Practical Approaches to Managing Hypertension: Reducing Global Cardiovascular Risk Joshua Furman, MD...

Practical Approaches to Managing Hypertension: Reducing Global

Cardiovascular RiskJoshua Furman, MD

Staff CardiologistMount Sinai Medical Center

Miami Beach, Florida

Key Question

Which class of agents do you presently consider first-line treatment for patients with hypertension? 1. Diuretics2. β-Blockers (BBs)3. Calcium channel blockers (CCBs)4. Angiotensin-converting enzyme inhibitors (ACEIs)5. Angiotensin receptor blockers (ARBs)6. All of the above

Use your keypad to vote now!

?

Faculty Disclosure

Dr Furman has no relevant financial relationships with any commercial interests to disclose.

Learning Objectives

State the prevalence of hypertension and its role in the cardiovascular disease continuum

Formulate hypertension management according to risk stratification

Describe the importance of targeting improvement in vascular function in patients with hypertension

Adapted from Dzau V, Braunwald E. Am Heart J. 1991;121:1244-1263.

Progression of Cardiovascular Disease: The Cardiovascular Continuum

Myocardial infarction

Myocardialischemia

Endothelialdysfunction and

atherothrombosis

Ventricular dysfunction

Ventricular dilation and hypertrophy

Hyperlipidemia,hypertension, diabetes, smoking, obesity, etc

Congestive heart failure and death

Peripheral arterial disease

Stroke

Sudden death

Development and Progression of Vascular Disease

Dzau V. Hypertension. 2001;37:1047-1052.

RISK FACTORS

Smoking

CLINICAL SEQUELAE

Oxidative Stress

Endothelial Dysfunction andSmooth Muscle Activation

NO • Local Mediators • Tissue ACE, AII

EndothelinCatecholamines

PAI-1, PlateletAggregation,Tissue Factor

VCAM/ICAMCytokines

ProteolysisInflammation

Growth FactorsCytokines

Matrix

Vasoconstriction ThrombosisInflammation Plaque

Rupture Vascular Lesionand Remodeling

BP DiabetesLDL

TimeACS = acute coronary syndrome; HF = heart failure; LVH = left ventricular hypertrophy. Adapted from Vasan RS, Levy D. Arch Intern Med. 1996;156:1789-1796.

Death/Sudden

Death

ObesityDiabetes

SmokingDyslipidemia

HF

Overt heartfailure

Systolicdysfunction

Diastolic dysfunction

Subclinicalleft ventricular

dysfunction

Hypertension

Risk Factors Atherothrombosis,left ventricular

remodeling

LVH

ACS

Progression From Hypertension to Heart Failure/Sudden Death

JNC 7 Cardiovascular Risk Factors

Hypertension Cigarette smoking Obesity (BMI ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus

Microalbuminuria or estimated GFR <60 mL/min

Age (men >55 yr; women >65 yr)

Family history of premature CVD

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

In Nearly 2 Out of 3 Adults With Hypertension, Hypertension Is Still Not Controlled

*Adults aged 18 to 74 years with hypertension. †Controlled = BP 140/90 mm Hg.‡Data were computed (M. Wolz, unpublished data, 2003) from the NHLBI.Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

30%41%

66%!7059

34

0

10

20

30

40

50

60

70

80

90

100

NHANES (1999-2000)‡

US

Po

pu

lati

on

(%

)*

TreatedAware Controlled†

4. Chamontin et al. Am J Hypertens. 1998;11(6 Pt 1):759-762. 5. Marques-Vidal et al. J Hum Hypertens. 1997;11:213-220.

Patients With BP Controlled Worldwide

Adapted from G. Mancia

1. JNC VI. Arch Intern Med. 1997;157:2413-2446. 2. Joffres et al. Am J Hypertens. 1997;10:1097-1102.3. Colhoun et al. J Hypertens. 1998;16:747-752.

USA1

27%

England3

6%

<140/90 mm HgCanada2

22%Australia5

France4

24%India5Scotland5

17.5%

Spain5

20%Finland5

20.5%

Germany5

22.5%

>65 yr only

<160/95 mm Hg

19%

9%

Point Total 10-Year Risk (%)<0 <1

0 11 12 13 14 15 26 27 38 49 5

10 611 812 1013 1214 1615 2016 25

17 30

10-Year NCEP/Framingham Risk Scores for Fatal or Nonfatal CHD in Men*

*A separate Framingham risk calculator exists for women.NCEP ATP III. 2002. NIH Publication No. 02-5215. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/.

Age (y) Points

20-34 -9

35-39 -4

40-44 0

45-49 3

50-54 6

55-59 8

60-64 10

65-69 11

70-74 12

75-79 13

TC (mg/dL)Age

20-39 yAge

40-49 yAge

50-59 yAge

60-69 yAge

70-79 y<160 0 0 0 0 0

160-199 4 3 2 1 0

200-239 7 5 3 1 0

240-279 9 6 4 2 1

280 11 8 5 3 1

HDL (mg/dL) Points60 -1

50-59 0

40-49 1

<40 2

SBP (mm Hg) Untreated Treated<120 0 0

120-129 0 1130-139 1 2140-159 1 2160 2 3

Smoking status

Age (y)20-39 40-49 50-59 60-69 70-79

Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1

Key Question

What percentage of patients with hypertension have 2 or more additional CV risk factors?

1. 20%

2. 30%

3. 40%

4. 50%

5. >50%


?

26% 25%

8%

RF = risk factor. Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S.

Men Women

2 RFs

3 RFs

1 RF

No Additional

RFs 4 or More RFs

27% 24%

12%

2 RFs

3 RFs

1 RF

No Additional

RFs 4 or More RFs

>50% of Hypertension Occurs in Presenceof 2 or More Risk Factors

CV Risk Factor Clustering With Hypertension: Framingham Offspring, Aged 18 to 74 Years

19% 22% 17% 20%

Risk of CHD in Mild Hypertension by Intensity of Associated Risk Factors

SBP 150-160 mm Hg + + + + + +TC 240-262 mg/dL − + + + + + HDL-C 33-35 mg/dL − − + + + +Diabetes − − − + + +Cigarette smoking − − − − + +ECG-LVH − − − − − +

42

36

30

24

18

12

6

0

46

1014

21

4010

-Yea

r P

rob

abil

ity

of

Eve

nt

(%)

Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S.

Risk Factors

Arch Intern Med. 1997;157:2413-2446; Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

JNC Reclassification of BP Based on Risk

CategorySBP

(mm Hg)DBP

(mm Hg) CategorySBP

(mm Hg)DBP

(mm Hg)

Optimal <120 and <80 Normal <120 and <80

Normal 120-129 and 80-84Prehypertension 120-139 or 80-89

Borderline 130-139 or 85-89

Hypertension

Stage 1 140-159 or 90-99 Stage 1 140-159 or 90-99

Stage 2 160-179 or 100-109Stage 2 ≥160 or ≥100

Stage 3 ≥180 or ≥110

JNC VIJNC VI JNC 7JNC 7

Adapted from: Stevens VJ et al. Ann Intern Med. 2001;134:1-11; Messerli FH et al. In: Griffin BP et al, eds. 2004. Manual of Cardiovascular Medicine. 2nd ed; Whelton SP et al. Ann Intern Med. 2002;136:493-503; Cutler JA et al. Am J Clin Nutr. 1997;65(suppl):643S-651S; Xin X et al. Hypertension. 2001;38:1112-1117; Whelton PK et al. JAMA. 1997;277:1624-1632.

BP

Dec

reas

e(m

m H

g)

SBP DBP

ExerciseLow-Salt

DietAlcohol

Reduction

Nonpharmacologic Interventionsand BP Reduction

5

4

3

2

1

0

6

7

Weight Loss(19.4 lb)

RESULTS • At 2 years, hypertension had developed in 154 participants in the

placebo group and 53 in the candesartan group (RRR 66%, P <.001) • At 4 years, hypertension had developed in 240 participants in the

placebo group and 208 in the candesartan group (RRR 15.6%, P <.007)

RESULTS • At 2 years, hypertension had developed in 154 participants in the

placebo group and 53 in the candesartan group (RRR 66%, P <.001) • At 4 years, hypertension had developed in 240 participants in the

placebo group and 208 in the candesartan group (RRR 15.6%, P <.007)

TROPHY = Trial of Preventing Hypertension. Julius S, et al. N Engl J Med. 2006;354:1685-1697.

Study Design: TROPHY

n = 4092 years candesartan +

2 years placebo

When a participant reached the study end point of stage 1 hypertension, treatment with antihypertensive agents was initiated

STUDY N = 809Participants had prehypertension:

SBP 130-139 mm Hg and DBP 89 mm Hg ORSBP 139 mm Hg and DBP 85-89 mm Hg

n = 4002 years placebo + 2 years placebo

TROPHY: Kaplan-Meier Curves of New Onset Clinical Hypertension

Years in Study

0 1 2 3 40

10

20

30

40

50

60

70

80

90

100

Cu

mu

lati

ve I

nci

den

ce (

%)

Candesartan

Placebo

TROPHY = Trial of Preventing Hypertension. Julius S et al. N Engl J Med. 2006;354:1685-1697.

Key Points for Optimal Hypertension Management

JNC 7 recommends:If SBP >20 mm Hg or DBP >10 mm Hg over goal,

consider initiating with 2-drug combination

<130/80 mm Hg in patients with diabetes or

renal disease

<140/90 mm HgJNC 7

BPGoals


Antihypertensive Medications: Mechanism of Action

Drug Class Mechanism of Action

Diuretics Rid body of excess fluids and sodium May enhance effect of other BP medications

ACEIs Lower levels of angiotensin II Dilate blood vessels

ARBs Block angiotensin II receptors Dilate blood vessels

BBs Decrease heart rate and cardiac output

CCBs Interrupt movement of calcium into heart and vessel cells

Aldosterone Receptor Blockers

Decrease salt and water retention

Renin Inhibitors Block action of renin, decreasing formation of angiotensin I

American Heart Association. December 11, 2006. Available at:http://www.americanheart.org/presenter.jhtml?identifier=3038158.

LIFESTYLE MODIFICATIONS

Not at Goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease)

Without Compelling Indications With Compelling Indications

Stage 1 Hypertension Thiazide-type diuretics for most; may consider ACEI, ARB, BB, CCB,

or combo

Stage 2 Hypertension 2-drug combos for most

(usually thiazide-type diuretics and ACEI,

or ARB, or BB, or CCB)

Compelling IndicationsOther drugs

(diuretic, ACEI, ARB, BB, CCB) as needed

If not at goal BP, optimize dosages or add drugs until goal BP achieved; consider consultation with hypertension specialist

INITIAL DRUG CHOICES

JNC 7: Algorithm for Hypertension


JNC 7 Highlights: Key Risk-Related Messages

Certain high-risk conditions are compelling indications for the initial use of specific antihypertensive drug classes


JNC 7: Compelling Indications for Antihypertensive Drug Classes

Recommended Drugs

AldoCompelling Indication Diuretic ACEI BB ARB CCB ANT

Heart failure • • • • •Post MI • • •High coronary disease risk • • • • Diabetes • • • • • Chronic kidney disease • •

Recurrent strokeprevention • •

Aldo ANT = aldosterone antagonist. Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

RESULTS • BP with both treatments• Primary end point (composite of cardiac mortality and morbidity)

occurred in valsartan 10.6% vs amlodipine 10.4%, HR 1.04• Amlodipine effects were more pronounced in the early period

• BP 4.0/2.1 mm Hg in the amlodipine group after 1 month

RESULTS • BP with both treatments• Primary end point (composite of cardiac mortality and morbidity)

occurred in valsartan 10.6% vs amlodipine 10.4%, HR 1.04• Amlodipine effects were more pronounced in the early period

• BP 4.0/2.1 mm Hg in the amlodipine group after 1 month

VALUE = Valsartan Antihypertensive Long-term Use Evaluation.Julius S, et al. Lancet. 2004;363:2022-2031.

Study Design: VALUE

Step 1: valsartan 80 mg/dayStep 2: valsartan 160 mg/day

n = 7649

Both regimens included HCTZ in steps 3 and 4Further drugs could be given to achieve BP control

Randomized, double-blind, parallel group comparison

STUDY N = 15,245Aged 50 years;

With treated or untreated hypertension and high risk of cardiac events

Step 1: amlodipine 5 mg/dayStep 2: amlodipine 10 mg/day

n = 7596

VALUE: Hazard Ratios for Prespecified Analyses in Patients With Hypertension at High CV Risk

Favors Valsartan Favors Amlodipine

Hazard RatioValsartan/Amlodipine

Primary cardiac composite end point

Cardiac mortality

Cardiac morbidity

All myocardial infarction

All congestive heart failure

All stroke

All-cause death

New-onset diabetes

0.5 1 2.0

Patients had hypertension and were at high CV risk. VALUE = Valsartan Antihypertensive Long-term Use Evaluation.

Julius S et al, for the VALUE trial group. Lancet. 2004;363:2022-2031.

Key Question

On average, how many drugs will a patient need to control hypertension?

1. 1

2. 2

3. 3

4. 4


?

Number of Antihypertensive Agents Needed to Achieve Systolic BP Control

*~50% patients required ≥3 medications. †Average per patient. Bakris et al. Am J Kidney Dis. 2000;36:646-661; ALLHAT. JAMA. 2002;288:2981-2997; Berl et al. Ann Intern Med. 2003;138:542-549; Bakris et al. Arch Intern Med. 2003;163:1555-1565; Wright et al. JAMA. 2002;288:2421-2431; Pepine et al. JAMA. 2003;290:2805-2816.

SBP achieved(mm Hg)

Number of BP Medications†

Trial

4321

ALLHAT 138IDNT 138RENAAL 141UKPDS 144ABCD 132MDRD 132HOT 138AASK 128INVEST 131 *

Hypertension and Diabetes: Global CV Risk Reduction With Evidence-Based Intervention

Adapted from Curb JD et al. JAMA. 1996;276:1886-1892; Hansson L et al. Lancet. 1998;351:1755-1762; Tuomilehto J et al. N Engl J Med. 1999:340:677-684.

Diabetes Approximately Doubles CVD Risk in Patients With Hypertension

Study

Patients With Diabetes

Patients Without Diabetes

Ratio(events per 1000 pt-yr)

Systolic Hypertension in the Elderly Program (SHEP)

CV events 63.0 36.8 1.71

Stroke 28.8 15.0 1.92

CHD events 32.2 15.2 2.12

Systolic Hypertension in Europe (Syst-Eur)

CV events 55.0 28.9 1.90

Stroke 26.6 12.3 2.16

CHD events 23.1 12.4 1.87

Hypertension Optimal Treatment (HOT) (DBP <90 mm Hg)

CV events 24.0 9.8 2.45

Target DBP (mm Hg)

Str

oke

, M

I, o

r C

V D

eath

(per

100

0 p

atie

nt-

year

s)

80 85 900

5

10

15

20

25 P = .005

Patients with hypertension and diabetes were given baseline felodipine, plus other agents in a 5-step regimen. Study N = 18,790; diabetes n = 1501.HOT = Hypertension Optimal Treatment; MI = myocardial infarction.Adapted from Hansson L et al, for the HOT Study Group. Lancet. 1998;351:1755-1762.

HOT Study: Fewer Major CV Events in Patients

With Diabetes Randomized to Lower BP Goal

UKPDS: Tight Glucose Versus Tight BP Control and CV Outcomes

Patients had hypertension and Type 2 diabetes. N = 1148.

Tight glucose control (goal <6.0 mmol/L or 108 mg/dL)Tight BP control (average 144/82 mm Hg)

*P <.05 compared to tight glucose control

StrokeAny Diabetic

End PointDM

DeathsMicrovascularComplications

-50

-40

-30

-20

-10

0

Rel

ativ

e R

isk

Red

uct

ion

(%

)

32%37%

10%

32%

12%

24%

5%

44%*

*

*

*

UKPDS = United Kingdom Prospective Diabetes Study.Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.

Antihypertensive Medications: Mechanism of Action

Drug Class Mechanism of Action

Diuretics Rid body of excess fluids and sodium May enhance effect of other BP medications

ACEIs Lower levels of angiotensin II Dilate blood vessels

ARBs Block angiotensin II receptors Dilate blood vessels

BBs Decrease heart rate and cardiac output

CCBs Interrupt movement of calcium into heart and vessel cells

Aldosterone Receptor Blockers

Decrease salt and water retention

Renin Inhibitors Block action of renin, decreasing formation of angiotensin 1

American Heart Association. December 11, 2006. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3038158.

Adapted with permission from Brown NJ et al. Circulation. 1998;97:1411-1420; Endemann DH. J Am Soc Nephrol. 2004;15:1983-1992.

The Renin-Angiotensin-Aldosterone System (RAAS)

Blood Pressure Vascular Proliferation Oxidative Stress Vascular Inflammation Thrombogenesis Aldosterone

ACE

Angiotensinogen

Renin

Angiotensin I

Angiotensin II

AT1

Kininogen

Kallikrein

Bradykinin

Inactive Peptides




ACE

Angiotensinogen

Renin

Angiotensin I

Angiotensin II

AT1

ARBs

Kininogen

Kallikrein

Bradykinin

Inactive Peptides

Renin

Inhibitors




ACE

Angiotensinogen

Renin

Angiotensin I

Angiotensin II

AT1

ARBs ARBs

Kininogen

Kallikrein

Bradykinin

Inactive PeptidesAT2AT2




ACE

ACEIs

Angiotensinogen

Renin

Angiotensin I

Angiotensin II

AT1

Kininogen

Kallikrein

BradykininKininase II

Inactive Peptides

NitricOxide

EUROPA Investigators. Lancet. 2003;362:782-788; HOPE Study Investigators. N Engl J Med. 2000;342:145-153; PEACE Trial Investigators. N Engl J Med. 2004;351:2058-2068; Pitt B, et al. Am J Cardiol. 2001;87:1058-1063.

PEACE: CV Death/MI/CABG/PCI

HOPE: CV Death/MI/Stroke

15

5

10

0

20

0

Placebo

Ramipril 10 mg

Time (years)

Per

cen

t

2 41

22% Risk ReductionHR = 0.78 (0.70–0.86)P <.001

3

Time (years)

12

4

10

01 3 4

14

0

Placebo

Perindopril 8 mg

86

2

52

EUROPA: CV Death/MI/Cardiac Arrest

20% Risk ReductionHR = 0.80 (0.71–0.91)P = .0003

40

20

30

0

50

0

Placebo

Quinapril 20 mg

Time (years)

1

4% Risk IncreaseHR = 1.04 (0.89–1.22)P = .6

10

2 3

QUIET: All CV Events

Time (years)

Trandolapril4 mg

Placebo30

20

1015

5

1 2 3 4 5

25

06

4% Risk ReductionHR = 0.96 (0.88–1.06)P = .43

Per

cen

tP

erce

nt

Per

cen

t

ACEI Trials in CAD Without HF: Primary Outcomes

MICRO-HOPE, PERSUADE: CV Events in Patients With Diabetes

MICRO-HOPE = Microalbuminuria, Cardiovascular, and Renal Outcomes (Heart Outcomes Prevention Evaluation); PERSUADE = Perindopril Substudy in Coronary Artery Disease and Diabetes.

HOPE Study Investigators. Lancet. 2000;355:253-259; Daly CA et al. Eur Heart J. 2005;26:1369-1378.

0 1 2 3 4 5

0

5

10

15

20

25

Follow-Up (years)

Pri

mar

y O

utc

om

e (%

)

MICRO-HOPE(n = 3577)

CV death/MI/stroke

Ramipril10 mg

Placebo

25% RRRP = .0004

0 1 2 3 4

0

5

10

15

20

25

Follow-Up (years)

PERSUADE(n = 1502)

CV death/MI/cardiac arrest

Perindopril8 mg

Placebo

19% RRRP = .13

5

0

2

4

6

8

10

Placebo Ramipril

Impact of ACE Inhibitors on the Risk of Developing New-Onset Diabetes Mellitus

RR = 0.66 (0.51-0.85) P <.001

HOPE Trial: Ramipril 10 mg QD vs placebo; 9297 patients with vascular disease or diabetes plus 1 other CV risk factor, 4355 with hypertension; BP: baseline (139/79 mm Hg); 2 years: ramipril (135/76 mm Hg), placebo (138/78 mm Hg).

Yusuf S et al. N Engl J Med. 2000;342:145-153.

5.4

3.6

Ne

w D

iag

no

sis

of

Dia

be

tes

(%

)

HOPE Study:Prevention of Diabetes With Ramipril

The occurrence of self-reported diabetes was reduced by 34% (95% CI, 15%-49%; P <.001) in the HOPE study. This effect was observed early and maintained consistently throughout the trial. HOPE Study Investigators. Lancet. 2000;355:253-259.

0.10

0.08

0.06

0.04

0.02

0

200 400 600 800 1000 1200 1400 1600

Days of Follow-Up (no diabetes at baseline)

Kap

lan

-Mei

er R

ates

Placebo Ramipril

MICRO-HOPE: Albuminuria in Patients With Diabetes

0.0

0.5

1.0

1.5

2.0

2.5

3.0

HOPE Study Investigators. Lancet. 2000;355:253-259.

4-51 2 30

P = .001

P = .02

Placebo

Ramipril

Mea

n A

lbu

min

/Cre

atin

ine

Rat

io (

uri

ne)

Time (y)

LIFE: Secondary End Points

No. ofEvents

Total Mortality

Angina Pectoris

CHF

Revascularization

New-Onset Diabetes

End Points

814

301

314

545

562

0.5 1 2

Favors Losartan Favors Atenolol

Hazard Ratio (95% CI)

Dahlof B et al. Lancet. 2002;359:995-1003.

LIFE: New-Onset Diabetes

Intention-to-Treat

Losartan

Atenolol

Pro

po

rtio

n o

f P

atie

nts

Wit

h

Fir

st E

ven

t (%

)

0

1

2

3

4

5

6

7

8

9

10

Adjusted Risk Reduction 25%, P = .001Unadjusted Risk Reduction 25%, P = .001

0 6 12 18 24 30 36 42 48 54 60 66

Study Month

Dahlof B et al. Lancet. 2002;359:995-1003.

CV Pharmacotherapy: Impact on Newly Diagnosed Diabetes

CA = calcium antagonist.Pepine CJ, Cooper-DeHoff RM. J Am Coll Cardiol. 2004;44:509-512. Sever PS et al. Lancet. 2003;361:1149-1158.

Randomized active treatment vs control (eg, placebo, diuretic, β-blocker diuretic)

100

30

20

10

0STOP-2

INSIG

HT

ALLHAT

Red

uct

ion

of

New

Dia

bet

es (

%) IN

VEST

ALPINE

SCOPE

CHARM

ANBP2

LIFE

HOPE

ALLHAT

CAPPP

STOP-2

VALUE

PEACE

ASCOT

ACEI or ARBCA + ACEI or ARBCA

Multiple Mechanisms of ACEIin Cardiovascular Disease

Blood pressure lowering

Cardioprotective effects Preload and afterload LV mass Sympathetic stimulation Reperfusion injury Improved myocardial

remodelingMetabolic syndrome Lipid neutral Improved glucose metabolism Increases adiponectin Decreased insulin resistance

Modified from: Lonn E et al. Eur Heart J Suppl. 2003;5:A43-A48.

Vasculoprotective effects Direct antiatherogenic Enhance endogenous

fibrinolysis Inhibit platelet aggregation Antimigratory for mononuclear

cells Matrix formation Improve endothelial function Antioxidant Anti-inflammatory Protection from plaque rupture Improved arterial compliance

and tone

Summary: The Case for Global CV Risk Management

CV disease remains the leading cause of death in both men and women in the United States

Data from the Framingham Heart Study have demonstrated clustering of risk factors—and that risk of death from CHD and stroke increases further with each added risk factor

Hypertension, a pivotal risk factor for CV disease, should prompt the search for the presence of additional risk factors

Recent clinical trials have provided evidence supporting a standard of care for the management of global CV risk

Case Study

Case Study: 55-Year-Old Man From India With Hypertension and Type 2 Diabetes

The patient is in for a checkup History

Hypertension Type 2 diabetes Nonsmoker No symptoms

Physical examination BP: 148/96 mm Hg Height: 64" Weight: 178 lb BMI: 30 kg/m2 Waist circumference: 38" Cardiac dysfunction status:

normal ventricular function (LVEF 68%)

Laboratory values Glucose: 148 mg/dL

(fasting) A1C: 8.8% Creatinine: 1.5 mg/dL Urinalysis: 1+ proteinuria Lipid profile (mg/dL):

TC: 268; LDL-C: 168; HDL-C: 42; TG: 296

Medications HCTZ 25 mg/d Glyburide 5 mg/d

10-Year NCEP/Framingham Risk Scores for Fatal or Nonfatal CHD in Men*

*A separate Framingham risk calculator exists for women.NCEP ATP III. 2002. NIH Publication No. 02-5215. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/.

Age (y) Points

20-34 -9

35-39 -4

40-44 0

45-49 3

50-54 6

55-59 8

60-64 10

65-69 11

70-74 12

75-79 13

TC (mg/dL)Age

20-39 yAge

40-49 yAge

50-59 yAge

60-69 yAge

70-79 y<160 0 0 0 0 0

160-199 4 3 2 1 0

200-239 7 5 3 1 0

240-279 9 6 4 2 1

280 11 8 5 3 1

Point Total 10-Year Risk (%)<0 <1

0 11 12 13 14 15 26 27 38 49 5

10 611 812 1013 1214 1615 2016 25

17 30

HDL (mg/dL) Points60 -1

50-59 0

40-49 1

<40 2

SBP (mm Hg) Untreated Treated<120 0 0

120-129 0 1130-139 1 2140-159 1 2160 2 3

Smoking status

Age (y)20-39 40-49 50-59 60-69 70-79

Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1

Decision Point

What is the JNC 7 goal for this patient who has hypertension, diabetes, and renal disease?1. <120/80 mm Hg

2. <130/80 mm Hg

3. <140/80 mm Hg

4. <140/90 mm Hg


?

Decision Point

The patient’s BP is 148/96 mm Hg whiletaking HCTZ 25 mg/d and glyburide 5 mg/d. To further lower BP, you would add a(n):

1. BB

2. CCB

3. ARB

4. ACE


?

PCE Takeaways

PCE Takeaways

1. Patients with hypertension often present with multiple cardiac risk factors

2. Be vigilant in your investigation of all clinical indicators

3. Creatively address patient adherence; not everyone responds to the same interventions

4. Clinical inertia is the enemy—don't settle for "close enough"

Key Question

How important is using an antihypertensive agent with proven risk reduction (reducingmorbidity and mortality) when choosing medications for your patients with hypertension?

1. Not important

2. Slightly important

3. Somewhat important

4. Extremely important


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Practical Approaches to Managing Hypertension: Reducing Global Cardiovascular Risk Joshua Furman, MD...

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