Hypertension

Blood pressure and cardiovascular disease

Blood pressure and cardiovascular disease

This major observational study affirms the notion that the lower the blood pressure the lower the cardiovascular outcomes. A group of 1.3 million outpatient adults was observed and analyzed over 8 years. The study finds that both systolic and diastolic blood pressure are independent contributors to increased CVD. In addition to guideline-driven blood pressure targets, the BP goal should be individualized based on the patient’s comorbidities, medication burden, and side effects.

GT

More evidence of Metformin benefits in early prediabetes

More evidence of Metformin benefits in early prediabetes

More good news for metformin. MET-REMODEL trial tested patients with known cardiovascular disease and insulin resistance, but without gross diabetes. Patients received metformin or placebo for 12 months.

Compared to the placebo group, subjects receiving metformin experienced the following improvements in 12 months: Less left ventricular mass index,  less LVM, lower systolic BP, decreased body weight and less oxidative stress.

Early start of metformin could be useful in adults with insulin resistance.  Long term side effects of metformin, however, need to be discussed thoroughly with patients.

GT

Jardiance lowers blood pressure significantly in African American adults

Jardiance lowers blood pressure significantly in African American adults

Jardiance shows positive outcomes in African American adults. It reduces the A1c by 0.8%, body weight by 2.7 pounds and more interestingly the systolic blood pressure by 8 mmHg, similar to a standard blood pressure medication.

A group of 150 African American participants were randomized to receive Jardiance 25 mg daily or placebo for 6-months.

The SGLT2 inhibitor would be a great choice for patients with concomitant hyperglycemia and systolic hypertension.

GT

Systolic Blood Pressure and Dementia Risk

Systolic Blood Pressure and Dementia Risk

About 9,000 adults were randomized to receive tight or less-tight systolic blood pressure control. They were followed for about 5 years for cognition and dementia outcomes.

Although the primary outcome was almost significant, the secondary outcomes were truly significant for improvement of mild cognitive impairment or probable dementia with intensive systolic blood pressure <120 mmHg over those who achieved sBP <140 mmHg.

While further trials are needed to clarify the above findings, there appears to be no harm of lowering the sBP down to <120 mmHg in this study.

GT

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

Clinical Hypertension Specialist

Clinical Hypertension Specialist

I am pleased to announce that, as of June 2016, I am a certified hypertension specialist, accredited by the American Society of Hypertension. Currently, there are about 1600 certified specialists in the U.S. and Canada.

Hypertension is a major public health concern. About 30% of Americans have elevated blood pressure. It is a main contributor to poor cardiovascular outcomes, leading to heart failure, myocardial infarction, peripheral vascular disease, stroke, vascular dementia and chronic kidney disease.

Hypertension is commonly seen in various endocrinological conditions such as diabetes mellitus, metabolic syndrome, adrenal, thyroid, parathyroid anomalies.

GT