1、Getting Blood Pressure to GoalRules of Three:3 drugs 3 months 3 behaviors(Activity-Diet-Control of Tobacco and Alcohol)3 Partners(PatientFamilyProvider)This program was sponsored by the National Kidney Foundation of Michigan(NKFM)and the Michigan Department of Community Health(MDCH).Funding was prov
2、ided by a generous grant from NKFM and MDCH and various pharma companies.Continuing Medical Education credit is provided by Wayne State University School of MedicineThe program was developed and prepared by:Diane Levine,MD Wayne State University Silas Norman,MD,University of MichiganRosalind Peters,
3、PhD,RN,Wayne State University Susan Steigerwalt,MD,St.John Hospital With input from the Hypertension Expert Group of NKFM and the expertise and creativity of its members with special thanks to Velma Theisen and Linda Smith Wheelock ACSW,MSBAConflict of InterestIndividual Speakers to Add their inform
4、ation prior to presenting Majority of US Hypertensive Patients Not at SBP Goal of 140 mm HgUnacceptable BP Control Rates Require Increased Awareness,More Aggressive TreatmentSignificance of HBP Problem50%of hypertensives are uncontrolled.Up to half are not receiving pharmacologic treatmentAntihypert
5、ensive therapy can Stroke 30%CHF 40-50%CAD 10-20%CAD Events-55%Mortality 10%o$1 Billion in direct medical costs/yearCardiovascular Mortality Risk Doubles With Each 20/10 mm Hg BP Increment*CV-Related Mortality Rates Are Higher in African AmericansCardiovascular Events in Treated Hypertensive Diabeti
6、c PatientsPreventing Kidney FailureAfrican Americans in Michigan have poorer blood pressure control than CaucasiansAfrican Americans are at five times greater risk of progression to end stage renal disease Better blood pressure control SLOWS PROGRESSION of renal diseaseBP control reduces the risk of
7、 stroke,MI,and CHFFactors Contributing to Poor BP ControlPatient FactorsAgeRace/ethnicityObesity AccessNon adherencelKnowledgelCostlComplex treatmentlPt/Provider CommunicationSecondary HTNProvider FactorsMeasurement issuesLack of knowledge/Disagreement with guidelinesConcern for side effectsNon-adva
8、ncing of drugs in asymptomatic patientsResponse to patients concerns over complexity of treatmentLack of time Measurement AccuracyAccuracy of office measurementslManual Regularly calibratedWhite-Coat SyndromeHome Monitoring lOmron Healthcare Arm(not wrist)monitorl Goal readings 135/85Measurement Acc
9、uracy*Patient Position:lBack supportedlFeet on the floorlArm at the level of the heartlNo talking Cuff Size lMost adults need a large cuff(See CD and AHA website for details)Take twiceCheck orthostatic blood pressure*CD provided to support review and standardization of BP measurementMeasurement Accu
10、racy:Orthostatic Hypotension20%prevalence in community dwelling adults over age 65Increases with agePresent in younger patients with diabetes or autonomic dysfunction“If orthostasis cannot be corrected,use standing BP to assess goal BP”(JNC-7)JNC 7:New BP ClassificationsJNC 7 Recommended BP Goals140
11、 and 90 mmHg lPatients with most conditions130 and 300mg/24 hr or 200mg/g urinary creatinineeGFR 160mmHgConcerns of increased cardiovascular risk with excessive lowering of DBP(J-Curve)Believe that more time is needed to reach goal VALUE,LANCET,2004:363:2022-2031Rule of 3“MDBP”3 Months3 Drugs3 Behav
12、iors(activity-diet-alcohol and tobacco control)3 Partners(Patient Family Provider)It Might Take 3 MonthsGetting BP to goal in 3 months lRequires multiple visitsGetting to Goal visit schedule:lMonthly until goal is reachedlIncrease visit frequency if Stage 2 lIncrease visit frequency with co morbid c
13、onditions At goal follow up visit schedule lEvery 3-6 months depending on co morbiditieslCheck K+and Creatinine 1-2x/yearDrug TherapyStep Approach:lStart with diuretic if no contraindicationslAdd ACEIlCalcium Channel Blocker(CCB)lBeta blockers but cautionMost patients require multiple drugs to achie
14、ve control(average=3.5 drugs)Use multiple drugs if:lBP 20/10 mmHg above goal(Stage 22 drugs)lStanding BP above goal in patients over age 65 or DMlNot at goal after 3 monthsMultiple Antihypertensive Agents Are Needed to Achieve Target Blood PressureDrug Treatment:DiureticsIf no compelling indications
15、(CHF,diabetes,CKD)lChlorthalidone(or other thiazides)firstlThen ACEI or ARB lRemember Beta Blockers ARE NOT for primary prevention and are inferior to diuretics as monotherapyVigilantly prevent hypokalemialSpironolactone/HCTZ is a great combination!lBring patients back in one week to check for diure
16、tic induced hypokalemia Watch for hyponatremiaDrug Treatment:ACE inhibitorsCheck Electrolytes,BUN,and Creatinine prior to startingRecheck K+and Creatinine 1 week after initiation of therapyGeneric available lBID Dosing:enalapril(5 mg bid-20mg bid)captopril(12.5 mg bid-50 mg bid)lDaily Dosinglisinopr
17、il(5-40 mg daily)Side effects:lCough-switch to ARB if affordable lHyperkalemia and acute renal failurelAngioedemaWhat Have We Learned?TreatmentTreatment of the very elderly decreases stroke and CAD but does not prolong survival(Lancet1999:353:793)Best drugs in rank order:lChlorthalidonelACE inhibito
18、r lHCTZ(Hypertension 2004;44:800)lCCB What Have We Learned?TreatmentACEI and ARB decrease new onset of diabetes by 25%compared to beta blockers(LIFE);23%compared to CCBs(VALUE trial)New onset of diabetes while undergoing treatment for hypertension confers the same excess CV risk as preexisting diabe
19、tes (Hypertension(2004)43 p.963)What Have We Learned?TreatmentMonotherapy with atenolol is NOT as efficacious as other antihypertensives for decreasing CV risk despite equivalent BP control(Lancet:2004:364:1684)Beta blockers are inferior to diuretics for blood pressure control and CV risk protection
20、(stroke,CHF)in older patients(MRC trial,1990;JAMA 1998;279:1903-1907;INVEST:JAMA 290:2805-2816;ASCOT Trial)Combination TreatmentsLogical/additive combinations Diuretic+ACEI or ARBDiuretic+Beta Blocker or sympatholyticsCCB+ACEI or ARBDiuretic+Beta Blocker+vasodilatorDiuretic+CCBCombination Treatments
21、Combinations with NO additive effectBeta Blocker+ACEIVasodilators+CCBCombination with additive side effectsBeta Blocker+clonidine or guanfacineBeta Blocker+verapamil or diltiazemClonidine/guanfacine+verapamil or diltiazemWhen adding In difficult to control patientsIt Takes 3 DRUGS!Choose a logical A
22、DDITIVE combinations:Diuretic+ACEI+CCBDiuretic+B Blocker+vasodilator Diuretic+clonidine+vasodilatorSpecial PopulationsDiabeteslACEI or ARBlDiuretics are important adjunct therapyl BS control associated with BP controlCKDlACEI or ARB are important to preserve renal functionlIf eGFR 50 start torsemide
23、 or furosemide bidPost MIlBeta blockerslACEI or ARBCheck K+and Creatinine prior to initiating and 1 week after initiating ACEIt Might Take 3 MonthsBut if not at goal by 6 months consider:lPatient reasons for non adherencelSleep Apnea lAlcohol overuselDiabeteslChronic Kidney DiseaselSecondary causes
24、lConsult with or refer to Hypertension Specialist VALUE,LANCET,2004:363:2022-2031Sleep ApneaUp to 60%males with resistant hypertension(also common in postmenopausal females)Suspect diagnosis-screen and referPathophysiology of hypertension likely SNS activationLifestyle:It Takes 3 BEHAVIORSExerciseDi
25、etControl of tobacco and alcoholLifestyle:Exercise4-9mmHg SBP reduction 30-45 minutes/day/5-7days/weekAerobic activity(e.g.brisk walking)Write a prescriptionFavorite PatientSig 40 minutes of walking 5X/wkBPMD 3333Lifestyle:DietWeight Control l5-20 mmHg SBP reduction/10kgLow Sodium(2.4 g)l2-8 mmHg SB
26、P reductionDASHl8-14 mmHg SBP reduction Control of Tobacco and AlcoholSmoking CessationlWrite prescription Alcohol Moderationl 2 alcoholic drinks/day menl 1 alcoholic drink/day womenl2-4 mmHg reduction in SBPAccess for other substancesPartners:It takes 3 PartnersPatient FamilyProviderProvider/Patien
27、t Relationship KeyThe Patient:Participation is crucialDescribe the journey“This is a serious disease”“I will need to see you every 4-6 weeks”“This is your goal 140/90(or 130/80)”“Achieving your goal is important because it lowers your risk ofShare goal settingl“Lets set some goals l“This how can you
28、 help l“What are you willing to do?l“We are a teamPatient,provider,“family”If we do not achieve your goalsPartners:PatientsPatient non-adherence to therapyLack of concern if asymptomaticFeel“better”with higher BP Dont worry about“touch”of high BP Mistrust of health care providers and health care sys
29、temImproved adherence withIncreased contact with providersSelf/home BP measurement-OMRON arm,usually LARGE ADULT cuff(Bladder encircling 80%arm)Use of patient record to keep track of influence of factors(e.g.diet)on BP Partners:“Family”,Friends,CommunityInvolve“family”whenever possible lEssential fo
30、r lifestyle modificationBe familiar with community resourcesPartners:ProvidersFollow JNC and MQIC*GuidelinesDocument Goal Schedule frequent visits to get to goal l3 months to goal!Tools to get to goalleGFR slide rule to assess renal function lCollaborative practice with APNs improves control*www.MQI
31、C.orgProvider Steps to Increase AdherenceWrite lifestyle prescriptionsConsider costs of drugs generics whenever possible Simplify drug regimens lDaily therapy or BIDAddress patients understanding of the disease and its treatment Telephone follow upslincrease adherence especially for“no shows”ltry to
32、 keep them in treatmentlAdditional follow up as negotiated with patientOffice RN or APN will increase BP control(Collaborative Practice)Key Points from Presentation Measurement Accuracy is importantDetermine Goal BPl140/90 130/80 DM CKDFollow guidelinesRules of 3(MDBP)l3 Monthsl3 Drugsl3 Behaviorsl3 PartnersHandoutsInformation contained on CDlTonights slide presentation share with colleagueslBP measurement protocollMQIC guidelineslNHLBI DASH diet informationlPatient Health Record lPrescription pads for exercise/lifestyle prescriptionsQuestions?Cases youd like to discuss?
