advertisement

Black

50 %
50 %
advertisement
Information about Black
Entertainment

Published on November 30, 2007

Author: Churchill

Source: authorstream.com

advertisement

Slide1:  RESISTANT HYPERTENSION CAN WE IMPROVE OUTCOMES? Henry R. Black, M.D New York University School of Medicine March 21, 2007 RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? WHAT CAUSES IT? HOW DO YOU EVALUATE IT? HOW DO YOU TREAT IT? RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT ? RESISTANT HYPERTENSION: DEFINITION PER JNC 7 (2003):  RESISTANT HYPERTENSION: DEFINITION PER JNC 7 (2003) Failure to reach goal BP (<140/90 mm Hg, <130/80 mm Hg with diabetes and chronic renal disease) At least a three-drug regimen, one of which is a diuretic Which the patient is taking Chobanian AV, et al. Hypertension. 2003;42:1206-1252. Prevalence of TOD in Refractory Hypertension:  Prevalence of TOD in Refractory Hypertension Cuspidi et al. J Hypertension 2001, 19:2063-2070 RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION THERE ARE NEARLY 1 BILLION HYPERTENSIVE ADULTS IN THE WORLD, PERHAPS 60-70 MILLION IN AMERICA. APPROXIMATELY 70% ARE AWARE THEY ARE HYPERTENSIVE. (45 MILLION). OF THOSE, 60% ARE BEING TREATED (27 MILLION). OF THOSE, 50% OVERALL ARE CONTROLLED TO GOAL (13-14 MILLION), 60% IF TREATED BY SPECIALISTS (11 MILLION). THIS LAST NUMBER IS HIGHER STILL IF WE ACCEPT A LOWER GOAL FOR DIABETIC HYPERTENSIVES. Percentage of People Over 60 Years of Age (2000-2025):  Percentage of People Over 60 Years of Age (2000-2025) Population Division of the Department of Economic and Social Affairs of the UN Secretariat, World Population Prospects: The 2002 Revision and World Urbanization Prospects (http://eas.un.org/unpp/) HYPERTENSION IN THE ELDERLY - NHANES III:  HYPERTENSION IN THE ELDERLY - NHANES III Age (yrs) Frequency of HBP subtypes In all undertreated subjects Franklin et al Hyp. 37:869, 2001 4% 10% 18% 28% 27% 13% UNDERTREATED PREVALENCE OF OBESITY AND DIABETES AMONG US ADULTS, 1991 AND 2001:  PREVALENCE OF OBESITY AND DIABETES AMONG US ADULTS, 1991 AND 2001 Mokdad: JAMA 2001, 286: 1195-1200; Sacks FM et al. Am J Cardiol. 2002;90(suppl 2):165-167 Obesity Diabetes Age-Adjusted Prevalence of Obesity (BMI > 30.0) in Americans Ages 20-74:  *NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988-94 and 1999-2002. Health, United States, 2004, CDC/NCHS. Age-Adjusted Prevalence of Obesity (BMI > 30.0) in Americans Ages 20-74 Percent of population PREVALENCE OF DIABETES BY AGE GROUP IN THE US:  Percent PREVALENCE OF DIABETES BY AGE GROUP IN THE US Age Group 20-44 45-64 65-74 75+ CDC. National Diabetes Fact Sheet. 2002. Source: 1997-1999 National Health Interview Survey and 1988-1994 National Health and Nutrition Examination Survey (NHANES) estimates projected to year 2000 3% 12% 22% 19% Algorithm for Treatment of Hypertension:  Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications GOAL: “THE END TOWARD WHICH EFFORT IS DIRECTED” (Webster’s):  GOAL: “THE END TOWARD WHICH EFFORT IS DIRECTED” (Webster’s) MJ’s Goal: 100% of his shots go in. MJ’s actual Shooting % 50.5%. GOAL OF ANTIHYPERTENSIVE THERAPY:  GOAL OF ANTIHYPERTENSIVE THERAPY < 140 mm Hg and < 90 mm Hg for most patients < 130 mm Hg and < 80 mm Hg for diabetics, patients with HF and those with CRF (and maybe soon for those with CAD) Goal is not dependent on age, gender or co-morbidity Antihypertensive Agents Neededto Achieve Goal BP ALLHAT:  Adapted from Cushman WC et al. J Clin Hypertens. 2002;4:393-404. Baseline 6 Months 3 Years 5 Years 1 Drug 2 Drugs 3 Drugs % <140/90 mm Hg Percentage of Patients 0 20 40 60 80 100 1 Year Antihypertensive Agents Neededto Achieve Goal BP ALLHAT Therapeutic Inertia: A Problem Even When Drugs Are Free:  Therapeutic Inertia: A Problem Even When Drugs Are Free Percent Adapted from Cushman WC et al. J Clin Hypertens 2002;4(6):393-404. 1Increased= in dose of step 1 blinded drug, an  in the number of drugs prescribed, or a change in prescription without a change in the # of drugs. ALLHAT Proportion of Participants on 2 or More Drugs with BP  140/90 Who Had Their Drugs Increased1 Independent Predictors of BP Control to <140/90 mmHg: The ALLHAT Study at Year 3:  Independent Predictors of BP Control to <140/90 mmHg: The ALLHAT Study at Year 3 Cushman WC et al. J Clin Hypertens. 2002;4:393–404. 1 versus private practice 2 versus west a more likely to be on 2 or more drugs (more intensively treated than reference group) b less likely to be on 2 or more drugs (less intensively treated than reference group)) More likely controlled Malea Community Health Center1 Canadian2 Puerto Rico/Virgin Islands2,b Less likely controlled Ageb Blackb Type 2 DM BMI (30kg/m2)a Prior Treatment Crea > 1.5 mg/dl ECG – LVHa Clinical Research Site Lives in Southb CLINICAL INERTIA MANAGEMENT OF HTN: NEW ENGLAND VA STUDY (n=800):  If DBP 90 mm Hg and SBP 155 mm Hg, medications  26% of time If DBP 90 mm Hg and SBP 165 mm Hg, medications  22% of time Patients with poorly controlled BP seen more often Patients who received more therapy achieved better control In 2 years SBP and DBP decreased only 1 mmHg and 2 mmHg Increases in therapy occurred at only 6.7% of visits CLINICAL INERTIA MANAGEMENT OF HTN: NEW ENGLAND VA STUDY (n=800) Berlowitz et al. N Engl J Med 1998;339:1957 What Is Clinical Inertia?:  What Is Clinical Inertia? Overestimation of care provided Use of “soft” reasons to avoid intensifying therapy Lack of education, training, and practice organization aimed at achieving therapeutic goals The failure of healthcare providers to initiate or intensify therapy when indicated Causes: Phillips LS et al. Ann Intern Med. 2001;135:825–834. Effects of Antihypertensive Drug Treatment on SBP in Essential Hypertensive Patients:  Effects of Antihypertensive Drug Treatment on SBP in Essential Hypertensive Patients Adapted with permission from Mancia G, Grassi G. J Hypertens. 2002;20:1461-1464. Effects of Antihypertensive Drug Treatment on SBP in Hypertensive Patients With Diabetes:  Effects of Antihypertensive Drug Treatment on SBP in Hypertensive Patients With Diabetes Adapted with permission from Mancia G, Grassi G. J Hypertens. 2002;20:1461-1464. Slide23:  “GOAL ORIENTED MANAGEMENT” BLOOD PRESSURE AT GOAL (N=437) (< 140 mm Hg/< 90mm Hg) SBP at Goal DBP at Goal Both at Goal 70 50 30 % AT GOAL 100 90 80 60 40 20 10 0 Initial visit Visit analyzed 51% 35% 28% 59% 86% 63% Singer et al. Hypertension. 2002. Slide25:  Blood Pressure Goals of Diabetics Distributed by Guideline Recommendations 100 90 80 70 60 50 40 30 20 10 0 SBP at Goal DBP at Goal Both at Goal HEDIS < 140/< 90 mm Hg JNC VI < 130/< 85 mm Hg ADA/NKF < 130/< 80 mm Hg % AT GOAL G. Singer et al, Hypertension 40:460, 2002 RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? WHAT CAUSES IT? CLASSIFICATION OF RESISTANT HYPERTENSION:  CLASSIFICATION OF RESISTANT HYPERTENSION Improper BP measurement and misclassification Specific identifiable disorder Secondary HTN Exogenous substances Too much salt Too much food Too much alcohol Complicating biologic factors Sleep apnea Metabolic Syndrome/Obesity Inappropriate or inadequate treatment Failure to adhere to the medical regimen Adapted from Setaro JF, Black HR. N Engl J Med. 1992;327:543-547. CAUSES OF RESISTANT HYPERTENSION:  CAUSES OF RESISTANT HYPERTENSION PROBLEMS WITH BP MEASUREMENT:  PROBLEMS WITH BP MEASUREMENT “White-coat hypertension” ~20 to 25% of those with elevated office BP Can be properly diagnosed by ABPM Reimbursed by Medicare (~$50), only for this Optimal treatment is controversial Poor technique in office BP measurements Proper sized cuff, slow deflate rate, rest (?) “Pseudohypertension” “Stiff pipes:” Usefulness of “Osler’s maneuver?” OFFICE RESISTANCE:  OFFICE RESISTANCE ABPM Studies: Office resistance versus “true” resistance (target organ effects) Up to half of apparently resistant patients have BP <135/85 mm Hg over 24 hr Highest BP tertile predicts target organ injury Home measurements may have a role ABPM = Ambulatory blood pressure monitoring..Hernandez del Rey R, et al. Blood Press Monit. 1998;3:331-337. Mezzetti A, et al. Am J Hypertens. 1997;10:1302-1307.Redon J, et al. Hypertension. 1998;31:712-718.Staessen JA, et al. JAMA. 2004;291:955-964. Rush University Hypertension Center A Review of 42 ABPM Cases in the last 8 months:  Rush University Hypertension Center A Review of 42 ABPM Cases in the last 8 months 9 5 17 11 Normal White-coat Office-resistance Hypertensive EXOGENOUS SUBSTANCES:  EXOGENOUS SUBSTANCES Amphetamines Anabolic steroids Anti-inflammatory agents Corticosteroids COX-2 inhibitors Anti-rejection drugs Cyclosporine Tacrolimus Appetite suppressants Phenylpropanolamine Caffeine Cocaine Erythropoietin Ephedra (Ma Huang) Ethanol Licorice Monoamine oxidase inhibitors Nicotine Sodium chloride Sympathomimetics Pseudoephedrine Reasons for Non-adherence:  Reasons for Non-adherence Financial constraints Perceived lack of treatment effectiveness Unwelcome side effects or drug tolerability issues Need for more than one agent or complex treatment regimens A lack of understanding of instructions provided by physicians Poor adherence is estimated to cost the US $100 billion annually* *Task Force for Non-compliance. Baltimore, Md: Task Force for Noncompliance, 1994. DiMatteo et al. Med Care 2002;794–811; Greenberg. Clin Ther 1984;6:592–9; Dezii. Man Care 2000;9(Suppl):2–6; Taylor & Shoheiber. Congest Heart Fail 2003;9:324– 32; Rudd. Am J Manag Care 1998;4:957–66; Degli et al. J Clin Hypertens 2004;6:76–84 Assessing Adherence:  Assessing Adherence Ask the patient (and/or Significant Other) Pharmacological principles Check a pulse rate (if β-blocker) Check standing BP (if α-blocker) Blood Tests [urate] if thiazide diuretic, losartan Call the pharmacy (in the presence of the patient): ask about refill frequency Use computerized pill-bottle caps Osterberg L, Blaschke T. N Engl J Med. 2005;353:487-497. Highly Adherent Patients are More Likely to Achieve Blood Pressure Control:  Highly Adherent Patients are More Likely to Achieve Blood Pressure Control *According to JNC VI definitions. Compliance measured based on medication possession ratio. Bramley et al. J Manag Care Pharm 2006;12:239–45. Patients With BP control* (%) Odds ratio = 1.45 P=0.026 (controlling for age, gender and comorbidities) 0 10 40 50 30 20 High (≥80%) Medium (50–79%) Low (<50%) 43 34 33 Level of Compliance MEDICATION ADHERENCE and MORTALITY :  MEDICATION ADHERENCE and MORTALITY Simpson et al BMJ: 333:15, 2006 CAUSES OF SECONDARY HYPERTENSION:  CAUSES OF SECONDARY HYPERTENSION Renal disorders Parenchymal disease Renovascular disease Endocrine disease Thyroid disease Mineralocorticoid excess Glucocorticoid excess Pheochromocytoma Hypercalcemia Acromegaly Sleep apnea Coarctation of the aorta CNS tumors Autonomic dysreflexia with spinal cord lesions Porphyria Carcinoid Secondary Hypertension, Effect of Age:  Anderson GH, et al. J Hypertens. 1994;12:609-615. Secondary Hypertension, Effect of Age Prevalence, % Prevalence of Secondary HTN Increases with Age n = 752 n = 861 n = 1120 n = 1211 n = 566 n = 138 PREVALENCE OF PRIMARY ALDOSTERONISM IN HYPERTENSIVE SUBJECTS*:  PREVALENCE OF PRIMARY ALDOSTERONISM IN HYPERTENSIVE SUBJECTS* Mosso L, et al. Hypertension. 2003;42:161-165. Calhoun DA, et al. 2002. Hypertension. 2002;40:892-896. Prevalence of PA, % SLEEP DISORDERED BREATHING IS RELATED TO POOR BP CONTROL:  SLEEP DISORDERED BREATHING IS RELATED TO POOR BP CONTROL % of pts with BP Controlled Apnea-Hypopnea Index/hr To Below 160/95 To Below 140/90 n = 599 HTN pts Grote et al J Hypertens 2000; 18:679 CAUSES OF RESISTANT HYPERTENSION - MAYO SERIES:  CAUSES OF RESISTANT HYPERTENSION - MAYO SERIES N = 104 RAS = Renal artery stenosis; OSA = Obstructive sleep apnea. Taler SJ, et al. Hypertension. 2002;39:982-988. CAUSES OF RESISTANCE IN YALE STUDY:  CAUSES OF RESISTANCE IN YALE STUDY Drug related (58%) Causes of Resistant Hypertension (RUSH Study):  Drug related (58%) Causes of Resistant Hypertension (RUSH Study) Secondary causes (5%) Nonadherence (16%) Psychological causes (9%) Office resistance (6%) Interfering substances (1%) Unknown (6%) Garg JP, et al. Am J Hypertens. 2005;18:619-626. RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? WHAT CAUSES IT? HOW DO YOU EVALUATE IT? Evaluation of Resistant Hypertension:  White-coat hypertension not confirmed but still likely? Work with patient to identify preferred and feasible solution. Evaluation of Resistant Hypertension Difficult-to-control blood pressure No Yes Yes Yes No No No No Confirmed with home or ambulatory blood pressure monitoring? Any common cause of secondary hypertension, such as renal vascular or renal parenchymal disease? Consider referral for further evaluation Adapted from O’Rorke JE, Richardson WS. BMJ. 2001;322:1229-1232. Controlled blood pressure? Slide46:  Is resistant hypertension present? Establish the diagnosis Is BP > 140/90 mm Hg (> 130/80 mm Hg in diabetic/renal patients)? Is BP measurement accurate? Is the patient taking 3 drugs, including a diuretic, at optimal doses? In older individuals, is pseudohypertension a factor? Is office resistance present? Are interfering substances a factor? Resolve economic, adverse effect, cultural, literacy, linguistic, and patient education issues Is obesity or metabolic syndrome present? Stop or reduce interfering substance, or maximize BP drug that competes least Are secondary causes a factor? DASH diet, weight loss, exercise Renal parenchymal disorders Renovascular disease Aldosteronism Thyroid disease Cushing’s syndrome Pheochromocytoma Aortic coarctation Sleep apnea Optimize and intensify pharmacotherapeutics Resistant Hypertension Treatment Algorithm Moser and Setaro NEJM, 2006 RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU EVALUATE IT? Biochemically RAS system perturbations SNS perturbations Hemodynamically Both Empirically (neither) PREVALENCE OF PRIMARY ALDOSTERONISM IN SUBJECTS WITH RESISTANT HYPERTENSION:  PREVALENCE OF PRIMARY ALDOSTERONISM IN SUBJECTS WITH RESISTANT HYPERTENSION Gallay BJ, et al. Am J Kidney Dis. 2001;37:699-705. Calhoun DA, et al. Hypertension. 2002;40:892-896. Eide IK, et al. J Hypertens. 2004;22:2217-2226. Strauch B, et al. J Hum Hypertens. 2003;17:349-352. Prevalence of PA, % PA = Primary aldosteronism. USE OF TBI (Thoracic bioimpedance) IN THE EVALUATION OF RESISTANT HYPERTENSION:  Volume vs Vasoconstriction Low Δ TBI vs High SVRI Low renin vs High renin Consider the mechanism of resistant hypertension SVRI = Systemic vascular resistance index. USE OF TBI (Thoracic bioimpedance) IN THE EVALUATION OF RESISTANT HYPERTENSION RESISTANT HYPERTENSION: STUDY DESIGN:  RESISTANT HYPERTENSION: STUDY DESIGN Hemodynamic care RN, HD RN, HD RN, HD Specialist care RN, MD RN, MD RN, MD BP HD BP HD Entry 1 month 2 months 3 months HD = Hemodynamic measurements. Taler SJ, et al. Hypertension. 2002;39:982-988. RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? WHAT CAUSES IT? HOW DO YOU EVALUATE IT? HOW DO YOU TREAT IT? Resistant Hypertension Selecting Effective Treatment:  Resistant Hypertension Selecting Effective Treatment R = Renin based; V = Volume based; HD = Hemodynamic; Rx = Treatment; A = Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; B = b-blocker; C = Calcium channel antagonist; D = Diuretic. Drug selection based on Renin Aldosterone Hemodynamics R and V drugs AB/CD rule Aldosterone antagonist HD based Rx Volume Rx RESISTANT HYPERTENSION MOSER AND SETARO NEJM, 2006:  RESISTANT HYPERTENSION MOSER AND SETARO NEJM, 2006 Adjust diuretic Rx Scr < 1.5 mg % use thiazides, 1.5 mg %, use Loop active agents Consult hypertension specialist TREATMENT ALGORITHM:  CO = Cardiac output; SVR = Systemic vascular resistance; DHP CCB = Dihydropyridine calcium channel blocker; ACEI = Angiotensin-converting enzyme inhibitor; ARB = Angiotensin receptor blocker; TBI = Thoracic bioimpedance index. TREATMENT ALGORITHM TREATMENT OF RESISTANT HYPERTENSION:  BP, mm Hg Entry Final *P < 0.01 vs entry. †P < 0.01 vs specialist care. Hemodynamic care - 56% at goal Specialist care - 33 % at goal Taler SJ, et al. Hypertension. 2002;39:982-988. TREATMENT OF RESISTANT HYPERTENSION HEMODYNAMICS OF RESISTANT HYPERTENSION:  HEMODYNAMICS OF RESISTANT HYPERTENSION *P < 0.01 vs entry. †P < 0.05 vs specialist care. Cardiac index, L/min/m2 CI SVRI Systemic vascular resistance index, d•sec•cm-5 m2 (000s) *† * Taler SJ, et al. Hypertension. 2002;39:982-988. MEDICATION USE IN RESISTANT HYPERTENSION MAYO SERIES:  MEDICATION USE IN RESISTANT HYPERTENSION MAYO SERIES Hemodynamic ` Specialist Care Care Entry Final Entry Final No. of HTN meds 3.6 4.3** 3.6 4.1** Total HTN DDD 5.3 6.1* 5.2 5.7* Diuretic DDD 1.1 2.1**†† 1.2 1.4* No. of changes 5.8† 4.6 No. of increases 3.8 3.0 No. of reductions 2.1 1.6 No. of nurse visits 6.2 6.2 Taler SJ, et al. Hypertension. 2002;39:982-988. *P < 0.05; **P < 0.01 vs entry; †P < 0.05; ††P < 0.01 vs specialist care. DDD = Defined daily dose. MEDICATION USE IN RESISTANT HYPERTENSION MAYO SERIES:  Hemodynamic Specialist Care (%) Care (%) Thiazide diuretic 66 76 Loop diuretic 58 48 Beta blocker 80** 52 Adrenergic inhibitor 14 20 Alpha blocker 24 26 Alpha beta blocker 2** 19 Calcium antagonist 78 80 ACE inhibitor 46 48 ARB 38 35 Vasodilator 20* 6 *P < 0.05, **P < 0.01 vs specialist care. MEDICATION USE IN RESISTANT HYPERTENSION MAYO SERIES ACE = Angiotensin converting enzyme; ARB = Angiotensin receptor blocker. Taler SJ, et al. Hypertension. 2002;39:982-988. Final Diagnosis:  Final Diagnosis Non-adherence Drug-related causes Suboptimal medication regimen Drug interaction Medication intolerance consistent with product labeling (objective intolerance) Interfering substance(s) Alcohol or illicit drugs Excess sodium Secondary hypertension Renal artery stenosis Primary hyperaldosteronism Pheochromocytoma Psychological causes Anxiety Medication intolerance inconsistent with product labeling (subjective intolerance) Office resistance RUSH vs Yale Experience:  RUSH vs Yale Experience *Garg JP, et al. Am J Hypertens. 2005;18:619-626. †Yakovlevitch M, Black HR. Arch Intern Med. 1991;151:1786-1792. GOAL BP: DEFINITION (YALE STUDY):  GOAL BP: DEFINITION (YALE STUDY) BP was considered to be at goal if a patient had a BP < 140/90 mm Hg or <150/90 mm Hg those over 65 on consecutive visits, or on the most recent clinic visit. Yakovlevitch M, Black HR. Arch Intern Med. 1991 YALE STUDY CHANGES IN MEDICATION REGIMEN:  YALE STUDY CHANGES IN MEDICATION REGIMEN GOAL BP: DEFINITION - RUSH STUDY:  GOAL BP: DEFINITION - RUSH STUDY BP was considered to be at goal if a patient had a BP < 140/90 mm Hg (for diabetics < 130/85 mm Hg after November 1997) on 2 consecutive visits, or on the most recent clinic visit Garg JP, et al. Am J Hypertens. 2005;18:619-626. Achievement of Goal BP by Selected Causes of Resistance:  Achievement of Goal BP by Selected Causes of Resistance % Patients Within Each Group Garg JP et al. Am J Hypertens. 2005;18:619-626. Drug- related Secondary HTN Interfering substances Psychological Nonadherent Office resistance 58% 5% 1% 9% 16% 6% RESISTANT HYPERTENSION: DRUG-RELATED CAUSES (RUSH):  RESISTANT HYPERTENSION: DRUG-RELATED CAUSES (RUSH) 58% Suboptimal med regimen 94% 5% 1% Drug interaction Objective intolerance Garg JP, et al. Am J Hypertens. 2005;18:619-626. BP Medications Prescribed (RUSH Series):  BP Medications Prescribed (RUSH Series) ARB = Angiotensin receptor blocker; ACE-I = Angiotensin converting enzyme inhibitor; CCB = Calcium-channel blocker. Garg JP, et al. Am J Hypertens. 2005;18:619-626. Diuretic Use (Suboptimal Regimen Subgroup RUSH Study):  Diuretic Use (Suboptimal Regimen Subgroup RUSH Study) Unchanged Changed Decreased Added Removed Increased Change Garg JP, et al. Am J Hypertens. 2005;18:619-626. Diuretic Use by Type (RUSH Study):  Diuretic Use by Type (RUSH Study) Sympatholytic Agent Use by Type (RUSH Study):  Sympatholytic Agent Use by Type (RUSH Study) Calcium antagonists use by subclass (RUSH Study):  Calcium antagonists use by subclass (RUSH Study) Overall Results (YALE and RUSH):  Overall Results (YALE and RUSH) RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION More powerful natriuretic agents b Blockers a b Blockers Better tolerated central sympatholytics Better tolerate vasodilators New devices that alter baroreceptors Drugs with different MOA ETA blockers – darusentan Hypothesis: Resistant Hypertension Will Become More Prevalent:  Hypothesis: Resistant Hypertension Will Become More Prevalent Aging population Increasing obesity Decreasing physical activity More attention to systolic hypertension Greater role for exogenous substances Newer stricter treatment goals Greater role for complex medical therapy RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION HOW DO YOU DEFINE IT? HOW MANY PEOPLE HAVE IT? WHAT CAUSES IT? HOW DO YOU EVALUATE IT? HOW DO YOU TREAT IT? CAN WE IMPROVE OUTCOMES? RESISTANT HYPERTENSION:  RESISTANT HYPERTENSION CAN WE IMPROVE OUTCOMES? Do not be satisfied when patient is not at BP goal Insure that BP is taken properly Always consider non adherence “Actively” reject that a secondary cause is present and evaluate guided by clinical clues Rationalize therapy and don’t be afraid to use multiple medications Refer to Hypertension Specialist if necessary American Society of Hypertension, Inc. (ASH):  American Society of Hypertension, Inc. (ASH) 2007 ANNNUAL SCIENTIFIC MEETING Hyatt Regency Chicago, Chicago, Illinois Saturday, May 19 - Tuesday, May 22, 2007 Slide77:  Hyatt Regency Chicago, Chicago, Illinois & other testing sites Saturday, May 19, 2007 HYPERTENSION SPECIALIST QUALIFYING EXAMINATION AGE DISTRIBUTION OF HYPERTENSIVES IN US POPULATION PROJECTED 2020 CENSUS:  AGE DISTRIBUTION OF HYPERTENSIVES IN US POPULATION PROJECTED 2020 CENSUS 2.7 6.5 11.2 25.3 29.2 13.6 11.5 Franklin SS. J Hypertension. 1999;17(suppl 5):S29-S36. Age Groups (y) 20% 80% 70.4 million hypertensives 29.1% of US population Hypertensives By Age Group (%) Slide80:  % of those at goal BP BP Control in CONVINCE Baseline (n=16,412) 23 20 52 EOT (n=15,446) 85 84 94 12 mo (n=14,576) 71 70 90 24 mo (n=12,263) 72 70 91 36 mo (n=4938) 68 67 92 Duration of study treatment Updated from Black HR, et al. Hypertension, 2001; 37:12-18 CLINICAL TRIALS IN HYPERTENSION CONVINCE Treatment Regimens:  CLINICAL TRIALS IN HYPERTENSION CONVINCE Treatment Regimens Fraction of Subjects EOT 6 months 12 months 18 months 24 months 30 months Step I Step II Step III Open-Label Average Number of Antihypertensive Agents Needed per Patient to Achieve Target BP Goals:  Number of BP Meds INVEST (136 mm Hg) CONVINCE (137 mm Hg) ALLHAT (138 mm Hg) IDNT (138 mm Hg) RENAAL (141 mm Hg) UKPDS (144 mm Hg) ABCD (132 mm Hg) MDRD (132 mm Hg) HOT (138 mm Hg) AASK (128 mm Hg) Trial SBP Achieved Adapted from Bakris GL et al. Am J Kidney Dis. 2000;36:646-661. Average Number of Antihypertensive Agents Needed per Patient to Achieve Target BP Goals 1 2 3 4

Add a comment

Related presentations

Related pages

BLACK.de – Massiv günstig | Ab dem 01. September 2016 ...

Erster legaler Schwarzmarkt in Dortmund. BLACK.de kommt ab dem 01. September 2016!
Read more

Black (Musiker) – Wikipedia

Black alias Colin Vearncombe (* 26. Mai 1962 in Liverpool, England; † 26. Januar 2016 in Cork, Irland) war ein britischer Musiker. Bekannt wurde er in ...
Read more

Black – Wikipedia

Black Paintings, Serie von monochromen Bildern in Schwarz; Black Park, Park im Oklahoma County, Oklahoma; Siehe auch: Black Forest; Black Island; Black Lake;
Read more

Black - Wikipedia

Black is the darkest color, the result of the absence or complete absorption of light. Like white and grey, it is an achromatic color, literally a color ...
Read more

Black | Define Black at Dictionary.com

Black definition, lacking hue and brightness; absorbing light without reflecting any of the rays composing it. See more.
Read more

Black | Livestream per Webradio hören

Black Internetradio kostenlos online hören auf radio.de. Alle Radiostreams und Radiosender im überblick. Jetzt online entdecken.
Read more

Willkommen bei black-i

Lederjacken für Damen und Herren für jeden Stil: Biker-Stil, Pilot-Style, Mäntel und Coats. Trendige Marken wie Tom Tailor, Mustang, JCC Ledermoden ...
Read more

Black - definition of black by The Free Dictionary

black (blăk) adj. black·er, black·est. 1. Being of the color black, producing or reflecting comparatively little light and having no predominant hue.
Read more

Black-Friday.de: Alle Shops, alle Deals! | Black Friday 2016

Jetzt den Black-Friday.de Newsletter abonnieren, Facebook-Fan werden oder unsere App laden und beim Black Friday 2016 keinen Deal verpassen!
Read more

Black people - Wikipedia

Black people (seen both capitalized and with lowercase "b") is a term used in certain countries, often in socially based systems of racial classification ...
Read more