Hypertension

Ambulatory blood pressure monitoring (higher awareness is needed)

Ambulatory blood pressure monitoring (higher awareness is needed)

Ambulatory blood-pressure measurement (ABPM) refers to home assessments of blood pressure every 20-30 minutes over a 24 hour period. In this study about 64,000 adults were followed for 5 years.

Authors found that ABPM is a better predictor of cardiovascular deaths or deaths from any cause, compared to clinic BP measurements. These results are in accordance with recent American Heart Association guidelines published in December 2017 and common sense approach that more data is better then less in reaching statistically meaningful results.

GT

Review of 2018 ADA Guidelines: hypertension in the context of diabetes

Review of 2018 ADA Guidelines: hypertension in the context of diabetes

ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.

GT

SPRINT trial: customized blood pressure goals

SPRINT trial: customized blood pressure goals

Further sub-analysis of SPRINT trial uncovers the point of balance between treatment benefit and harm in the setting of cardiovascular illness. The higher the baseline CVD risk, the more benefit is achieved by intensive blood pressure therapy; while the lower the risk, the higher the harm. Baseline cardiovascular status is obtained by the 10 year ASCVD risk estimator, which can be found online here.


GT

Systolic blood pressure in heart failure

Systolic blood pressure in heart failure

The study finds that low systolic blood pressure in the hospital is associated with increased re-hospitalization and mortality rates among patients with heart failure but preserved ejection fraction (EF>50%). Mortality disadvantage was seen as far out as in 1 month, 1 year and 2.6 years after discharge in those with hospital systolic BP < 120 mmHg. These results could change hospitalists' approach to blood pressure management in heart failure.

GT

Merit-based payment for blood pressure care

Merit-based payment for blood pressure care

I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.

GT

The other aldosterone blocker, eplerenone, helps with hypertension

The other aldosterone blocker, eplerenone, helps with hypertension

The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity.

Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension.

The eplerenone dose ranged from 25-400 mg daily. Patients were followed for 8-16 weeks while on therapy. There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications related to hypertension.

The study finds that eplerenone 50-200 mg/day reduces systolic BP by approximately 9 mmHg and diastolic BP by 4 mmHg compared to taking no medication.

CDSR

Aldosterone vs. renin, a cardiometabolic cat-and-mouse game

Aldosterone vs. renin, a cardiometabolic cat-and-mouse game

Study results are important from several aspects. It confirms prior findings that excess aldosterone increases cardiometabolic sequelae, like cardiovascular events, diabetes, atrial fibrillation and mortality, independent of high blood pressure.

More importantly the study guides us on how to objectively reduce the above risks: the dose of mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, could be adjusted to achieve higher plasma renin activity of ≥1 μg/L/hr.

Plasma renin activity is clinically available and a good biochemical measure of hyperaldosterone end-product, as shown in the figure below.

GT

Outlook on new blood pressure guidelines

Outlook on new blood pressure guidelines

Unlike previous guidelines, the 2017 guideline emphasizes individualized cardiovascular risk assessment and aggressive management of blood pressure at levels of 140/90 mm Hg or higher in patients with a 10-year risk of cardiovascular events of >10%.

Absolute risk is an important determinant of the need for treatment. It’s reasonable to consider more aggressive treatment goals in the highest-risk patients, as SPRINT showed. But while a blood-pressure treatment target of <130/80 mmHg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.

NEJM

Primary hyperaldosteronism amplifies cardio-metabolic anomalies

Primary hyperaldosteronism amplifies cardio-metabolic anomalies

Important to diagnose primary hyperaldosteronism early as a cause of high blood pressure since patients are even at a higher risk for: stroke, coronary artery disease, atrial fibrillation, heart failure, left ventricular hypertrophy, diabetes and metabolic syndrome.

Risks were evenly high for both aldosterone-producing adenoma and bilateral adrenal hyperplasia. About 13,000 patients were followed for 9 years.

GT

Borderline high blood pressure and uric acid levels

Borderline high blood pressure and uric acid levels

About 3,500 participants with pre-hypertension were followed for 5 years. Authors found that adults with pre-hypertension and hyperuricemia were at a higher risk of advancing to gross hypertension, compared to those with normal uric acid levels.

Should serum uric acid be checked in persons with borderline high blood pressure? If elevated, should it be treated? Further research would be required to answer these clinical dilemmas.

GT

An overview of new hypertension guidelines

An overview of new hypertension guidelines

New definitions:

  • Normal BP: <120/80 mmHg
  • Elevated BP “Pre HTN”: 120-130/<80
  • Stage 1 HTN: 130-140/80-90
  • Stage 2 HTN: >140/90

 

New targets for treatment:

  • If ASCVD 10-year-risk is <10%, then target BP <140/90
  • If ASCVD 10-year-risk is ≥10%, then target BP <130/80
    • Established CVD
    • DIABETES
    • CKD
    • AGE>65  and “healthy”

 

GT

2017 ADA position statement: hypertension in diabetes

2017 ADA position statement: hypertension in diabetes

High blood pressure is common in patients with diabetes. Both hypertension and diabetes are independent risk factors for poor cardiovascular outcomes. Obviously the concomitant presence of both HTN and DM in an individual magnifies the chance for CVD events. It is important to screen, diagnose and treat high blood pressure appropriately in someone with diabetes, particularly type 2. 

ADA published a position statement on the subject in Diabetes Care, September 2017. The article is comprehensive in regard to proper diagnosis, clinic vs. home BP measurements, target blood pressure values, life style modifications, pharmacological agent initiation and titration, and barriers to therapy.  Recommendations are listed below with slightly modified wording for easier and succinct reading:

GT

Hypertension SPRINT trial: patient perception

Hypertension SPRINT trial: patient perception

The NIH sponsored SPRINT trial was published in NEJM November 2015. It uncovered that adults with increased risk of cardiovascular disease, but without diabetes, performed better when systolic BP was < 120 mmHg rather than < 140 mmHg. Cardiovascular events and mortality were about 25% less in participants with tighter systolic blood pressure control. About 9,000 patients were followed for 5 years.

Secondary analysis of the SPRINT study shows that patient-reported outcomes - physical activity, mental function, depression score and treatment satisfaction - were similar among adults with final sBP < 120 mmHg and those with sBP < 140 mmHg. 

What would be your systolic blood pressure goal for a 57 year old male smoker without diabetes?

GT

Midlife factors and dementia: a 25 year study

Midlife factors and dementia: a 25 year study

About 15,000 middle aged adults were followed for 25 years. The following characteristics were associated with higher rates of dementia: diabetes, prehypertension, hypertension, smoking, APOE ε4 genotype, black race, older age and lower educational level. These are important findings to share and discuss with relevant patients.

GT

Important indicators of masked hypertension

Important indicators of masked hypertension

Masked hypertension is present when clinic blood pressure is normal <140/90 mmHg, but elevated at home ≥135/85 mmHg. It is an independent hazard for cardiovascular disease and is more common in adults with poor physical activity, diet and smoking habits.

Individuals with such characteristics would benefit from home BP measurements when they appear to have "normal" blood pressure in the office. Important to be aware of masked hypertension as its frequency could be as high as 30% in those with "appropriate" clinic blood pressure values.

GT

Resistant hypertension, review

Resistant hypertension, review

This article reviews recent advances in resistant hypertension: poor therapy adherence, undertreatment with chlorthaladone and spironolactone, precise patient selection for renal nerve denervation (knowledge of accessory renal arteries and possible reinnervation), baroreflex activation therapy via unilateral carotid sinus stimulation, and refractory hypertension (a severe form, defined as uncontrolled blood pressure in spite of using ≥5 agens, including the long-acting thiazide and aldosterone antagonist).

Resistant hypertension is thought to be from salt-sensitivity upregulation (renal), while refractory HTN from sympathetic overdrive (neurogenic). Both types of severe hypertension increase the risk of clinical events strikingly; heart failure, stroke, coronary heart disease, end-stage nephropathy, and all-cause mortality.

GT

White coat syndrome in refractory hypertension

White coat syndrome in refractory hypertension

The study defines refractory hypertension as office blood pressure ≥135/85 mmHg while the patient is taking at least 5 medications, including chlorthalidone and spironolactone. Authors find that white coat syndrome is negligible in adults with refractory high blood pressure. In perspective, about 30-40% of hypertensive patients have some degree of white coat BP elevation.

GT

Metformin helps with blood pressure too

Metformin helps with blood pressure too

This meta-analysis reveals that Metformin can lower systolic BP by 5 and 3 mmHg in prediabetic and obese individuals. This finding is in accordance with the notion of insulin resistance being at the center of metabolic syndrome; manifestations of which are increased blood pressure, blood sugars and "abdominal" obesity. About 4,000 subjects from 28 studies were included in the meta-analysis.

GT

New Treatment for blood pressure: Baroreflex activation therapy (BAT)

New Treatment for blood pressure: Baroreflex activation therapy (BAT)

Baroreflex activation therapy (BAT) is a new method to treat patients with advanced high blood pressure. It works by electrically stimulating the carotid sinus, leading to reduced sympathetic tone.

Impressively systolic BP dropped on average by 35 mmHg and diastolic BP by 17 mmHg. About 25% of patients reduced the number of anti-hypertensive medications by half. Full benefits were seen within the first 6 months of procedure, but more importantly results were maintained in 6 years.

I believe more research is needed to approve BAT for mainstream clinical use, given the procedural nature of treatment.

GT