What Have We Learned

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What Have We Learned
11th Annual Conference on Hypertension SMA-ASH
Carolinas Georgia Chapter Hilton Head, SC August
17, 2007
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Day 1

• While where you are born correlates with CV risk,
  your size at birth correlates with risk of
  developing renal disease, hypertension, and
  diabetes mellitus.
• In children with hypertension, the goal is to
  reduce BP to lowest antihypertensive dose possible with the
  greatest BP lowering effect to achieve the
  highest adherence. In those with diabetes or
  renal disease, reduce BP to which may require more than 1 medication.

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Day 1

• In the non-invasive evaluation of vascular risk
  we learned that when the Augmentation Index is
  the greatest over a 4-year follow-up (greatest
  degree of reflective wave occurring earlier in
  the systolic cycle) your risk for CV and overall
  survival on dialysis is significantly reduced.
  That said, these non-invasive techniques are not
  quite ready for clinic use, but the day is
  approaching when they may be used.
• A spot urine protein (albumin) correlates with
  24-hour urine determination. It should be done
  for those with diabetes where there is evidence
  for renal outcome improvement. In the IMPROVE
  trial, 405 patients with hypertension, 75
  diabetic, found that if you had microalbuminuria,
  it did not matter if you received an ACE
  inhibitor or an ARB, but in overt proteinuria,
  the 2 drugs together were better than either one
  alone.

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Day 1

• Generalized screening for microalbuminuria is not
  ready for prime time.
• In the patient with multiple risk factors,
  obesity is likely to be present and increase in
  the years ahead. Lose 5-10 weight by walking 30
  minutes per day include an ACE or ARB in your
  regimen in controlling your BP, use a statin, and
  try to prevent the development of diabetes.

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Day 2

• Pre-HTN is associated with increased CVD and
  predicts the risk of developing HTN. 1/3 of these
  individuals have the metabolic syndrome.
  Lifestyle changes can prevent pre-HTN from going
  on to HTN but adoption is incomplete.
  Pharmacologic strategies, based on the TROPHY
  study, are promising.
• Best Outcomes for BP control occurs when the
  PROCESS of care is improved and with the use of
  non-physician extenders. Contact patients that
  miss their appointment getting them into the
  office. This is a missed opportunity for
  healthcare improvement.

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Day 2

• Up to 1 of all those with hypertension present
  to the ED over the next year with a hypertensive
  crisis. All of these patients presenting with
  severe hypertension deserve an early triage. Most
  of these individuals actually have severe
  hypertension (urgency) and not an emergency. The
  clinical state of the patient and not the
  severity of BP elevation determines the need for
  parenteral (admission) vs oral (outpatient) BP
  reduction.

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Day 2

• All B-blockers are not similar. Atenolol, as an
  initial antihypertensive agent, is inferior for
  preventing stroke and CVD to multiple
  comparators. Higher generation B-Blockers
  (nebivolol, for example) affects central aortic
  BP and arterial stiffness differently than
  atenolol. Future clinical trials are necessary to
  evaluate if these differences translate into
  differences in outcome.

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Day 2

• Direct Renin Inhibitors, which are effective
  antihypertensive agents, will work best when
  combined with an additional RAS blocker (ACEI or
  ARB) because of Ang 1-12, a newly discovered
  peptide that stimulates ang II, that is
  upregulated when Renin activity is inhibited.
• Fixed-does combinations will be required to
  effectively get BP to goal. The newer fixed-dose
  combinations do not lower BP any better than the
  older fixed dose-combinations.

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Day 2

• While we diagnosis elevated BP in those with the
  metabolic syndrome as BP 130/85 mm Hg, there is
  no evidence as to what the goal for BP reduction
  should be.
• Sirbutramine and orlistat are available as
  pharmacologic agents for weight loss in those
  with the metabolic syndrome but for a variety of
  reasons are not often used in those with obesity
  and hypertension.

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Day 3

• There are 2 approaches to screening lipids in
  children, a population-based and an
  individualized approach. Children and adolescents
  should be screened in a health care providers
  office emphasizing the communication between the
  adult cardiologist caring for an adult parent
  with premature CVD and the pediatrician. Also,
  screening should occur for children whose parents
  have been found to have a cholesterol of 240
  mg/dL or greater.
• Children and adolescents between age 2 and 19
  should be screened when the cholesterol is
  between the 75th (170 mg/dL) and the 95th (200
  mg/dL) percentile.
• Children at age 10 or older can have
  pharmacologic therapy used to lower their LDL to
  the current optimal goal of
• Bile acids, ezetimibe, and statins can be used in
  children begining at age 10 but statins should
  not be used in adolescent females.

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Day 3

• Preeclampsia is more common in mothers with
  multiple pregnancies, who are older, with
  diabetes, and are obese. It increases the risk
  for atherosclerosis and CV disease in later life.
• Women presenting beyond week 20 need to have a
  good history for chronic hypertension and be
  screened for proteinuria to differentiate
  pre-eclampsia (hypertension presenting after 20
  weeks with clinical proteinuria) or superimposed
  pre-eclampsia with chronic hypertension from
  chronic hypertension (present before 20 weeks).
• Consideration should be made to replace ACE
  inhibitors, ARBs, and atenolol before conception.
  Atenolol has been associated with Intra Uterine
  Growth Retardation (IUGR).
• Methyldopa, Labetalol, and amlodipine can be used
  orally, as necessary, if at least 48 hours from
  delivery. If within 24-48 hours of delivery, use
  parenteral hydralazine and labetalol The goal for
  both should be no lower than 150/100 mm Hg. Only
  the mother benefits from BP control.

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Day 3

• Chronic Kidney disease needs to be recognized
  early. Patients need to be appropriately referred
  to a nephrologist so that anemia, bone and
  mineral metabolism (calcium and phosphorus), and
  pre-dialysis issues can be appropriately
  addressed.
• All diabetics should be considered for a statin,
  aspirin, ACE inhibitor, and metformin therapy.
• Hypertensive patients with 3 or more risk factors
  should have their LDL cholesterol reduced 30-40
  as in the ASCOT-LLA trial.
• Statins are especially safe with extremely low
  rates of muscle, liver, and renal toxicity.