were sustained for as long as 6
  years
• ? cardiovascular events
• ? adherence to medications

• Bunting BA, et al. The Asheville Project
  Clinical and economic outcomes of a
  community-based long-term medication therapy
• management program for hypertension and
  dyslipidemia. J Am Pharm Assoc. 2008482331.

31
Quality Improvement and Clinical Decision Support

• A proven concept that improves care!
• Alerts
• Reminders
• Reports
• Templates for management
• Built-in access to guidelines
• Enhances implementation of quality improvement
  initiatives

32
Clinical-Community Reporting Efforts

• RWJF Aligning Forces for Quality
• Public reporting Wisconsin Collaborative for
  Healthcare Quality

• http//www.wchq.org/reporting/results.php?category
  _id0topic_id17source_id0providerType0regio
  n0measure_id78

33
Hypertension and Sodium

• The Connection

34
The Effect of Sodium Intake on Blood Pressure

• Sodium intake is one of several dietary factors
  that increases blood pressure
• Sodium is the principal cation of the
  extracellular fluid and functions as the osmotic
  determinant in regulating extracellular fluid
  volume and plasma volume
• Sodium is stored in the blood and in the fluid
  surrounding the cells kidneys control the body
  sodium concentration by clearing excess sodium
  through urine

35
The Effect of Sodium Intake on Blood Pressure

• Sodium affects blood pressure by changing blood
  volume
• Absorbed sodium remains in the extracellular
  compartments, including
• plasma (at 140 mmol/L interstitial fluid 145
  mmol/L plasma water 150 mmol/L muscle tissue
  3 mmol/L)
• These levels maintain blood pressure in the
  normal range
• Increased sodium intake increased blood volume
  higher blood pressure
• Sodium reduction decreased blood volume lower
  blood pressure

• Institute of Medicine. Dietary reference intakes
  for water, potassium, sodium chloride, and
  sulfate. Washington, DC National
• Academies Press 2004.

36
Excess Sodium Intake Leads to Hypertension

• Sodium, through hypertension, is a major
  contributor to death, disability, disparities,
  and costs attributable to cardiovascular diseases
  (CVD)
• Economic burden
• Treatment for heart disease, stroke, and other
  CVD accounts for 1 in 6 U.S. health dollars spent
  (273 billion in 2008)
• Globally, 8.5 million deaths could be averted
  over 10 years from 2006 to 2015 through a 15
  reduction in sodium intake

• Vital Signs MMWR 2011 60(4)1-38
• Heidenreich PA, et al. Forecasting the future of
  cardiovascular disease in the United States a
  policy statement from the
• American Heart Association. Circulation
  2011123933944.
• Asaria P, et al. Chronic disease prevention
  health effects and financial costs of strategies
  to reduce salt intake and control
• tobacco use. Lancet 2007370204453.

37
Sodium Reduction Benefits All Ranges of Blood
Pressure

• Evidence supports a strong, direct relationship
  between blood pressure and vascular mortality
• No evidence of a blood pressure
  thresholdvascular mortality increases throughout
  the range of blood pressures in both
  nonhypertensive and hypertensive individuals
• Average blood pressure was reduced by 22.7/9.1 mm
  Hg in patients with resistant hypertension when
  switched from a high to low sodium diet
• In most individuals blood pressure is reduced
  within days to weeks of reducing sodium intake

• Institute of Medicine. Dietary reference intakes
  for water, potassium, sodium chloride, and
  sulfate. Washington, DC National
• Academies Press 2004.
• Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S,
  Dell'Italia J, Calhoun DA. Effects of dietary
  sodium reduction on blood
• pressure in subjects with resistant hypertension
  results from a randomized trial. Hypertension.
  2009 54 475 - 481

38
DASH and DASH Sodium Trials

• Dietary Approaches to Stop Hypertension (DASH)
  Trial
• Compared the effects of three diets typical
  American diet, fruits and vegetable diet, and a
  diet rich in fruits and vegetables and low fat
  dairy, and reduced in saturated fat, total fat,
  and cholesterol
• All diets provided 3,000 mg sodium per day
• Combination diet (DASH) produced the largest
  blood pressure reduction after 8 weeks average
  ? of 5.5 / 3.0 mm Hg
• Participants with hypertension experienced an
  average blood pressure ? of 11.4 / 5.5 mm Hg
• DASH Sodium Trial
• DASH diet and three levels of sodium intake
  1,150 mg, 2,300 mg, and 3,450 mg
• DASH diet and a low level of sodium ? SBP by 7.1
  mg Hg
• Participants with HTN experienced a BP ? of 11.5
  mm Hg

• Appel LJ, Moore TJ, Obarzanek E, et al. A
  clinical trial of the effects of dietary patterns
  on blood pressure. N Engl J Med
  19973361117-1124
• Sacks et al. Effects on Blood Pressure of Reduced
  Dietary Sodium and the Dietary Approaches to Stop
  Hypertension (DASH) Diet. N Engl J Med
• 2001 3443-10

39
Sodium Intake Levels Recommended and Actual

• Recommended levels of sodium intake
• 2010 Dietary Guidelines for Americans
• Reduce sodium to lt 2300 mg/day
• For specific populations 1,500 mg/day
• 51 years old
• African Americans
• Have high blood pressure, diabetes, or chronic
  kidney disease
• About half the U.S. population and the majority
  of adults
• Actual sodium intake
• Average daily sodium intake for U.S. adults is
  gt3,300 mg/day

• USDA and HHS. Dietary Guidelines for Americans,
  2010. 7th edition. Washington, DC Government
  Printing Office 2010.
• Vital Signs MMWR 2012 61(Early Release)1-7

40
Individual Sodium Reduction Has Population
Benefits

• Reducing the sodium content by 25 of the top 10
  food category contributors to sodium intake could
  result in a 360 mg reduction in average sodium
  consumption in the United States
• Reducing average population sodium consumption by
  400 mg has been projected to avert up to 28,000
  deaths from any cause and save 7 billion in
  health-care expenditures annually

• CDC, MMWR2012611-7.
• Bibbins-Domingo K, Chertow GM, Coxson PG, et al.
  Projected effect of dietary salt reductions on
  future cardiovascular disease. N
• Engl J Med 20103625909.

41
Reducing Sodium Intake Reduces Blood
Pressure

• Reducing average population sodium intake to
  1,500 mg/day may
• Reduce cases of hypertension by 16 million
• Save 26 billion health care dollars
• Gain 459,000 Quality Adjusted Life Years (QALYs)
• Even reducing sodium intake to 2,300 mg/day could
• Reduce cases of hypertension by 11 million
• Save 18 billion health care dollars
• Gain 312,000 QALYs

• Sacks FM, et al. Effects on blood pressure of
  reduced dietary sodium and the Dietary Approaches
  to Stop Hypertension (DASH)
• diet. DASH-Sodium Collaborative Research Group.
  N Eng J Med 2001344310.
• Palar K, et al. Potential societal savings from
  reduced sodium consumption in the U.S. adult
  population. Am J Health
• Promot 200924(1)4957.

42
Percent of US persons exceeding their 2010
Dietary Guidelines for Americans
sodium intake recommendations

Age Group
All people age 51 and older should reduce
sodium intake to 1,500 mg/day. MMWR
2011601413-1417
43
Most of the sodium we eat comes from processed
and restaurant foods

• Mattes RD, et al. Relative contributions of
  dietary sodium sources. J AM Coll Nutr
  199110383393.

44
44 of US sodium intake comes from ten types of
foods
Rank Food Types
1 Bread and rolls 7.4
2 Cold cuts and cured meats 5.1
3 Pizza 4.9
4 Poultry 4.5
5 Soups 4.3
6 Sandwiches 4.0
7 Cheese 3.8
8 Pasta mixed dishes 3.3
9 Meat mixed dishes 3.2
10 Savory snacks 3.1

• CDC, MMWR2012611-7.

45
Other Guidelines and Recommendations

• Institute of Medicine
• Reduce the sodium content of the U.S. food supply
• Health practitioners commitment to incorporate
  guidelines on sodium intake into prevention
  messages and standards of care
• Million Hearts
• Reduce population sodium intake by 20 by January
  1, 2017
• Healthy People 2020
• Reduce mean U.S. population sodium intake to
  2,300 mg per day by 2020
• American Heart Association
• Reduce population sodium intake to 1500 mg per
  day

46
Other Guidelines and Recommendations

• American Medical Association
• Stepwise, minimum 50 reduction in sodium in
  processed foods, fast-food products, and
  restaurant meals over the next decade
• Physicians and other clinicians should educate
  patients about the benefits of long-term,
  moderate reductions in sodium intake
• Substantial public health benefits accrue from
  small reductions in population blood pressure
  distribution, achievable with long-term modest
  reduction in sodium intake
• AMA supports the National Salt Reduction
  Initiative
• Aim is to lower U.S. population sodium intake by
  20 over five years through sodium reduction in
  packaged, processed and restaurant foods by 25
  over that time period

• Dickinson B, Havas S. Reducing the Population
  Burden of Cardiovascular Disease by Reducing
  Sodium Intake A Report of the
• Council on Science and Public Health. Arch
  Intern Med. 2007167(14)1460-1468.

47
Adults with Self-Reported Hypertension
Who Received
and Acted on Low-Salt Advice
Age, years
50
Advice and behavioral change

• Behavioral Risk Factor Surveillance System, 19
  states, 1 territory, and Washington, DC, 2007

48
Role of the Provider

• AMA recommends that health care providers educate
  patients on how to reduce sodium intake
• However, nearly 70 of primary health care
  providers report advising their patients to
  remove the salt shaker from the table, and the
  majority reported advising patients to add less
  salt during cooking, even though these behaviors
  are unlikely to result in major sodium reduction

• Havas S, Dickinson BD, Wilson M. The urgent need
  to reduce sodium consumption.
• JAMA. 20072981439-41.
• Fang J, Cogswell M, Keenan N, Merritt R. Primary
  Health Care Providers' Attitudes
• and Counseling Behaviors Related to Dietary
  Sodium Reduction. Archives of
• Internal Medicine 2012172(1)76-78.
  doi10.1001/archinternmed.2011.620.

Image adapted from CDC Vital Signs Fact Sheet,
Wheres the Sodium
49
Health Care Providers Who Agree with Importance
of Sodium Reduction for their Patients
Statement Most of my patients should reduce
their sodium intake
Health care provider
Fang J, Cogswell M, Keenan N, Merritt R. Primary
Health Care Providers' Attitudes and Counseling
Behaviors Related to Dietary Sodium Reduction.
Archives of Internal Medicine 2012172(1)76-78.
doi10.1001/ archinternmed.2011.620.
50
Role of the Provider

• Patients may be able to lower the required dose
  of blood pressure medicines through reduced
  sodium intake
• Patients with normotension or prehypertension
  may reduce or prolong their risk for developing
  hypertension through sodium reduction
• Referral to a Registered Dietitian for Counseling
• Education during BP screenings
• Downloadable CDC resource Reducing Sodium in
  Your Diet to Help Control Your Blood Pressure
• Advise consumption of fresh fruits and
  vegetables, frozen fruits and vegetables without
  sauce, and no salt added canned vegetables
• Advise limiting processed foods high in sodium

51
Role of the Provider

• Current food environment makes it difficult for
  consumers who want or need to consumes less
  sodium to do so
• Reduction of sodium in the food supply, coupled
  with consumer education and knowledgeable use of
  food labels, may provide greater choice and
  control over sodium intake, a modifiable risk
  factor for high blood pressure, heart disease,
  and stroke

52
Patient Education Its Not the Salt Shaker,
Its the Food Choices!

• www.cdc.gov/salt

53
Community and Population-based Changes to Promote
Prevention
54
Community Partners

• Community health workers and Promotores de Salud
• A liaison between health and social services and
  the community facilitating access to care
• Provides a trusted liaison through a shared
  culture with the people they serve
• Barbershop- and beauty shop-based interventions
  to improve hypertension control
• Faith-based support programs

• Ferdinand KC, et al. Community-based approaches
  to prevention and management of hypertension and
  cardiovascular disease.
• Journal of Clinical Hypertension. 2012. Online
  ahead of print. DOI10.1111/j.1751-7176.2012.00622
  .x

55
Population-Based StrategySBP Distributions
Reductions in SBP Reduction in Mortality Reduction in Mortality Reduction in Mortality
Reductions in SBP Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7

• Stambler .Hypertension.
• 1991 117-120.

56
CDC Efforts Related to Hypertension Control

• Community Transformation Grants
• Sodium Reduction in Communities
• WISEWOMAN program
• State Health Departments
• Million Hearts Initiative

57
Public Health

• Public health approaches such as increasing
  physical activity and reducing trans-fats and
  salt in processed foods can achieve a downward
  shift in the distribution of a populations blood
  pressure.
• In addition to CDC activities on the previous
  slide, CDC funds many other programs to promote
  healthy lifestyles.

• http//www.nhlbi.nih.gov/guidelines/hypertension/e
  xpress.pdf

58
Quick Facts about Hypertension and Sodium
9 in 10 people eat too much sodium 44 of the
sodium we eat comes from 10 types of
foods Reducing sodium by 1,200 mg/day can save
20 B
Every 39 seconds an adult dies of heart attack,
stroke, or other cardiovascular disease Nearly
1 in 2 people with hypertension doesn't have it
under control
Image adapted from CDC Vital Signs Fact Sheet,
Wheres the Sodium
Image adapted from CDC Vital Signs Fact Sheet,
High Blood Pressure and Cholesterol
59
Educator Toolkit

• Hypertension Control and Sodium Reduction

60
Resources

• CDC Vital Signs Hypertension and Cholesterol
• http//www.cdc.gov/vitalsigns/CardiovascularDiseas
  e/index.html
• CDC Vital Signs Wheres the Sodium?
• http//www.cdc.gov/vitalsigns/Sodium/index.html
• CDC Vital Signs Prevalence, Treatment, and
  Control of Hypertension
• http//www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.
  htm?s_cidmm6004a4_w

61
Resources

• CDC Grand Rounds Sodium Reduction Time for
  Choice
• http//www.cdc.gov/about/grand-rounds/archives/201
  1/April2011.htm
• CDC Blood Pressure Information
• http//www.cdc.gov/bloodpressure/
• DASH Diet
• http//www.nhlbi.nih.gov/health/public/heart/hbp/d
  ash/new_dash.pdf

62
Resources

• JNC VII
• http//www.nhlbi.nih.gov/guidelines/hypertension/
  
• The Asheville Project
• http//www.innovations.ahrq.gov/content.aspx?id33
  80
• Morisky Medication Adherence Questionnaire
• http//www.ncbi.nlm.nih.gov/pubmed?termMorisky20
  DE2C20Ang20A2C20Krousel-Wood20M2C20Ward20
  H.20Predictive20Validity20of20a20Medication2
  0Adherence

63
Important Hypertension Trials

• SHEP (Systolic Hypertension in the Elderly
  Program)
• In persons aged 60 years and over with isolated
  systolic hypertension, antihypertensive
  stepped-care drug treatment with low-dose
  chlorthalidone as step 1 medication reduced the
  incidence of total stroke by 36
• ALLHAT (Antihypertensive and Lipid-Lowering
  Treatment to Prevent Heart Attack Trial)
• The mean systolic blood pressure was 4mm Hg
  higher in blacks and 2 mm Hg higher in non-blacks
  in the lisinopril group than in the
  chlorthalidone group. Blood pressure control was
  8-13 better in the chlorthalidone group than in
  the lisinopril group for blacks. Although in the
  trial overall the chlorthalidone group was better
  controlled than the lisinopril group, this
  difference between the two groups among blacks is
  quite striking.
• MRFIT (Multiple Risk Factor Intervention Trial)
• Changed protocol in clinics using primarily HCTZ
  to chlorthalidone due in part to an a higher
  trend in mortality in clinics using predominantly
  hydrochlorothiazide. Changing to chlorthalidone
  was associated with a trend toward better
  outcomes.
• TROPHY (Trial of Preventing Hypertension)
• Found that it is possible to prevent or delay the
  onset of clinical hypertension in people with
  blood pressure that falls within the
  "prehypertension" category

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Important Hypertension Trials

• TOHP (Trials of Hypertension Prevention)
• Sodium reduction, previously shown to lower blood
  pressure, may also reduce long term risk of
  cardiovascular events.
• TONE (Trial of Nonpharmacologic Interventions in
  the Elderly)
• Reduced sodium intake and weight loss constitute
  a feasible, effective, and safe nonpharmacologic
  therapy of hypertension in older persons.
• HYVET (Hypertension in the Very Elderly Trial)
• According to Timothy Gardner, M.D., President of
  the American Heart Association The results of
  HYVET demonstrate that effective antihypertensive
  treatment with indapamide (Natrilix SR) in
  persons aged 80 years old or older, is beneficial
  in reducing the risk of cardiovascular events,
  and thus extends the patient group in whom
  prevention must be pursued.

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Case Studies

• From Medscape Education
• Timing is Everything 24-Hour Control of Blood
  Pressure 
• William C. Cushman, MD
• http//theheart.medscape.org/viewarticle/759171

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How well prepared are your residents for managing
hypertension?

• Study from Johns Hopkins of baseline knowledge of
  PGY3 internal medicine residents
• Hypertension 62-66
• Lipid Management 31-36
• Diabetes 35-40
• Smoking 53-54
• Obesity 44-47
• Total of 15 Chronic Diseases 48-50
• Baseline knowledge of PGY3 did not differ from
  PGY1 and PGY2

• Sisson SD, Dalal D. Internal Medicine residency
  training on topics in ambulatory care A status
  report. Am Jour of Medicine. 2011124(1)86-90.

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Discussion Questions (could be used before
delivering the module or after)

• You have a busy Family Medicine Practice
• At what point would you consider referring a
  patient for hypertension control?
• How does team-based care delivery for
  hypertension control work in your clinic?
• Can you think of ways to improve your health
  information technology to improve hypertension
  control?
• How do you guide your patients to reduce sodium
  in their diet?