Disclosure Unraveling confusion in the blood I have no relevant financial relationships with any pressure guidelines companies related to the content of this course. CON: When is low too low? Asian Health Symposium October 10, 2019 Meghana D. Gadgil, MD, MPH 1 2 Average US blood pressure is too high Age-adjusted hypertension prevalence in Asian-Americans 70 60 50 40 30 20 10 0 NHW Asian Ind ian Chin ese Filip ino Jap an ese Korea n Vietn ame se Wome n Me n Zhou et al. Racial/Ethnic Differences in Hypertension Prevalence, Treatment, and Control for Outpatients in Northern Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2015 Update: a report from the 3 American Heart Association. Circulation . 2015;e29-322 4 California 2010–2012. Am J Hypertens. 2015 May; 28(5): 631–639. 3 4 1 | [footer text here]
Rates of treatment and control are low HTN classification between different societies 10 0 80 60 40 Women 20 0 10 0 80 60 Men 40 20 0 NHW ian ese ino ese n se Korea ame Ind Filip Chin an Jap Asian Vietn Trea tm ent Con trol Zhou et al. Racial/Ethnic Differences in Hypertension Prevalence, Treatment, and Control for Outpatients in Northern Ihm et al. Circ J. 2019 Feb 25;83(3):504-510 5 California 2010–2012. Am J Hypertens. 2015 May; 28(5): 631–639. 6 5 6 Asian cohorts and primary prevention of CVD outcomes: Age matters Case 1 37 y/o woman of Chinese descent with HTN, hypothyroidism and hyperlipidemia. She has two children who are 7 and 9 years old. She has a family history of MI in her father at age 45. She takes amlodipine 5mg, levothyroxine 75mcg and atorvastatin 40mg daily. Her BP is 138/74 and HR is 72. What is your treatment goal? Ihm et al. Circ J. 2019 Feb 25;83(3):504-510 7 8 7 8 2 | [footer text here]
Young people at high risk – aim for <130/80 Young people at high risk – aim for <130/80 • 30 636 participants • SCHS (Singapore Chinese § MESA: controlling BP <120/80 in the long-term prevents end-organ damage 1 Health Study) § Korean nationwide study with 2.5 million young adults, BP 130-139/80-89 • Ages 46 to 85 years associated with 25% increase in CVD events in men, 27% increase in women aged • Between 1994 and 2005 • Overall, no improvement in 20-39 2 CVD mortality with § Hong Kong-based retrospective cohort study: 28,014 adult patients with T2DM BP<130/80 without CVD. No change with <130/80 vs. 140/90 except in people <65 years 3 Talaei et al. J Am Heart Assoc. 2018 Apr 10;7(8). pii: e008911. doi: 10.1161/JAHA.118.008911. 1. Liu K et al. J Am Heart Assoc 2015; 4: e002275. 2. Son JS et al. JAMA 2018; 320: 1783–1792 3. Fai Wan et al. Diabetes Care 2018 Jun; 41(6): 1134-1141 9 9 10 Case 2 Healthy behaviors are declining in Asian-Americans 70 % 43 y/o Vietnamese man establishing care. He has no prior 20 11 -2 01 2 60 % medical history, and a sedentary lifestyle with a 14 hour-a- 20 15 -2 01 6 day occupation. His diet consists of high-sodium, high- 50 % refined carb takeout at least 4 nights a week. BMI = 29. BP 40 % 144/89, HR 78. ASCVD=7.3% 30 % 20 % ACC/AHA guidelines --> Start antihypertensive 10 % 0% Sed en tary be ha vio r Hea lth y Diet Normal BMI What would you do? 11 12 Kalra et al, Am J Cardiol. 2019 Jul 15;124(2):270-277 11 12 3 | [footer text here]
Propensity towards harm through overdiagnosis and overtreatment Interventions prior to pharmacotherapy § Active lifestyle – walk to and from the bus taking him to work § Designation of a pre-existing condition § Multiple medications cause significant side effects § Meal delivery system that emphasizes plant-based foods § 80% of people with newly diagnosed hypertension according to the ACC/AHA § Stop refined carbohydrates and added sugars at work guideline would have no expected benefit in terms of CVD risk reduction with BP lowering (<130/80) § No eating after dinner § SPRINT: 63 people needed to be treated for 3.3 years to prevent 1 from § Set 5% weight loss goal experiencing a CVD event § Reassess in 3 months § SPRINT: 50 people treated intensively over 3.3 years, 1 person experienced a serious adverse drug effect § Repeat Katy J. L. Bell, Jenny Doust, Paul Glasziou. Incremental Benefits and Harms of the 2017 American College of 13 Cardiology/American Heart Association High Blood Pressure Guideline. JAMA Internal Medicine , 2018. 13 14 Case 3 Adults over Age 60: No improvement and some harm 75 year old South Asian male with HTN, well-controlled § Increased risk of syncope (RR 1.52 [CI1.22-2.07]) § No improvement in renal outcomes, cognitive decline or dementia targeting lower hyperlipidemia and gout. He maintains a lacto-ovo vs. higher blood pressure goal vegetarian diet and briskly walks 3 miles daily. His § No change in risk of fractures or falls, quality of life or functional status between medications include benazepril 10mg daily, allopurinol 140/90 vs 130/80 100mg daily and crestor 5mg daily. He is afebrile, HR 64, § Subgroup analysis of SPRINT showed trend towards increase hypotension, syncope, electrolyte abnormalities, AKI in patients 75 and older BP 138/74. Physical exam is unremarkable. § Secondary prevention of stroke: RR, 0.76 [CI, 0.66 to 0.92] with BP<140/90 - Supported by the National Kidney Foundation What would be your threshold for treatment escalation? Quaseem et al. Ann Intern Med. 2017;166(6):430-437 15 16 15 16 4 | [footer text here]
So what would you do? So what should we do? § Screen for hypertension with individualized BP Patient Blood pressure Treatment Goal thresholds 37 y/o woman with HTN 138/74 <130/80 – increase amlodipine § Support BP < 130/80 in young people with CVD risk 43 y/o man with obesity 144/89 <130/80 – weight loss § Targeting < 130/80 in adults over 60 has no benefit and 75 y/o man, 138/74 <140/90 – no change community-dwelling may cause HARM § Encourage weight loss § High quality diet § Increase physical activity § Modulate alcohol intake 17 18 17 18 ACP and AAFP Guidelines – Adults over 60 Thank you! Questions? § PRIMARY PREVENTION: For adults over 60, aim for BP < 150/80 to reduce risk of heart disease and stroke § SECONDARY PREVENTION: Target BP < 140/90 reduces risk of recurrent stroke Few people in trials achieved this value Ann Intern Med. 2017;166(6):430-437. 20 Presentation Title 19 20 5 | [footer text here]
Sodium consumption is too high CVD is of paramount importance in Asian-Americans 1. Go AS et al. Heart disease and stroke statistics - 2014 update. A report from the American Heart Association. Circulation 2014; 129: e28-e292. What We Eat in America, NHANES 2007-2010 for average intakes by age-sex group. Institute of Medicine Dietary Reference Intakes for Tolerable Upper Intake Levels (UL). 2. Volgman AS. Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments. A scientific statement from the American Heart Association. Circulation. 2018;138:e1–e34. 21 Presentation Title 22 Con: when is low too low 21 22 6 | [footer text here]
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