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BP accuracy is the ghost in the machine
SAN FRANCISCO – Amid all the talk about subgroup blood pressure targets and tiny differences in drug regimens at a recent hypertension meeting, there was an elephant in the room that attendees refused to ignore.
“We do it wrong,” said Dr. Steven Yarows, a primary care physician in Chelsea, Mich., who estimated he’s taken 44,000 blood pressures in his 36 years of practice.
Everyone in medicine is taught that people should rest a bit and not talk while their blood pressure is taken; that the last measurement matters more than the first; and that most Americans need a large-sized cuff. Current guidelines are based on patients sitting for 5-10 minutes alone in a quiet room while an automatic machine averages their last 3-5 blood pressures.
But when Dr. Yarows asked his 300 or so audience members – hypertension physicians who paid to come to the meeting – how many actually followed those rules, four hands went up. It’s not good enough; “if you are going to make a diagnosis that lasts a lifetime, you have to be accurate,” he said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney Cardiovascular Disease, and American Society of Hypertension.
There’s resistance. No one has a room set aside for blood pressure; staff don’t want to deal with it; and at a time when primary care doctors are nickel and dimed for everything they do, insurers haven’t stepped up to pay to make accurate blood pressure a priority.
To do it right, you have to ask patients to come in 10 minutes early and have a room set up for them where they can sit alone with a large oscillometric cuff to average a few blood pressures at rest, Dr. Yarows said. They also need at least one 24-hour monitoring.
“Most of the time, the patient walks over from the waiting room, they get on the scale which automatically elevates the blood pressure tremendously, and then they sit down and talk about their family while their blood pressure is being taken.” Even in normotensive patients, that alone could raise systolic pressure 20 mm Hg or more, he said. It makes one-time blood pressure pretty much meaningless.
The biggest problem is that blood pressure is hugely variable, so it’s hard to know what matters. In one of Dr. Yarows’ normotensive patients, BP varied 44 mm Hg systolic and 37 mm Hg diastolic over 24 hours. In a hypertensive patient, systolic pressure varied 62 mm Hg and diastolic 48 mm Hg over 24 hours. Another patient was 114/85 mm Hg at noon, and 159/73 mm Hg an hour later. “That’s a huge spread,” he said.
Twenty-four hour monitoring is the only way to really know if patients are hypertensive and need treatment. “Any person you suspect of having hypertension, before you place them on medicine, you should have 24 hour blood pressure monitoring. This is the most effective way to determine if they do have high blood pressure,” and how much it needs to be lowered, he said.
Dr. Yarows had no disclosures.
SAN FRANCISCO – Amid all the talk about subgroup blood pressure targets and tiny differences in drug regimens at a recent hypertension meeting, there was an elephant in the room that attendees refused to ignore.
“We do it wrong,” said Dr. Steven Yarows, a primary care physician in Chelsea, Mich., who estimated he’s taken 44,000 blood pressures in his 36 years of practice.
Everyone in medicine is taught that people should rest a bit and not talk while their blood pressure is taken; that the last measurement matters more than the first; and that most Americans need a large-sized cuff. Current guidelines are based on patients sitting for 5-10 minutes alone in a quiet room while an automatic machine averages their last 3-5 blood pressures.
But when Dr. Yarows asked his 300 or so audience members – hypertension physicians who paid to come to the meeting – how many actually followed those rules, four hands went up. It’s not good enough; “if you are going to make a diagnosis that lasts a lifetime, you have to be accurate,” he said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney Cardiovascular Disease, and American Society of Hypertension.
There’s resistance. No one has a room set aside for blood pressure; staff don’t want to deal with it; and at a time when primary care doctors are nickel and dimed for everything they do, insurers haven’t stepped up to pay to make accurate blood pressure a priority.
To do it right, you have to ask patients to come in 10 minutes early and have a room set up for them where they can sit alone with a large oscillometric cuff to average a few blood pressures at rest, Dr. Yarows said. They also need at least one 24-hour monitoring.
“Most of the time, the patient walks over from the waiting room, they get on the scale which automatically elevates the blood pressure tremendously, and then they sit down and talk about their family while their blood pressure is being taken.” Even in normotensive patients, that alone could raise systolic pressure 20 mm Hg or more, he said. It makes one-time blood pressure pretty much meaningless.
The biggest problem is that blood pressure is hugely variable, so it’s hard to know what matters. In one of Dr. Yarows’ normotensive patients, BP varied 44 mm Hg systolic and 37 mm Hg diastolic over 24 hours. In a hypertensive patient, systolic pressure varied 62 mm Hg and diastolic 48 mm Hg over 24 hours. Another patient was 114/85 mm Hg at noon, and 159/73 mm Hg an hour later. “That’s a huge spread,” he said.
Twenty-four hour monitoring is the only way to really know if patients are hypertensive and need treatment. “Any person you suspect of having hypertension, before you place them on medicine, you should have 24 hour blood pressure monitoring. This is the most effective way to determine if they do have high blood pressure,” and how much it needs to be lowered, he said.
Dr. Yarows had no disclosures.
SAN FRANCISCO – Amid all the talk about subgroup blood pressure targets and tiny differences in drug regimens at a recent hypertension meeting, there was an elephant in the room that attendees refused to ignore.
“We do it wrong,” said Dr. Steven Yarows, a primary care physician in Chelsea, Mich., who estimated he’s taken 44,000 blood pressures in his 36 years of practice.
Everyone in medicine is taught that people should rest a bit and not talk while their blood pressure is taken; that the last measurement matters more than the first; and that most Americans need a large-sized cuff. Current guidelines are based on patients sitting for 5-10 minutes alone in a quiet room while an automatic machine averages their last 3-5 blood pressures.
But when Dr. Yarows asked his 300 or so audience members – hypertension physicians who paid to come to the meeting – how many actually followed those rules, four hands went up. It’s not good enough; “if you are going to make a diagnosis that lasts a lifetime, you have to be accurate,” he said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney Cardiovascular Disease, and American Society of Hypertension.
There’s resistance. No one has a room set aside for blood pressure; staff don’t want to deal with it; and at a time when primary care doctors are nickel and dimed for everything they do, insurers haven’t stepped up to pay to make accurate blood pressure a priority.
To do it right, you have to ask patients to come in 10 minutes early and have a room set up for them where they can sit alone with a large oscillometric cuff to average a few blood pressures at rest, Dr. Yarows said. They also need at least one 24-hour monitoring.
“Most of the time, the patient walks over from the waiting room, they get on the scale which automatically elevates the blood pressure tremendously, and then they sit down and talk about their family while their blood pressure is being taken.” Even in normotensive patients, that alone could raise systolic pressure 20 mm Hg or more, he said. It makes one-time blood pressure pretty much meaningless.
The biggest problem is that blood pressure is hugely variable, so it’s hard to know what matters. In one of Dr. Yarows’ normotensive patients, BP varied 44 mm Hg systolic and 37 mm Hg diastolic over 24 hours. In a hypertensive patient, systolic pressure varied 62 mm Hg and diastolic 48 mm Hg over 24 hours. Another patient was 114/85 mm Hg at noon, and 159/73 mm Hg an hour later. “That’s a huge spread,” he said.
Twenty-four hour monitoring is the only way to really know if patients are hypertensive and need treatment. “Any person you suspect of having hypertension, before you place them on medicine, you should have 24 hour blood pressure monitoring. This is the most effective way to determine if they do have high blood pressure,” and how much it needs to be lowered, he said.
Dr. Yarows had no disclosures.
EXPERT ANALYSIS FROM JOINT HYPERTENSION 2017
How to apply SPRINT findings to elderly patients
SAN FRANCISCO – The benefit of lowering blood pressure exceeded the potential for harm, even among the most frail elderly, in SPRINT, but it’s important to remember who was excluded from the trial when using the findings in the clinic, according to Mark Supiano, MD.
SPRINT (Systolic Blood Pressure Intervention Trial) excluded people with histories of stroke, diabetes, heart failure, and chronic kidney disease with a markedly reduced glomerular filtration rate. People living in nursing homes, assisted living centers, and those with prevalent dementia were also excluded, as were individuals with a standing systolic pressure below 110 mm Hg (N Engl J Med. 2015 Nov 26;373:2103-16).
Even with those exclusions, however, the 2,636 patients in SPRINT who were 75 years and older “were not a super healthy group of older people,” Dr. Supiano said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
They were at high risk for cardiovascular disease (CVD), with a median 10-year Framingham risk score of almost 25%. More than a quarter had gait speeds below 0.8 m/sec, and almost a third were classified as frail. Many had mild cognitive impairment at baseline.
In the United States, Dr. Supiano and his colleagues estimate that there are almost 6 million similar people 75 years or older with hypertension who would likely achieve the same benefits from hypertension control as elderly subjects in the trial. “As a geriatrician, there are very few things that I can offer patients 75 years and older that will have a profound improvement in their overall mortality.” Blood pressure control is one of them, said Dr. Supiano, chief of geriatrics at the University of Utah, Salt Lake City, and a SPRINT investigator.
In SPRINT, intensive treatment to systolic pressure below 120 mm Hg showed greater benefit for patients 75 years and older than it did for younger patients, even among the frail, with a 34% reduction in fatal and nonfatal CVD events versus patients treated to below 140 mm Hg, and a 33% lower rate of death from any cause.
It should be no surprise that older patients had greater benefit from tighter control, because elderly patients have “a greater CVD risk. There’s more bang for the buck” with blood pressure lowering in an older population. “Overall, benefits exceed the potential for harm, even among the frailest older patients,” Dr. Supiano said.
“A systemic target of less than 140 mm Hg is, I believe, appropriate for most healthy people age 60 and older. A benefit-based systemic target of less than 120 mm Hg may be appropriate for those at higher CVD risk.” Among patients 60-75 years old, that would include those with a Framingham score above 15%. Among patients older than age 75 with an elevated CVD risk, treatment to below 120 mm Hg makes sense if it aligns with patient’s goals of care, Dr. Supiano said.
The 120–mm Hg target in SPRINT was associated with a greater incidence of some transient side effects in the elderly, including hypotension, syncope, acute kidney injury, and electrolyte imbalance, but not a higher risk of serious adverse events or injurious falls.
There were concerns raised at the joint sessions about the effect of blood pressure lowering on the cognitive function of older people. Dr. Supiano noted that the cognitive outcomes in SPRINT, as well as outcomes in patients with chronic kidney disease, have not yet been released, but are expected soon.
Dr. Supiano had no relevant disclosures.
SAN FRANCISCO – The benefit of lowering blood pressure exceeded the potential for harm, even among the most frail elderly, in SPRINT, but it’s important to remember who was excluded from the trial when using the findings in the clinic, according to Mark Supiano, MD.
SPRINT (Systolic Blood Pressure Intervention Trial) excluded people with histories of stroke, diabetes, heart failure, and chronic kidney disease with a markedly reduced glomerular filtration rate. People living in nursing homes, assisted living centers, and those with prevalent dementia were also excluded, as were individuals with a standing systolic pressure below 110 mm Hg (N Engl J Med. 2015 Nov 26;373:2103-16).
Even with those exclusions, however, the 2,636 patients in SPRINT who were 75 years and older “were not a super healthy group of older people,” Dr. Supiano said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
They were at high risk for cardiovascular disease (CVD), with a median 10-year Framingham risk score of almost 25%. More than a quarter had gait speeds below 0.8 m/sec, and almost a third were classified as frail. Many had mild cognitive impairment at baseline.
In the United States, Dr. Supiano and his colleagues estimate that there are almost 6 million similar people 75 years or older with hypertension who would likely achieve the same benefits from hypertension control as elderly subjects in the trial. “As a geriatrician, there are very few things that I can offer patients 75 years and older that will have a profound improvement in their overall mortality.” Blood pressure control is one of them, said Dr. Supiano, chief of geriatrics at the University of Utah, Salt Lake City, and a SPRINT investigator.
In SPRINT, intensive treatment to systolic pressure below 120 mm Hg showed greater benefit for patients 75 years and older than it did for younger patients, even among the frail, with a 34% reduction in fatal and nonfatal CVD events versus patients treated to below 140 mm Hg, and a 33% lower rate of death from any cause.
It should be no surprise that older patients had greater benefit from tighter control, because elderly patients have “a greater CVD risk. There’s more bang for the buck” with blood pressure lowering in an older population. “Overall, benefits exceed the potential for harm, even among the frailest older patients,” Dr. Supiano said.
“A systemic target of less than 140 mm Hg is, I believe, appropriate for most healthy people age 60 and older. A benefit-based systemic target of less than 120 mm Hg may be appropriate for those at higher CVD risk.” Among patients 60-75 years old, that would include those with a Framingham score above 15%. Among patients older than age 75 with an elevated CVD risk, treatment to below 120 mm Hg makes sense if it aligns with patient’s goals of care, Dr. Supiano said.
The 120–mm Hg target in SPRINT was associated with a greater incidence of some transient side effects in the elderly, including hypotension, syncope, acute kidney injury, and electrolyte imbalance, but not a higher risk of serious adverse events or injurious falls.
There were concerns raised at the joint sessions about the effect of blood pressure lowering on the cognitive function of older people. Dr. Supiano noted that the cognitive outcomes in SPRINT, as well as outcomes in patients with chronic kidney disease, have not yet been released, but are expected soon.
Dr. Supiano had no relevant disclosures.
SAN FRANCISCO – The benefit of lowering blood pressure exceeded the potential for harm, even among the most frail elderly, in SPRINT, but it’s important to remember who was excluded from the trial when using the findings in the clinic, according to Mark Supiano, MD.
SPRINT (Systolic Blood Pressure Intervention Trial) excluded people with histories of stroke, diabetes, heart failure, and chronic kidney disease with a markedly reduced glomerular filtration rate. People living in nursing homes, assisted living centers, and those with prevalent dementia were also excluded, as were individuals with a standing systolic pressure below 110 mm Hg (N Engl J Med. 2015 Nov 26;373:2103-16).
Even with those exclusions, however, the 2,636 patients in SPRINT who were 75 years and older “were not a super healthy group of older people,” Dr. Supiano said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
They were at high risk for cardiovascular disease (CVD), with a median 10-year Framingham risk score of almost 25%. More than a quarter had gait speeds below 0.8 m/sec, and almost a third were classified as frail. Many had mild cognitive impairment at baseline.
In the United States, Dr. Supiano and his colleagues estimate that there are almost 6 million similar people 75 years or older with hypertension who would likely achieve the same benefits from hypertension control as elderly subjects in the trial. “As a geriatrician, there are very few things that I can offer patients 75 years and older that will have a profound improvement in their overall mortality.” Blood pressure control is one of them, said Dr. Supiano, chief of geriatrics at the University of Utah, Salt Lake City, and a SPRINT investigator.
In SPRINT, intensive treatment to systolic pressure below 120 mm Hg showed greater benefit for patients 75 years and older than it did for younger patients, even among the frail, with a 34% reduction in fatal and nonfatal CVD events versus patients treated to below 140 mm Hg, and a 33% lower rate of death from any cause.
It should be no surprise that older patients had greater benefit from tighter control, because elderly patients have “a greater CVD risk. There’s more bang for the buck” with blood pressure lowering in an older population. “Overall, benefits exceed the potential for harm, even among the frailest older patients,” Dr. Supiano said.
“A systemic target of less than 140 mm Hg is, I believe, appropriate for most healthy people age 60 and older. A benefit-based systemic target of less than 120 mm Hg may be appropriate for those at higher CVD risk.” Among patients 60-75 years old, that would include those with a Framingham score above 15%. Among patients older than age 75 with an elevated CVD risk, treatment to below 120 mm Hg makes sense if it aligns with patient’s goals of care, Dr. Supiano said.
The 120–mm Hg target in SPRINT was associated with a greater incidence of some transient side effects in the elderly, including hypotension, syncope, acute kidney injury, and electrolyte imbalance, but not a higher risk of serious adverse events or injurious falls.
There were concerns raised at the joint sessions about the effect of blood pressure lowering on the cognitive function of older people. Dr. Supiano noted that the cognitive outcomes in SPRINT, as well as outcomes in patients with chronic kidney disease, have not yet been released, but are expected soon.
Dr. Supiano had no relevant disclosures.
EXPERT ANALYSIS FROM JOINT HYPERTENSION 2017
Nocturia linked to hypertension, diuretic use in community-based study of black men
SAN FRANCISCO – Nocturia is a sign of uncontrolled hypertension and also is associated with diuretic use in middle-aged black men, according to a study conducted at 53 barbershops in and around Los Angeles.
In the study, investigators averaged the last three of five automated blood pressure readings in 1,748 black men aged 35-49 years old and asked them about symptoms of nocturia – defined in the study as getting up two or more times per night to urinate – and about what blood pressure medications they were taking, if any.
Men with untreated hypertension – defined as at or above 135/85 mm Hg – were 34% more likely to report nocturia than were men who were normotensive.
However, “what really grabbed our attention was the treated group,” lead investigator Ronald Victor, MD said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The highest risk of nocturia, more than three times the risk of normotensive men, was among men treated with a diuretic who still had elevated blood pressure readings in the barbershop. Their risk was about 2.5 times greater in men who were treated but uncontrolled and were not on a diuretic, said Dr. Victor, director of the hypertension center at Cedars-Sinai Medical Center, Los Angeles.
Among men treated and controlled down to a systolic blood pressure of almost 120 mm Hg, those with a diuretic included in their regimen had about twice the risk of nocturia as did normotensive men; those controlled without a diuretic had no elevated risk of nocturia. The results were statistically significant and were adjusted for nocturia confounders, including diabetes, body mass index, sleep apnea, and an enlarged prostate.
“Nocturia is far more likely when hypertension is inadequately treated,” especially with a diuretic, than when untreated, Dr. Victor said. “The data suggest that nocturia may be a side effect of blood pressure drugs unless strict blood pressure control is achieved. Appropriate treatment of blood pressure without a diuretic may be really beneficial in terms of reducing nocturia.”
Not all the data on the specific medications the men in the study were taking were available, but the most common antihypertensive prescribed for them was short-acting, low-dose hydrochlorothiazide, he noted.
It has been shown that hydrochlorothiazide wears off in the evening when dosed in the morning, so blood pressure might appear to be well-controlled in the daytime, but patients become hypertensive at night, leading to pressure natriuresis and nocturia. “This might [help] explain our data,” Dr. Victor said, noting that longer-acting, more potent diuretics, such as chlorthalidone, might reduce the risk.
The team plans further work to see if tighter nighttime blood pressure control reduces nocturia and improves sleep. Maybe, he noted, “if you take your blood pressure meds correctly, you sleep better. That would be a fantastic public health message; we’ll see.”
Middle-aged black men are underrepresented in hypertension research, in part because of a mistrust of doctors and medical institutions. Enrolling black men in barbershops seemed a good way to address the problem; barbers are trusted and respected members of the community, and the shops themselves are warm and relaxed, which is why hypertension was defined in the study a bit lower than the usual 140/90 mm Hg, Dr. Victor commented.
A total of 45% of the men were hypertensive; only 16% were controlled on medication. Nocturia prevalence was higher than expected in the general population, at about 29% overall, and ranged from 24% in normotensive men to 50% in men whose hypertension was treated but uncontrolled.
Average blood pressures were 120/71 mm Hg in the normotensive men; 143/87 mm Hg in untreated hypertensive men; and 148/91 mm Hg in treated but uncontrolled men. The mean age in the study was 43 years. “We capped it at 49 because after that, nocturia is so prevalent, and dominated by prostate disease,” Dr. Victor said.
The investigators had no disclosures. The National Institutes of Health funded the work.
SAN FRANCISCO – Nocturia is a sign of uncontrolled hypertension and also is associated with diuretic use in middle-aged black men, according to a study conducted at 53 barbershops in and around Los Angeles.
In the study, investigators averaged the last three of five automated blood pressure readings in 1,748 black men aged 35-49 years old and asked them about symptoms of nocturia – defined in the study as getting up two or more times per night to urinate – and about what blood pressure medications they were taking, if any.
Men with untreated hypertension – defined as at or above 135/85 mm Hg – were 34% more likely to report nocturia than were men who were normotensive.
However, “what really grabbed our attention was the treated group,” lead investigator Ronald Victor, MD said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The highest risk of nocturia, more than three times the risk of normotensive men, was among men treated with a diuretic who still had elevated blood pressure readings in the barbershop. Their risk was about 2.5 times greater in men who were treated but uncontrolled and were not on a diuretic, said Dr. Victor, director of the hypertension center at Cedars-Sinai Medical Center, Los Angeles.
Among men treated and controlled down to a systolic blood pressure of almost 120 mm Hg, those with a diuretic included in their regimen had about twice the risk of nocturia as did normotensive men; those controlled without a diuretic had no elevated risk of nocturia. The results were statistically significant and were adjusted for nocturia confounders, including diabetes, body mass index, sleep apnea, and an enlarged prostate.
“Nocturia is far more likely when hypertension is inadequately treated,” especially with a diuretic, than when untreated, Dr. Victor said. “The data suggest that nocturia may be a side effect of blood pressure drugs unless strict blood pressure control is achieved. Appropriate treatment of blood pressure without a diuretic may be really beneficial in terms of reducing nocturia.”
Not all the data on the specific medications the men in the study were taking were available, but the most common antihypertensive prescribed for them was short-acting, low-dose hydrochlorothiazide, he noted.
It has been shown that hydrochlorothiazide wears off in the evening when dosed in the morning, so blood pressure might appear to be well-controlled in the daytime, but patients become hypertensive at night, leading to pressure natriuresis and nocturia. “This might [help] explain our data,” Dr. Victor said, noting that longer-acting, more potent diuretics, such as chlorthalidone, might reduce the risk.
The team plans further work to see if tighter nighttime blood pressure control reduces nocturia and improves sleep. Maybe, he noted, “if you take your blood pressure meds correctly, you sleep better. That would be a fantastic public health message; we’ll see.”
Middle-aged black men are underrepresented in hypertension research, in part because of a mistrust of doctors and medical institutions. Enrolling black men in barbershops seemed a good way to address the problem; barbers are trusted and respected members of the community, and the shops themselves are warm and relaxed, which is why hypertension was defined in the study a bit lower than the usual 140/90 mm Hg, Dr. Victor commented.
A total of 45% of the men were hypertensive; only 16% were controlled on medication. Nocturia prevalence was higher than expected in the general population, at about 29% overall, and ranged from 24% in normotensive men to 50% in men whose hypertension was treated but uncontrolled.
Average blood pressures were 120/71 mm Hg in the normotensive men; 143/87 mm Hg in untreated hypertensive men; and 148/91 mm Hg in treated but uncontrolled men. The mean age in the study was 43 years. “We capped it at 49 because after that, nocturia is so prevalent, and dominated by prostate disease,” Dr. Victor said.
The investigators had no disclosures. The National Institutes of Health funded the work.
SAN FRANCISCO – Nocturia is a sign of uncontrolled hypertension and also is associated with diuretic use in middle-aged black men, according to a study conducted at 53 barbershops in and around Los Angeles.
In the study, investigators averaged the last three of five automated blood pressure readings in 1,748 black men aged 35-49 years old and asked them about symptoms of nocturia – defined in the study as getting up two or more times per night to urinate – and about what blood pressure medications they were taking, if any.
Men with untreated hypertension – defined as at or above 135/85 mm Hg – were 34% more likely to report nocturia than were men who were normotensive.
However, “what really grabbed our attention was the treated group,” lead investigator Ronald Victor, MD said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The highest risk of nocturia, more than three times the risk of normotensive men, was among men treated with a diuretic who still had elevated blood pressure readings in the barbershop. Their risk was about 2.5 times greater in men who were treated but uncontrolled and were not on a diuretic, said Dr. Victor, director of the hypertension center at Cedars-Sinai Medical Center, Los Angeles.
Among men treated and controlled down to a systolic blood pressure of almost 120 mm Hg, those with a diuretic included in their regimen had about twice the risk of nocturia as did normotensive men; those controlled without a diuretic had no elevated risk of nocturia. The results were statistically significant and were adjusted for nocturia confounders, including diabetes, body mass index, sleep apnea, and an enlarged prostate.
“Nocturia is far more likely when hypertension is inadequately treated,” especially with a diuretic, than when untreated, Dr. Victor said. “The data suggest that nocturia may be a side effect of blood pressure drugs unless strict blood pressure control is achieved. Appropriate treatment of blood pressure without a diuretic may be really beneficial in terms of reducing nocturia.”
Not all the data on the specific medications the men in the study were taking were available, but the most common antihypertensive prescribed for them was short-acting, low-dose hydrochlorothiazide, he noted.
It has been shown that hydrochlorothiazide wears off in the evening when dosed in the morning, so blood pressure might appear to be well-controlled in the daytime, but patients become hypertensive at night, leading to pressure natriuresis and nocturia. “This might [help] explain our data,” Dr. Victor said, noting that longer-acting, more potent diuretics, such as chlorthalidone, might reduce the risk.
The team plans further work to see if tighter nighttime blood pressure control reduces nocturia and improves sleep. Maybe, he noted, “if you take your blood pressure meds correctly, you sleep better. That would be a fantastic public health message; we’ll see.”
Middle-aged black men are underrepresented in hypertension research, in part because of a mistrust of doctors and medical institutions. Enrolling black men in barbershops seemed a good way to address the problem; barbers are trusted and respected members of the community, and the shops themselves are warm and relaxed, which is why hypertension was defined in the study a bit lower than the usual 140/90 mm Hg, Dr. Victor commented.
A total of 45% of the men were hypertensive; only 16% were controlled on medication. Nocturia prevalence was higher than expected in the general population, at about 29% overall, and ranged from 24% in normotensive men to 50% in men whose hypertension was treated but uncontrolled.
Average blood pressures were 120/71 mm Hg in the normotensive men; 143/87 mm Hg in untreated hypertensive men; and 148/91 mm Hg in treated but uncontrolled men. The mean age in the study was 43 years. “We capped it at 49 because after that, nocturia is so prevalent, and dominated by prostate disease,” Dr. Victor said.
The investigators had no disclosures. The National Institutes of Health funded the work.
AT JOINT HYPERTENSION 2017
Key clinical point:
Major finding: The highest risk of nocturia, more than 3 times the risk of normotensive men, was among men treated with a diuretic who still had elevated blood pressure.
Data source: A community-based, cross-sectional study of 1,748 black men aged 35-49 years with blood pressures measured in 53 barbershops.
Disclosures: The investigators had no disclosures. The National Institutes of Health funded the work.
For treatment-resistant hypertension, drug urine screen advised
SAN FRANCISCO – The best way to make sure that patients are taking their blood pressure medications is to screen their urine for the drugs and metabolites, according to Robert Carey, MD, professor of medicine and dean emeritus of the University of Virginia, Charlottesville.
Dr. Carey shared his thoughts on the matter during his presentation on treatment resistant hypertension, at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
In up to about half the cases of apparent resistant hypertension, people simply aren’t taking their medications. Urine screening, “I believe, is the most accurate and best method of verifying adherence,” far more reliable than asking patients, or counting prescription refills, he said.
“I’m sort of a mad dog on documenting adherence because I think if we don’t document it and treat it, we will be stuck with a lot of inertia, and things won’t get better,” Dr. Carey said. He recommended speaking with patients, getting their permission to check urine levels, and reporting back results. It won’t make a difference in every case, but sometimes it will, especially if there’s an intervention to improve adherence, he noted.
Urine screening is available in most teaching hospitals and in commercial labs. “I think we will be seeing more and more availability. It has been demonstrated to be cost effective,” he said.
If adherence isn’t a problem, obesity, high sodium intake, and other lifestyle issues should be addressed, as well as the use of drugs that can raise blood pressure, especially NSAIDS, contraceptives, and hormone replacement therapies.
A workup for secondary causes also is in order. About 20% of patients will have primary aldosteronism, so all patients should be screened. Renal parenchymal disease and renal vascular disease also are common. Renal artery stenosis usually can be managed medically and rarely requires stenting. “One might take the tack of nonscreening until there’s a reduction in renal function or blood pressure goes way out of control,” Dr. Carey said.
Pheochromocytoma and Cushing’s syndrome are rare causes. Obstructive sleep apnea also is on the list “but I’m not sure it should be there. For one thing, CPAP [continuous positive airway pressure] only lowers blood pressure 1 or 2 mm. Secondly, CPAP does not prevent cardiovascular disease events in patients with moderate to severe sleep apnea and established cardiovascular risk,” he said.
If there’s no secondary cause that can be addressed, “the first thing to do is check the diuretic, and substitute in a long-acting, thiazide-like diuretic, either chlorthalidone or indapamide.” They lower blood pressure more effectively than do the thiazide diuretics, such as chlorothiazide and hydrochlorothiazide. They also provide better protection against cardiovascular events. “Once you make that substitution, you need to add a mineralocorticoid receptor antagonist, spironolactone or eplerenone. We have excellent data for both [classes of] diuretics to be added,” Dr. Carey said.
“Once we get beyond that point, we have to search the literature, and generally, we’ll come up with a goose egg in terms of randomized clinical trials. Another step is to add a beta-blocker or a vasodilating beta-blocker, [but] you would need to know precisely the mechanism of vasodilation,” he noted. After that, “you could add hydralazine or minoxidil,” a more potent vasodilator, but they have to be given with a beta-blocker and diuretic. If those approaches fail, “consider referring to a hypertension specialist,” he said.
Dr. Carey did not report any industry ties.
SAN FRANCISCO – The best way to make sure that patients are taking their blood pressure medications is to screen their urine for the drugs and metabolites, according to Robert Carey, MD, professor of medicine and dean emeritus of the University of Virginia, Charlottesville.
Dr. Carey shared his thoughts on the matter during his presentation on treatment resistant hypertension, at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
In up to about half the cases of apparent resistant hypertension, people simply aren’t taking their medications. Urine screening, “I believe, is the most accurate and best method of verifying adherence,” far more reliable than asking patients, or counting prescription refills, he said.
“I’m sort of a mad dog on documenting adherence because I think if we don’t document it and treat it, we will be stuck with a lot of inertia, and things won’t get better,” Dr. Carey said. He recommended speaking with patients, getting their permission to check urine levels, and reporting back results. It won’t make a difference in every case, but sometimes it will, especially if there’s an intervention to improve adherence, he noted.
Urine screening is available in most teaching hospitals and in commercial labs. “I think we will be seeing more and more availability. It has been demonstrated to be cost effective,” he said.
If adherence isn’t a problem, obesity, high sodium intake, and other lifestyle issues should be addressed, as well as the use of drugs that can raise blood pressure, especially NSAIDS, contraceptives, and hormone replacement therapies.
A workup for secondary causes also is in order. About 20% of patients will have primary aldosteronism, so all patients should be screened. Renal parenchymal disease and renal vascular disease also are common. Renal artery stenosis usually can be managed medically and rarely requires stenting. “One might take the tack of nonscreening until there’s a reduction in renal function or blood pressure goes way out of control,” Dr. Carey said.
Pheochromocytoma and Cushing’s syndrome are rare causes. Obstructive sleep apnea also is on the list “but I’m not sure it should be there. For one thing, CPAP [continuous positive airway pressure] only lowers blood pressure 1 or 2 mm. Secondly, CPAP does not prevent cardiovascular disease events in patients with moderate to severe sleep apnea and established cardiovascular risk,” he said.
If there’s no secondary cause that can be addressed, “the first thing to do is check the diuretic, and substitute in a long-acting, thiazide-like diuretic, either chlorthalidone or indapamide.” They lower blood pressure more effectively than do the thiazide diuretics, such as chlorothiazide and hydrochlorothiazide. They also provide better protection against cardiovascular events. “Once you make that substitution, you need to add a mineralocorticoid receptor antagonist, spironolactone or eplerenone. We have excellent data for both [classes of] diuretics to be added,” Dr. Carey said.
“Once we get beyond that point, we have to search the literature, and generally, we’ll come up with a goose egg in terms of randomized clinical trials. Another step is to add a beta-blocker or a vasodilating beta-blocker, [but] you would need to know precisely the mechanism of vasodilation,” he noted. After that, “you could add hydralazine or minoxidil,” a more potent vasodilator, but they have to be given with a beta-blocker and diuretic. If those approaches fail, “consider referring to a hypertension specialist,” he said.
Dr. Carey did not report any industry ties.
SAN FRANCISCO – The best way to make sure that patients are taking their blood pressure medications is to screen their urine for the drugs and metabolites, according to Robert Carey, MD, professor of medicine and dean emeritus of the University of Virginia, Charlottesville.
Dr. Carey shared his thoughts on the matter during his presentation on treatment resistant hypertension, at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
In up to about half the cases of apparent resistant hypertension, people simply aren’t taking their medications. Urine screening, “I believe, is the most accurate and best method of verifying adherence,” far more reliable than asking patients, or counting prescription refills, he said.
“I’m sort of a mad dog on documenting adherence because I think if we don’t document it and treat it, we will be stuck with a lot of inertia, and things won’t get better,” Dr. Carey said. He recommended speaking with patients, getting their permission to check urine levels, and reporting back results. It won’t make a difference in every case, but sometimes it will, especially if there’s an intervention to improve adherence, he noted.
Urine screening is available in most teaching hospitals and in commercial labs. “I think we will be seeing more and more availability. It has been demonstrated to be cost effective,” he said.
If adherence isn’t a problem, obesity, high sodium intake, and other lifestyle issues should be addressed, as well as the use of drugs that can raise blood pressure, especially NSAIDS, contraceptives, and hormone replacement therapies.
A workup for secondary causes also is in order. About 20% of patients will have primary aldosteronism, so all patients should be screened. Renal parenchymal disease and renal vascular disease also are common. Renal artery stenosis usually can be managed medically and rarely requires stenting. “One might take the tack of nonscreening until there’s a reduction in renal function or blood pressure goes way out of control,” Dr. Carey said.
Pheochromocytoma and Cushing’s syndrome are rare causes. Obstructive sleep apnea also is on the list “but I’m not sure it should be there. For one thing, CPAP [continuous positive airway pressure] only lowers blood pressure 1 or 2 mm. Secondly, CPAP does not prevent cardiovascular disease events in patients with moderate to severe sleep apnea and established cardiovascular risk,” he said.
If there’s no secondary cause that can be addressed, “the first thing to do is check the diuretic, and substitute in a long-acting, thiazide-like diuretic, either chlorthalidone or indapamide.” They lower blood pressure more effectively than do the thiazide diuretics, such as chlorothiazide and hydrochlorothiazide. They also provide better protection against cardiovascular events. “Once you make that substitution, you need to add a mineralocorticoid receptor antagonist, spironolactone or eplerenone. We have excellent data for both [classes of] diuretics to be added,” Dr. Carey said.
“Once we get beyond that point, we have to search the literature, and generally, we’ll come up with a goose egg in terms of randomized clinical trials. Another step is to add a beta-blocker or a vasodilating beta-blocker, [but] you would need to know precisely the mechanism of vasodilation,” he noted. After that, “you could add hydralazine or minoxidil,” a more potent vasodilator, but they have to be given with a beta-blocker and diuretic. If those approaches fail, “consider referring to a hypertension specialist,” he said.
Dr. Carey did not report any industry ties.
EXPERT ANALYSIS FROM JOINT HYPERTENSION 2017
Pediatric hypertension diagnosis requires repeat ambulatory pressure session
SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.
Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.
Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.
“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.
“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.
The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.
“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.
There was no external funding for the work, and the investigators had no disclosures.
SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.
Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.
Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.
“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.
“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.
The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.
“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.
There was no external funding for the work, and the investigators had no disclosures.
SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.
Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.
Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.
“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.
“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.
The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.
“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.
There was no external funding for the work, and the investigators had no disclosures.
AT JOINT HYPERTENSION 2017
Key clinical point:
Major finding: Half of the children in a study had a change in their ABPM classification from the first to the last session.
Data source: Review of 102 children with at least two ABPM sessions 6 months apart.
Disclosures: There was no external funding for the work, and the investigators had no disclosures.
How to lower blood pressure in real-world primary care clinics
SAN FRANCISCO – In just 6 months, a commonsense quality improvement program increased the rate of blood pressure control from 66% to 75% among 21,035 hypertensive patients at 16 primary care clinics in northwestern South Carolina.
The American Medical Association collaborated with the Care Coordination Institute in Greenville, S.C., to develop the program, dubbed “MAP,” which stands for measuring blood pressure accurately; acting rapidly to manage uncontrolled blood pressure; and partnering with patients to promote blood pressure self-management.
With the success in South Carolina, it’s likely the program will be rolled out to other parts of the country, Dr. Egan said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension
Twelve of the 16 practices had significant increases in BP control. In patients uncontrolled at baseline, mean BP fell from 149/85 mm Hg to 139/80 mm Hg. In controlled patients, BP fell about 10/5 mm Hg. The findings were statistically significant.
To reduce white coat hypertension and improve BP accuracy, patients who had an initial, attended BP at or above 140/90 mm Hg were put in a room by themselves for 5 minutes for three automated BP measurements, which were then averaged. Staff made sure patients were positioned properly and had the correctly sized cuff on their arm, among other measures. A program facilitator was onsite to help.
Patients who had BPs at or above 140/90 mm Hg when they were left alone were switched to drugs that have been proven to help. For white patients younger than 55 years, that meant a renin-angiotensin system blocker first and a calcium channel blocker second. For older African American patients, the calcium channel blocker came first. A diuretic was added if needed as a third step, and then spironolactone as a fourth. “That was basically the regimen in the absence of compelling indications for other agents,” Dr. Egan said.
Single-pill combinations were encouraged to help with compliance. The investigators also worked with nearby pharmacies to use generic drugs to keep costs low, and to ensure that patients could pick up all their prescriptions at one visit. Many of the patients had multiple chronic conditions and were on a half dozen or more drugs. Picking them all up at one pharmacy visit has been shown to improve adherence.
There was follow-up every 2 weeks for patients with stage 2 hypertension, at least by phone. Stage 1 patients had monthly follow-ups. Lifestyle changes were encouraged, as well as home BP monitoring. The clinics were given a few home monitors to send home with patients, and patients reported their results. If BP was elevated at home, patients were contacted and advised before their next visit.
They were also given a cookbook that matched the DASH diet with the southern palate. “We tried to make it taste good and not cost more,” Dr. Egan said. “It’s been quite popular for our patients who are willing to give it a try. It’s free on our website.”
With the intervention, “not only did [patients] take their new medications, but they also were probably taking previous medications more reliably,” he said.
It’s likely that the program reduced hypertension comorbidities, Dr. Egan noted, but there was no cost-benefit analysis.
There was no pharmaceutical industry funding. Dr. Egan disclosed research support from Boehringer.
SAN FRANCISCO – In just 6 months, a commonsense quality improvement program increased the rate of blood pressure control from 66% to 75% among 21,035 hypertensive patients at 16 primary care clinics in northwestern South Carolina.
The American Medical Association collaborated with the Care Coordination Institute in Greenville, S.C., to develop the program, dubbed “MAP,” which stands for measuring blood pressure accurately; acting rapidly to manage uncontrolled blood pressure; and partnering with patients to promote blood pressure self-management.
With the success in South Carolina, it’s likely the program will be rolled out to other parts of the country, Dr. Egan said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension
Twelve of the 16 practices had significant increases in BP control. In patients uncontrolled at baseline, mean BP fell from 149/85 mm Hg to 139/80 mm Hg. In controlled patients, BP fell about 10/5 mm Hg. The findings were statistically significant.
To reduce white coat hypertension and improve BP accuracy, patients who had an initial, attended BP at or above 140/90 mm Hg were put in a room by themselves for 5 minutes for three automated BP measurements, which were then averaged. Staff made sure patients were positioned properly and had the correctly sized cuff on their arm, among other measures. A program facilitator was onsite to help.
Patients who had BPs at or above 140/90 mm Hg when they were left alone were switched to drugs that have been proven to help. For white patients younger than 55 years, that meant a renin-angiotensin system blocker first and a calcium channel blocker second. For older African American patients, the calcium channel blocker came first. A diuretic was added if needed as a third step, and then spironolactone as a fourth. “That was basically the regimen in the absence of compelling indications for other agents,” Dr. Egan said.
Single-pill combinations were encouraged to help with compliance. The investigators also worked with nearby pharmacies to use generic drugs to keep costs low, and to ensure that patients could pick up all their prescriptions at one visit. Many of the patients had multiple chronic conditions and were on a half dozen or more drugs. Picking them all up at one pharmacy visit has been shown to improve adherence.
There was follow-up every 2 weeks for patients with stage 2 hypertension, at least by phone. Stage 1 patients had monthly follow-ups. Lifestyle changes were encouraged, as well as home BP monitoring. The clinics were given a few home monitors to send home with patients, and patients reported their results. If BP was elevated at home, patients were contacted and advised before their next visit.
They were also given a cookbook that matched the DASH diet with the southern palate. “We tried to make it taste good and not cost more,” Dr. Egan said. “It’s been quite popular for our patients who are willing to give it a try. It’s free on our website.”
With the intervention, “not only did [patients] take their new medications, but they also were probably taking previous medications more reliably,” he said.
It’s likely that the program reduced hypertension comorbidities, Dr. Egan noted, but there was no cost-benefit analysis.
There was no pharmaceutical industry funding. Dr. Egan disclosed research support from Boehringer.
SAN FRANCISCO – In just 6 months, a commonsense quality improvement program increased the rate of blood pressure control from 66% to 75% among 21,035 hypertensive patients at 16 primary care clinics in northwestern South Carolina.
The American Medical Association collaborated with the Care Coordination Institute in Greenville, S.C., to develop the program, dubbed “MAP,” which stands for measuring blood pressure accurately; acting rapidly to manage uncontrolled blood pressure; and partnering with patients to promote blood pressure self-management.
With the success in South Carolina, it’s likely the program will be rolled out to other parts of the country, Dr. Egan said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension
Twelve of the 16 practices had significant increases in BP control. In patients uncontrolled at baseline, mean BP fell from 149/85 mm Hg to 139/80 mm Hg. In controlled patients, BP fell about 10/5 mm Hg. The findings were statistically significant.
To reduce white coat hypertension and improve BP accuracy, patients who had an initial, attended BP at or above 140/90 mm Hg were put in a room by themselves for 5 minutes for three automated BP measurements, which were then averaged. Staff made sure patients were positioned properly and had the correctly sized cuff on their arm, among other measures. A program facilitator was onsite to help.
Patients who had BPs at or above 140/90 mm Hg when they were left alone were switched to drugs that have been proven to help. For white patients younger than 55 years, that meant a renin-angiotensin system blocker first and a calcium channel blocker second. For older African American patients, the calcium channel blocker came first. A diuretic was added if needed as a third step, and then spironolactone as a fourth. “That was basically the regimen in the absence of compelling indications for other agents,” Dr. Egan said.
Single-pill combinations were encouraged to help with compliance. The investigators also worked with nearby pharmacies to use generic drugs to keep costs low, and to ensure that patients could pick up all their prescriptions at one visit. Many of the patients had multiple chronic conditions and were on a half dozen or more drugs. Picking them all up at one pharmacy visit has been shown to improve adherence.
There was follow-up every 2 weeks for patients with stage 2 hypertension, at least by phone. Stage 1 patients had monthly follow-ups. Lifestyle changes were encouraged, as well as home BP monitoring. The clinics were given a few home monitors to send home with patients, and patients reported their results. If BP was elevated at home, patients were contacted and advised before their next visit.
They were also given a cookbook that matched the DASH diet with the southern palate. “We tried to make it taste good and not cost more,” Dr. Egan said. “It’s been quite popular for our patients who are willing to give it a try. It’s free on our website.”
With the intervention, “not only did [patients] take their new medications, but they also were probably taking previous medications more reliably,” he said.
It’s likely that the program reduced hypertension comorbidities, Dr. Egan noted, but there was no cost-benefit analysis.
There was no pharmaceutical industry funding. Dr. Egan disclosed research support from Boehringer.
AT JOINT HYPERTENSION 2017
Higher BP targets suggested for elderly, cognitively impaired
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
EXPERT ANALYSIS FROM Joint Hypertension 2017
VIDEO: What’s new in AAP’s pediatric hypertension guidelines
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
EXPERT ANALYSIS FROM THE AHA/ASH JOINT SCIENTIFIC SESSIONS
