The Hypertension Treatment Center

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1 Patricia F. Kao MD MS Asst Professor, EVMS Nephrology & HTN April 26, 2014 The Hypertension Treatment Center

2 I have no conflicts of interest to disclose

3 Objectives Describe the role of Hypertension Treatment Centers Review the initial approach and evaluation of the complex hypertensive patient Discuss the definition and diagnosis of different patterns of blood pressure Discuss future options in the management patients with refractory hypertension

4 Hypertension Treatment Centers Multidisciplinary team of highly trained nurses, social workers, dieticians, hypertension specialists (internal medicine, nephrology, cardiology) Patients often referred for second opinions regarding refractory HTN cases Can provide ongoing management of blood pressure in difficult cases

5 Hypertension Treatment Centers Goals are to: Establish the correct diagnosis Optimize therapy Provide extensive patient education

6 Hypertension Treatment Centers Initial evaluation will include: Detailed history and physical exam, including dietary salt intake, lifestyle patterns, and social and psychosocial stressors Ophthalmologic assessment and funduscopic exam performed to identify severity Presenter of disease name and target organ damage by grading retinal changes

7 Standard BP measurement Taken after 5 min in a quiet room Patient seated comfortably with back supported Upper arm bared without constrictive clothing Legs should not be crossed Arm should be supported at the level of the heart Bladder of the BP cuff should encircle at least 80% of the arm circumference BP device should be deflated at a rate of 2-3 mm/sec No talking during the measurement

8 Establishing the Correct Diagnosis 24 hr urine studies for: Na (helps evaluate dietary salt intake and also makes sure salt intake is adequate enough to evaluate aldo levels properly when needed) Aldosterone when indicated (hx of hypokalemia or inconclusive plasma renin and Presenter aldo) name Metanephrines when indicated (hx of flushing, diaphoresis, episodic or fluctuating BP)

9 Other Causes of Secondary Renal Artery Stenosis Hypertension Several large studies (CORAL and ASTRAL) have failed to show a clear benefit to renal artery stenting. I only recommend w/u in high risk pts: Hx of flash pulmonary edema Unexplained rapid worsening of renal function Uncontrolled HTN on maximal medical therapy (5 or more meds)

10 Once potentially treatable secondary causes are ruled out, the next step is to characterize the BP pattern

11 Ambulatory Blood Pressure Monitoring (ABPM) 24 hr monitoring of blood pressure Useful for diagnosis of: White coat hypertension Apparent drug resistance Nocturnal hypertension Masked hypertension Non-dipper status

12 ABPM Also helpful in: better defining resistant HTN Identifying hypotensive symptoms while the patient is being treated with anti-hypertensive meds Identifying autonomic dysfunction states Monitoring episodic hypertension

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17 Masked Hypertension Defined as normal office BP and elevated home BP Prevalence ranges from 8% in the general population to as much as 20% in hypertensive patients receiving treatment

18 Masked Hypertension May be caused by reactivity to daily life stressors and behavioral factors such as smoking, alcohol use, contraceptive use in women, and sedentary habits High risk populations are patients Presenter with name CKD or Diabetes Mellitus

19 Masked Hypertension No large outcomes studies of this condition, however the CV risk profile has been reported to be similar to that of sustained HTN Associated with increased risks of: metabolic risk factors left ventricular mass index carotid intima-media thickness impaired large artery distensibility

20 Target organ damage and masked hypertension in the general population: the Finn-Home study. Hanninen, Marjo-Riitta; Niiranen, Teemu; Puukka, Pauli; Kesaniemi, Yrjo; Kahonen, Mika; Jula, Antti; Journal of Hypertension. 31(6): , June DOI: /HJH.0b013e32835fa5dc

21 White Coat Hypertension (WCH) Defined as having an elevated office BP and normal home BP measurements Prevalence is 12-18% in the general population Originally thought to be a benign condition, however, Verdecchia et al published Presenter a study name of 4406 subjects in 2005 suggesting that WCH is an independent risk factor for CVA

22

23 Verdecchia et al., Hypertension 2005;45(2):

24 Non-Dipping Normal diurnal variation in BP should have a 10-20% decrease in sys BP during sleep, referred to as dipping. This was first described by O Brien et al. in 1998 in the Lancet. Non-Dipping has been associated with worse CV outcomes, even in subjects who are normotensive

25 Non-Dipping Verdecchia et al. published a study in Hypertension, 1998, looking at CV outcomes in non-dippers CV events included MI, CVA, sudden death, angina pectoris, coronary revascularization, TIA, aortoiliac occlusive disease, thrombotic occlusion of a retinal artery, and progressive cardiac or renal failure

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28 Nocturnal Hypertension BP measured during sleep is higher than that measured when the patient is awake A risk factor for increased CV disease The AASK trial reported an abnormal dipping pattern in 80% of patients, and Presenter nocturnal name HTN found in 40%. All of these patients had HTN that was well-controlled based on office BP readings.

29 Ambulatory Blood Pressure Monitoring CMS will only reimburse for ABPM use in suspected white coat HTN Several task forces have advocated more wide spread use and access to ABPM Crucial in distinguishing different Presenter patterns name of BP

30 Ambulatory Blood Pressure Monitoring BP patterns is crucial for guiding which BP readings to use for titrating meds (AM or PM readings, exclusively home readings) Once we have categorized a patient s BP pattern, can also tailor the timing of meds appropriately

31 Morning or Evening Dosage Several studies have looked at bedtime dosing of calcium channel blockers and ARB s to restore nocturnal dipping status.

32 Currently a study being conducted at the University of Iowa and at Duke University, randomizing patients to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. Study will examine whether QHS dosing reduces CV risk compared with traditional AM dosing of antihypertensive meds.

33 What else is on the horizon? The Symplicity renal denervation system has received much attention Involves a catheter passed through femoral access that performs radiofrequency ablation to the lumen of the renal arteries

34 Renal Denervation SYMPLICITY HTN -1 and SYMPLICITY HTN -2 trials showed significant lowering of BP in patients with resistant HTN. However, these were unblinded studies

35 Renal Denervation Symplicity HTN-3 was recently published in the New England Journal of Medicine this month Prospective, single-blind, randomized, shamcontrolled trial of 535 patients Results did not show a significant reduction sys BP at 6 months

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38 Renal Denervation Although the results of SYMPLICITY HTN-3, the authors will cont to follow the subjects for up to 5 yrs to determine if the 6 month end point was too short Also no way to confirm that the Symplicity catheter system successfully denervated the renal nerves. Different methods of renal denervation may need to be investigated in future trials

39 THANK YOU!

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