Given at Primary Care Winter Refresher conference, February 2010

1. Hypertension: There’s Nothing “Uncomplicated” About It Jon Zlabek MD, FACP

2. Learning Objectives Confront the cold hard truth Understand the dangers of “Therapeutic Inertia” Review the basics of hypertension management Understand the approach to resistant hypertension

3. The Problem

4. The Cold Hard Truth As health care providers, we stink at managing hypertension, and our patients die needlessly because of it.

5. Hypertension Affects ~31% of U.S. adults Most common primary diagnosis Incidence is increasing Control is poor: Only 53% are on therapy Only 31% are controlled Hypertension 2006;47:345-51Stroke 2006;37:577-617

6. Why Should I Care? It’s just a number, right?

7. Target Organ Damage Brain Stroke or transient ischemic attack Heart Left ventricular hypertrophy Coronary artery disease Heart failure Peripheral arterial disease Kidney Chronic kidney disease Eye Hypertensive retinopathy

8. Hypertension About 60% of all strokes are attributable to hypertension That’s 468,000 strokes per year in USA Blood pressure control decreases initial stroke rate by 35-40% CHF decreased by >50% MI decreased by 20-25% JNC-7 NHLBI

9. We Missed the News Flash! Stroke & heart disease death rises linearly from 115/75 mmHg JNC-7 NHLBI

10. We Missed the News Flash!

13. We Missed the News Flash! Stroke & heart disease death rises linearly from 115/75 mmHg 141/88 should take on a new meaning with this tidbit Get them off the bubble and into the “safe zone” JNC-7 NHLBI

14. The Dangers of “Therapeutic Inertia”

15. Therapeutic Inertia? Definition Healthcare providers’ failure to increase therapy when treatment goals are unmet Hypertension 2006;47:345-51

16. Therapeutic Inertia? Blood pressure control rates haven’t changed much in the last 15 years Lots of reasons given: Patient compliance Access to care Cost Hypertension 2006;47:345-51

17. Therapeutic Inertia 7253 patients with hypertension seen by 168 physicians at 40 sites in the southeast US Seen in the clinic  4 times in 2003 Recorded the last BP taken while sitting At least one visit with BP  140/90 Hypertension 2006;47:345-51

18. Therapeutic Inertia A visit with “therapeutic inertia” was defined as one where an elevated blood pressure was recorded, but there was no increase in dose or number of antihypertensive medications Hypertension 2006;47:345-51

19. Therapeutic Inertia Medications were changed at only 13.1% of visits with an elevated blood pressure Hypertension 2006;47:345-51

20. Therapeutic Inertia Overall, patients’ BP improved from the first to the final visit 39.5% controlled at first visit 45.1% controlled at final visit Patient were placed into quintiles based on the therapeutic inertia they experienced Hypertension 2006;47:345-51

21. Therapeutic Inertia Quintile 1 patients experienced low therapeutic inertia Their physicians were “doers” Quintile 5 patients experiencedhigh therapeutic inertia Their physicians were “watchers” Hypertension 2006;47:345-51

22. Therapeutic Inertia “Doer” group: SBP decreased by 6.8 mmHg Increased control rate 53.0% to 75.5% “Watcher” group SBP increased by 1.8 mmHg Worse control rate 22.2% to 7.7% Hypertension 2006;47:345-51

23. “Watchers” “Doers”

24. Therapeutic Inertia Patients in the “doer doctor” group were 33 timesmore likely to have achieved blood pressure control at the last visit than those in the “watcher doctor” group Hypertension 2006;47:345-51

25. Therapeutic Inertia If medication changes were made at 30% of the visits, instead of 13% . . . BP control would increase from 45% to 66% Cardiovascular and all-cause mortality in this group would be reduced ~10-15% Hypertension 2006;47:345-51

26. What Causes Therapeutic Inertia? We think we’re better than we really are Physician self-reported care is overestimated when compared to actual care Annals of Internal Medicine 2001;135(9):825-34

27. What Causes Therapeutic Inertia? Use of “soft” reasons to avoid intensification of therapy Perception that control was improving Patient aversion to medication therapy Annals of Internal Medicine 2001;135(9):825-34

28. What Causes Therapeutic Inertia? Lack of training/education Not understanding the need for multiple medications at maximal doses Lack of practice organization focused on therapeutic goals Poor or no quality initiatives Lack of electronic aids (flowsheets, etc) Annals of Internal Medicine 2001;135(9):825-34

29. How to Fix Therapeutic Inertia??? Be aware that we as humans “drift” toward this Continually remind yourself and your patients of the devastation that comes with stroke and heart disease

30. How to Fix Therapeutic Inertia??? Some providers may need to be more “industrious” during clinic visits It’s much easier to “see you in 6 months” than to prescribe a medication “Watching” 141/88 takes on a new light when we realize that risk of death goes up linearly from 115/75

31. Tips Compiled from GL’s Best HTN Providers Intense focus on rechecking the BP and getting it into the CWS Theme of patients sitting and relaxing for a while before taking/retaking BP Provider rechecks it and gives it to MA to enter MA rechecks it after the provider leaves

32. Tips Compiled from GL’s Best HTN Providers Repeated, intense follow up every month until patient is at goal Theme of not hesitating to consult a hypertension specialist

33. Tips Compiled from GL’s Best HTN Providers Up-front and repeated speech about the “evils” of hypertension Scare them with reality Talk about end organ effects “What you can’t feel can kill you” “Can’t enjoy retirement with a stroke”

34. Tips Compiled from GL’s Best HTN Providers Use medications before or as they change their lifestyle, then take them away if/when they change Don’t fall into the “I’ll try harder from now on” trap Push BP down to the “safe zone”, not just barely to goal levels

35. Tips Compiled from GL’s Best HTN Providers Remind patients: Importance of lifestyle changes It will take at least 3 medicines to get to goal Importance of their engagement in this Involve them in treatment decisions Make sure they are clear on BP goal number Get a home BP monitor

36. Tips Compiled from GL’s Best HTN Providers More tips: Use medications combinations to save money and improve compliance Offer nurse-only (free) BP checks Monthly audits by MA to find patient that are missing things or needs appt Very strong theme of a close working relationship with their MAs

37. Other Tips To Improve . . . Make sure patients take their BP medications the morning of the appointment even if they are fasting Make sure your MA/RN does not “round off” to zeros or fives 140 mmHg counts as not controlled; 139 mmHg counts as controlled

38. Other Tips To Improve . . . RE-CHECK and RE-RECORD At the end of your history – You Write it on a sticker and give to your nurse/MA to enter in CWS If it is not entered discretely in CWS, it doesn’t count After you are long gone – Your nurse/MA Minimizes “white coat” effect

39. The Basics of Hypertension Management

40. New Guidelines Coming! JNC 7 released in 2003 JNC 8 upcoming Summer 2010 Data presented here from JNC 7 with my predictions of JNC 8 in red italics

41. Basics of Measurement Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level. Use an appropriate sized cuff Small cuff = falsely high readings

42. Initial Strategy Make the diagnosis At least 3 visits over weeks-months, assuming no end organ damage or BP less than 180/110 Define the goal blood pressure level Use history, exam and tests to: Seek out easily correctable causes Assess target organ damage Remember the vascular milieu TREAT AND REPEAT!

43. Goal Blood Pressure Levels <130/80 for: Diabetes Chronic kidney disease CAD or CAD equivalent: Carotid disease PAD AAA 10 year cardiovascular risk ≥ 10% <140/90 mmHg for others JNC-7 NHLBICirculation 2007;115:2761-2788

44. Initial Tests Creatinine Urinalysis Potassium and Sodium Calcium TSH Hemoglobin or Hematocrit Glucose Fasting Lipid Panel EKG

45. What to Tell Patients Now, and Reinforce at Each Visit “We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure” “Most patients eventually need 3-4 medications to achieve goal blood pressure levels”

46. What to Tell Patients Now, and Reinforce at Each Visit “I will be seeing you for brief 5 minute appointments with lab tests every month until your blood pressure goal is reached” Tip: Double book these patients – they are quick Very high yield “bread and butter” E&M code for the time spent

47. Coding a 5 minute uncontrolled HTN follow up S: Mr. Smith returns for a blood pressure follow up. It has been running 160/85 at home. He has no hyper- or hypotensive side effects on his meds. O: BP 159/87. He appears well. A: Uncontrolled hypertension P: Increase lisinopril to 40 mg a day. Check potassium and creatinine. F/U in 1 month. 2 1 2 99213 = 0.97 RVU and $143

48. Treatment – First 3 Drugs Thiazide diuretic Triamterene/HCTZ 37.5/25 in AM Using a thiazide alone makes a lot of extra work chasing K levels F/U one month with Na, K, Creatinine Option for dihydropyridine calcium channel blocker, e.g. amlodipine or ACE-I/ARB JNC-7 NHLBINEJM 2009;361:878-87

49. Treatment – First 3 Drugs 2. Add a low dose ACE-I e.g. lisinopril 10 mg daily Stop Triamterene/HCTZ and replace with Chlorthalidone (best) or HCTZ 25 mg daily Change to ARB if cough develops F/U one month with K, Creatinine JNC-7 NHLBI

50. Treatment – First 3 Drugs 2. Titrate ACE-I Increase to lisinopril 20 mg F/U one month with K, Creatinine Increase to lisinopril 40 mg F/U one month with K, Creatinine A bump of up to 35% in creatinine with ACE-I is acceptable JNC-7 NHLBI

51. Treatment – First 3 Drugs 3. Add a dihydropyridine calcium channel blocker e.g. amlodipine 5 mg daily Warning – don’t add non-dihydropyridine here (diltiazem), as decreases in pulse limit your future beta blocker use F/U one month – no lab needed Titrate amlodipine to 10 mg daily JNC-7 NHLBI

52. Don’t Forget Lifestyle!

53. Don’t Forget Lifestyle Proven approaches: Weight reduction (5-20 mmHg/10 kg) DASH eating plan (8-14 mmHg) Dietary Approaches to Stop Hypertension dashdiet.org Sodium restriction (2-8 mmHg) Physical activity (4-9 mmHg) Moderation of alcohol (2-4 mmHg) JNC-7 NHLBI

54. Still Not At Goal? If you’ve come this far and still haven’t reached your goal, you officially have “resistant hypertension” Don’t throw in the towel! This is a good time to consider a consult with a hypertension specialist

55. The Approach to Resistant Hypertension

56. Resistant Hypertension Blood pressure of ≥140/90 or ≥130/80 with diabetes or renal disease, despite full doses of 3 medications, including a diuretic What is the PRIMARY reason for uncontrolled resistant hypertension? NEJM 2006;355:385-92

57. Resistant Hypertension “A suboptimal medical regimen has been shown to be the primary cause of resistant hypertension . . .” NEJM 2006;355:385-92

58. Other Causes Medications/drugs (<2%) NSAIDS Stimulants Herbals (ginseng and yohimbine) Appetite suppressants Steroids Adherence to therapy NEJM 2006;355:385-92

59. Other Causes Inadequate diuresis High sodium intake (>150 mmol/day) Alcohol (>3-4 drinks/day) Obesity JNC-7 NHLBINEJM 2006;355:385-92

60. “Secondary” Causes Affects 10% of all patients with resistant hypertension Affects 18% of those over age 60 with resistant hypertension NEJM 2006;355:385-92

61. “Secondary” Causes Renal parenchymal disease (1-8%) Renovascular disease (3-4%) Aldosteronism (1.5-15%) Thyroid disease (1-3%) Cushing’s syndrome (<0.5%) Pheochromocytoma (<0.5%) Coarctation of the aorta (<1%) Sleep apnea (unknown) NEJM 2006;355:385-92

62. Treatment – After the First 3 4. Add a beta blocker e.g. metoprolol 25 mg twice a day F/U one month Titrate to a pulse around 60

63. Treatment – After the First 3 5/6. Add a direct renin inhibitor Aliskiren (Tekturna) 150 mg daily F/U one month with K, Creatinine Titrate to 300 mg daily in a month

64. Treatment – After the First 3 5/6. Add an alpha blocker e.g. doxazosin 1 mg daily Warn of orthostatic hypotension/lightheadedness F/U one month Titrate to 2 mg, 4 mg and 8 mg at monthly F/U visits

65. Treatment – Drug 7 and Beyond Spironolactone (aldosterone blocker) Watch K carefully Hydralazine (direct vasodilator) Must be beta-blocked and diuresed Nitrate if coronary disease and angina

66. Treatment – Drug 7 and Beyond Avoid centrally acting drugs due to poor side effect profile Clonidine Reserpine Guanfacine

67. Resistant Hypertension Consider consultation with a “hypertension specialist” per JNC-7 That’s us in Vascular Medicine! We love these patients! JNC-7 NHLBINEJM 2006;355:385-92

68. Take Home Points “We are treating your high blood pressure to prevent stroke, heart attack, and kidney failure” Stroke and heart disease death rises linearly from 115/75 mmHg Get them off the bubble and into the “safe zone”

69. Take Home Points Be diligent in management and follow up 5 minute monthly appts until controlled Avoid “Therapeutic Inertia” RE-CHECK and RE-RECORD in CWS Consult a HTN specialist if control is difficult or for secondary evaluation

70. Thanks!