Hypertension Evaluation and Management Identify High Blood Pressure - - PowerPoint PPT Presentation

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Hypertension Evaluation and Management Identify High Blood Pressure - - PowerPoint PPT Presentation

Nov 24, 2022 321 likes •587 views

Hypertension Evaluation and Management Identify High Blood Pressure Reduce Salt Personalize BP Target Erica S. Spatz, MD, MHS Assistant Professor, Cardiovascular Medicine Center for Outcomes Research and Evaluation Yale University

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Erica S. Spatz, MD, MHS Assistant Professor, Cardiovascular Medicine Center for Outcomes Research and Evaluation Yale University School of Medicine

Hypertension Evaluation and Management

ü Identify High Blood Pressure ü Reduce Salt ü Personalize BP Target

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Disclosures

  • Develop outcome measures under a contract with the Centers for

Medicare and Medicaid Services (CMS)

  • NIH/NIMHD funded U54. Project Lead: Health Disparities in

Hypertension: A Precision Medicine-based Approach for Early Risk Stratification

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Hypertension: The Silent Killer

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Hypertension: A Global Health Crisis

Forouzanfar MH, JAMA. 2017

29% 29% 26% 26% 45% 45%

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Forouzanfar MH, JAMA. 2017

Higher burden of st stroke in low and middle income regions. HTN accounted for 14% of deaths (>10 million) & >212 million DALYs in 2015 1.4-fold increase since 1990

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China: Million Persons Project

Lu J, Lu Y. Lancet.,2017

Overall, ½ of adults aged 35 to 75 had HTN Only 1/3 were treated 1 in 12 were controlled (<140/90)

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HTN in the US: A Tale of “2” Cities

Manhattan and Brooklyn Heights, HTN rates of 16-25% Bronx and

  • ther parts
  • f Brooklyn,

HTN rates of 30-40%

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US Hypertension Prevalence

RA RACE

18 and Over Age-Adjusted Prevalence 29% White 28% Black 42% Hispanic 26% Asian 25%

Beckman AL…Spatz ES. JAMA Cardiology, 2017; Wang YC...Schwartz JE Am J Epidemiol, 2017

FPL: Federal Poverty Level

IN INCOME

25 and Over <100% FPL 100-300% FPL >300% FPL 50.8% 50.8% 40.3%

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The problem is likely much worse.

Other phenotypes of hypertension, typically not measured, also portend worse cardiovascular outcomes.

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HTN Masked HTN Nocturnal Non- Dipping

Evaluation: Phenotypes of HTN

Wang YC...Schwartz JE Am J Epidemiol, 2017

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Masked HTN

NIMHD Precision Medicine Grant: ABPM Trajectory Phenotypes

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ACC/AHA 2017 Guidelines

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ACC/AHA 2017 Guidelines

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Evaluation Summary

  • Personalized, Population Health Approach

– Engage persons inside and outside of the medical setting – Focused screening: populations at risk; families; networks – Attention to contextual environment

  • Diagnosis of HTN

– Home-based monitoring – 24-hour ABPM – Develop cheap, convenient BP detection devices

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Hypertension Management

To reach BP goal of 120/80 mmHg and… to improve cardiovascular outcomes

?

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Powles, J et al. BMJ Open. 2013

A Global Taste of Salt Intake

  • Salt intake is high across

the globe.

  • N America 4-5 g/d of

sodium (goal <2.3 g/d)

  • Central, Asian Pacific,

East Asia, and Eastern Europe have the highest salt intake

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Will lowering salt reduce CV risk?

Menta A (PURE); O’Donnell MJ (PURE), Mozaffarian D, (NutriCode). NEJM, 2014

We eat too much salt. Lower sodium intake is associated with lower blood pressure and fewer cardiovascular events At an individual level, yes in some populations, though its difficult and the benefits are less certain. 😈Population Level 😈 😕Individual Level 😕

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Salt Reduction: Challenge

“The issue is not what you do with your salt shaker.”

  • -David Katz, MD

Yale University Preventive Medicine

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Salt Reduction: Individual Level

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Personalized Approach

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Individualize based on risk

ü Personal evidence of target organ damage ü Family hx of stroke, CAD, blindness or renal disease

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Individualize based on risk

SPRIN INT AC ACCORD HO HOPE 3 Goal Treat to Target Treat to Target Fixed dose med trial Strategy tested <140 vs <120 <140 vs <120 ARB/thiazide v. placebo In In w whom? High r risk p patients Di Diab abetes In Intermediate r risk What worked? <120 mmHg <140 mmHg <140 mmHg At what expense? ++ meds ++ side effects resulting in ED visits More side effects (renal) No difference in discontinuation (25% both arms) At what benefit? 25% RRR in MACE, (no reduction in MI

  • r stroke)

No difference in MACE or death. Fewer strokes. Benefit restricted to group with systolic BP >142 mmHg

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Shared Decision Making

  • Personalize identification and characterization of BP patterns
  • Assess BP in context of overall CV risk
  • Co-design goals
  • Find therapies with the least burden
  • Manage contributors to hypertension – lifestyle, stress
  • Openly address adherence
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A person-centered approach takes a health system

Assess R Risk F Factors ü Diet ü Physical Activity ü Stress ü Weight ü Social context ü Physical env ü SES ü Access to care ü Out of pocket costs Health P Promotion ü Personalize diagnosis ü Elicit preferences and goals ü Do shared decision making ü Improve health system support ü Continued feedback and realignment

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