1 2 Average US blood pressure is too high Age-adjusted - - PDF document

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1 2 Average US blood pressure is too high Age-adjusted - - PDF document

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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

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Meghana D. Gadgil, MD, MPH

Unraveling confusion in the blood pressure guidelines CON: When is low too low?

Asian Health Symposium October 10, 2019

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Disclosure

I have no relevant financial relationships with any companies related to the content of this course.

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Average US blood pressure is too high

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2015 Update: a report from the American Heart Association. Circulation. 2015;e29-322

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Age-adjusted hypertension prevalence in Asian-Americans

10 20 30 40 50 60 70

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 California 2010–2012. Am J Hypertens. 2015 May; 28(5): 631–639.

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Rates of treatment and control are low

20 40 60 80 10 20 40 60 80 10 NHW Asian Ind ian Chin ese Filip ino Jap an ese Korea n Vietn ame se Trea tm ent Con trol

Women Men

Zhou et al. Racial/Ethnic Differences in Hypertension Prevalence, Treatment, and Control for Outpatients in Northern California 2010–2012. Am J Hypertens. 2015 May; 28(5): 631–639.

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HTN classification between different societies

Ihm et al. Circ J. 2019 Feb 25;83(3):504-510

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Asian cohorts and primary prevention of CVD outcomes: Age matters

Ihm et al. Circ J. 2019 Feb 25;83(3):504-510

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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?

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Young people at high risk – aim for <130/80

§ MESA: controlling BP <120/80 in the long-term prevents end-organ damage1 § Korean nationwide study with 2.5 million young adults, BP 130-139/80-89

associated with 25% increase in CVD events in men, 27% increase in women aged 20-392

§ Hong Kong-based retrospective cohort study: 28,014 adult patients with T2DM

without CVD. No change with <130/80 vs. 140/90 except in people <65 years3

  • 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

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Young people at high risk – aim for <130/80

Talaei et al. J Am Heart
  • Assoc. 2018 Apr 10;7(8). pii:
  • e008911. doi:
10.1161/JAHA.118.008911.
  • 30 636 participants
  • SCHS (Singapore Chinese
Health Study)
  • Ages 46 to 85 years
  • Between 1994 and 2005
  • Overall, no improvement in
CVD mortality with BP<130/80

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Case 2

43 y/o Vietnamese man establishing care. He has no prior medical history, and a sedentary lifestyle with a 14 hour-a- day occupation. His diet consists of high-sodium, high- refined carb takeout at least 4 nights a week. BMI = 29. BP 144/89, HR 78. ASCVD=7.3% ACC/AHA guidelines --> Start antihypertensive What would you do?

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Healthy behaviors are declining in Asian-Americans

0% 10 % 20 % 30 % 40 % 50 % 60 % 70 %

Sed en tary be ha vio r Hea lth y Diet Normal BMI 20 11

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01 2 20 15

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01 6

Kalra et al, Am J Cardiol. 2019 Jul 15;124(2):270-277

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Interventions prior to pharmacotherapy

§ Active lifestyle – walk to and from the bus taking him to work § Meal delivery system that emphasizes plant-based foods § Stop refined carbohydrates and added sugars at work § No eating after dinner § Set 5% weight loss goal § Reassess in 3 months § Repeat

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Propensity towards harm through

  • verdiagnosis and overtreatment
§ Designation of a pre-existing condition § Multiple medications cause significant side effects § 80% of people with newly diagnosed hypertension according to the ACC/AHA

guideline would have no expected benefit in terms of CVD risk reduction with BP lowering (<130/80)

§ SPRINT: 63 people needed to be treated for 3.3 years to prevent 1 from

experiencing a CVD event

§ SPRINT: 50 people treated intensively over 3.3 years, 1 person experienced a

serious adverse drug effect

Katy J. L. Bell, Jenny Doust, Paul Glasziou. Incremental Benefits and Harms of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. JAMA Internal Medicine, 2018.

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Case 3

75 year old South Asian male with HTN, well-controlled hyperlipidemia and gout. He maintains a lacto-ovo vegetarian diet and briskly walks 3 miles daily. His medications include benazepril 10mg daily, allopurinol 100mg daily and crestor 5mg daily. He is afebrile, HR 64, BP 138/74. Physical exam is unremarkable. What would be your threshold for treatment escalation?

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Adults over Age 60: No improvement and some harm

§ Increased risk of syncope (RR 1.52 [CI1.22-2.07]) § No improvement in renal outcomes, cognitive decline or dementia targeting lower
  • vs. higher blood pressure goal
§ No change in risk of fractures or falls, quality of life or functional status between

140/90 vs 130/80

§ Subgroup analysis of SPRINT showed trend towards increase hypotension,

syncope, electrolyte abnormalities, AKI in patients 75 and older

§ Secondary prevention of stroke: RR, 0.76 [CI, 0.66 to 0.92] with BP<140/90
  • Supported by the National Kidney Foundation
Quaseem et al. Ann Intern Med. 2017;166(6):430-437

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So what would you do?

Patient Blood pressure Treatment Goal 37 y/o woman with HTN 138/74 <130/80 – increase amlodipine 43 y/o man with obesity 144/89 <130/80 – weight loss 75 y/o man, community-dwelling 138/74 <140/90 – no change

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So what should we do?

§ Screen for hypertension with individualized BP

thresholds

§ Support BP < 130/80 in young people with CVD risk § Targeting < 130/80 in adults over 60 has no benefit and

may cause HARM

§ Encourage weight loss § High quality diet § Increase physical activity § Modulate alcohol intake

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Thank you! Questions?

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Presentation Title 20

ACP and AAFP Guidelines – Adults over 60

§ 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.

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Presentation Title 21

Sodium consumption is too high

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).

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Con: when is low too low 22

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.
  • 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.

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