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    Refractory Hypertension 020310a

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    Angga Harahap
    This document summarizes four cases of refractory hypertension and reviews recent advances in hypertension management. Case 1 describes a 61-year-old woman with uncontrolled blood pressure due to non-adherence from inability to afford medications. Case 2 involves a 54-year-old woman where cocaine use was identified as a potential cause of secondary hypertension. Case 3 is a 62-year-old man diagnosed with primary hyperaldosteronism. Case 4 is a 77-year-old woman with obesity and sleep apnea potentially contributing to refractory hypertension. The document also reviews the ACCOMPLISH trial that found combination therapy with an ACE inhibitor and calcium channel blocker reduced cardiovascular events more than ACE inhibitor and diuretic combination

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    Refractory Hypertension 020310a

    Uploaded by

    Angga Harahap
    78 views33 pages
    This document summarizes four cases of refractory hypertension and reviews recent advances in hypertension management. Case 1 describes a 61-year-old woman with uncontrolled blood pressure due to non-adherence from inability to afford medications. Case 2 involves a 54-year-old woman where cocaine use was identified as a potential cause of secondary hypertension. Case 3 is a 62-year-old man diagnosed with primary hyperaldosteronism. Case 4 is a 77-year-old woman with obesity and sleep apnea potentially contributing to refractory hypertension. The document also reviews the ACCOMPLISH trial that found combination therapy with an ACE inhibitor and calcium channel blocker reduced cardiovascular events more than ACE inhibitor and diuretic combination

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    This document summarizes four cases of refractory hypertension and reviews recent advances in hypertension management. Case 1 describes a 61-year-old woman with uncontrolled blood pressure due to non-adherence from inability to afford medications. Case 2 involves a 54-year-old woman where cocaine use was identified as a potential cause of secondary hypertension. Case 3 is a 62-year-old man diagnosed with primary hyperaldosteronism. Case 4 is a 77-year-old woman with obesity and sleep apnea potentially contributing to refractory hypertension. The document also reviews the ACCOMPLISH trial that found combination therapy with an ACE inhibitor and calcium channel blocker reduced cardiovascular events more than ACE inhibitor and diuretic combination

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    78 views33 pages

    Refractory Hypertension 020310a

    Uploaded by

    Angga Harahap
    This document summarizes four cases of refractory hypertension and reviews recent advances in hypertension management. Case 1 describes a 61-year-old woman with uncontrolled blood pressure due to non-adherence from inability to afford medications. Case 2 involves a 54-year-old woman where cocaine use was identified as a potential cause of secondary hypertension. Case 3 is a 62-year-old man diagnosed with primary hyperaldosteronism. Case 4 is a 77-year-old woman with obesity and sleep apnea potentially contributing to refractory hypertension. The document also reviews the ACCOMPLISH trial that found combination therapy with an ACE inhibitor and calcium channel blocker reduced cardiovascular events more than ACE inhibitor and diuretic combination

    Copyright:

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    Download as ppt, pdf, or txt
    of 33

    Refractory Hypertension: Four Cases

    Paul R. Chelminski, MD, MPH, FACP Associate Professor of Medicine Associate Residency Program Director

    Objectives
    1.Review JNC-7 Guidelines 2.Understand common barriers to achieving blood pressure control 3.Review some causes of secondary hypertension. 4.Review recent advances in our understanding of the HTN management

    JNC-7* Highlights
    CVD risk doubles with each 20/10mmHg increment over 115/75 SBP more important CV risk factor Two or more agents usually required Thiazides are first choice and first line Consider 2 agents if BP >20/10 above goal Targets
    140/90 130/80 if diabetic or CKD
    *Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure, 7th Report http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf.

    HTN Classification

    Meds: Compelling Indications

    HTN Control: Clinical Impact


    Decreased CVD Incidence
    Stroke:35-40% MI: 20-25% CHF: >50%

    12mmHg BP reduction over 10 yrs will prevent one death in every 11 patients NNT is 9 patients with underlying CVD or target organ damage

    BP Control in Clinical Settings


    >70% non-diabetic & diabetic patients with sub-optimal control 91% adherent to regimens 70% taking fewer than 3 antihypertensives Therapeutic Inertia:
    45% did not have therapy intensified at first f/u visit 36% had no change at 2nd f/u visit

    Challenges to Improving Blood Pressure Control


    Four Cases of Refractory Hypertension

    Barriers to HTN control


    Cost Medication side effects Lack of gratifying response to therapy (patient does not feel better) Need for lifestyle changes Tedium: titration- requiring multiple visits & close monitoring by MD & patient

    Case 1
    Visit 1 61 yo female with HTN, hyperparathyroidism, h/o DVT Presents with pins & needles in LEs Meds
    coumadin, Sensipar amlodipine, lisinopril, furosemide, HCTZ, metoprolol

    Social Hx: non-smoker,uninsured BP 194/129 (re-check, 172/111); ?nonadherence to one medication; recent SBPs ~140 Labs: Na 145, K 3.7, Cr 0.8, Ca 11.7, B12 465 Dispo: Restart meds & f/u 4 days

    Case 1
    Visit 2 c/o Fatigue Patient confirms medications BP 204/132 (re-check, 210/135) Receives clonidine in clinic & admitted for hypertensive urgency & management of hypercalcemia

    Case 1
    Hospitalization & Visit 3 Hydrated with decrease in Ca++ Source of HTN identified: non-adherence d/t inability to afford meds D/C Meds: lisinopril, metoprolol, furosemide (Walmart $4drugs to rescue) BP at f/u 147/101 Amlodipine added

    Obstacles to Optimizing HTN Management


    Adherence
    Cost Literacy!

    Clinical Uncertainty
    50% doctors dont intervene due to uncertainty about accuracy of triage BP (home blood pressures lower)

    Competing Medical Demands


    Trial evidence conflicting about influence of multiple comorbididities

    Time constraints
    Largely unstudied

    Case 2
    54 yo female with HTN, diabetes, hypercholesterolemia BP Meds: amlodipine, lisinopril, HCTZ spironolactone BP 7/09: 166/83; A1c 9.0%: Substitute chlorthalidone for HCTZ BP 1/09: 164/68; A1c: 7.3%: ?Nonadherence to one med

    Case 2
    Social Hx: No tobacco; no ETOH; h/o cocaine use but denies current.

    Drugs That Cause HTN


    Drugs of abuse
    Cocaine, methamphetamine Alcohol

    OTC decongestants Prescription


    Venlafaxine/SNRIs Estrogens/OCPs Corticosteroids Namenda Erythropoietin Tacrolimus/Cyclosporin

    Case 3
    62 yo male with HTN, palpitations, myalgias Meds: felodipine (5mg), atenolol (100mg), benazepril (20mg), minoxidil (10mg prn elevated BP), KCL 80mEq/d Social: no tobacco; retired farmer ROS: no CP, no SOB/DOE, no syncope BP 182/99, P 64. +S4 gallop Labs: K+ 2.8; aldo 90, renin <0.2 (ratio=450)

    Case 3
    Dx: Hyperaldosteronism Etiology: Adrenal adenoma (rare malignancy), adrenal hyperplasia W/U:
    Aldo/Renin: Ratio >30 suggests primary hyperaldosteronism MRI of abdomen

    Rx
    Medical: spironolactone ?Surgery

    Case 3: Denouement
    Spironolactone, 100mg bid started Orthostasis at home with SBPs in 70s Decreased minoxidil to 5mg/d and atenolol to 50mg/d BP 139/90 K+ (4.7)-palpitations, myalgias resolved.

    Case 4 77yo female with refractory HTN, diet


    controlled DM, obesity, OA

    Case 4
    BP 159/79 (Re-check, 160/79) ROS: Daytime sleepiness, snoring, nighttime arousals K+ 4.1, Cr 0.87 Sleep study: OSA Denouement: Awaiting outcome of CPAP trial

    The ACCOMPLISH Trial

    Study objective
    Comparison of cardiovascular events between group treated with combination benazepril-HCTZ versus combination benazepril-amlodipine, with hypothesis that benazepril-amlodipine would be superior in reducing cardiovascular events.
    HCTZ

    Study design
    Total 11,506 patients recruited for study Multi-center Randomized, double-blind trial Similar patient demographic and comorbidities in each group Intention to treat model

    Who are the patients?


    This study has a high predominance of patients who are elderly, obese, Caucasian, have multiple co-morbidities (including diabetes, dyslipidemia, and CAD), and difficult to control HTN, requiring multiple agents.
    at high risk for cardiac events

    Who are the patients?


    38% Receiving 3 or more drugs at enrolment Only 37% had BP <140/70 60% had diabetes Average age 68yrs (fairly geriatric)

    Patient randomized

    Study procedures (contd)


    Algorithm outlined by study for optimization of blood pressure control

    20 mg benazepril 5 mg amlodipine

    20 mg benazepril 12.5 mg HCTZ One month

    40 mg benazepril 5 mg amlodipine BP > 140/90 without diabetes OR BP > 130/80 with diabetes No Yes Three months

    40 mg benazepril 12.5 mg HCTZ BP > 140/90 without diabetes OR BP > 130/80 with diabetes Yes No

    Continue current regimen

    40 mg benazepril 10 mg amlodipine

    40 mg benazepril 25 mg HCTZ BP > 140/90 without diabetes OR BP > 130/80 with diabetes

    Continue current regimen

    BP > 140/90 without diabetes OR BP > 130/80 with diabetes

    Six months

    Add other agents Eg beta blocker, alpha blocker, clonidine, spironolactone

    Study Endpoints
    Primary endpoint Time to first event One event per patient Composite of a cardiovascular event and death from cardiovascular causes Secondary endpoints Multiple events counted for a patient Including composite of cardiovascular events, hospitalization from heart failure, death from any cause

    Results: Improved BP Control


    Both benazepril/ amlodipine and benazepril/ HCTZ combination therapy improved blood pressure control
    Amlodipine Mean SBP Mean DBP % BP <140/90 131.6 73.3 75.4 HCTZ 132.5 74.4 72.4

    Results: CV Mortality and Events


    Benazepril/amlodipine group saw: Decreased primary endpoints at 30 mos. Decrease secondary endpoints: death from CV causes, non-fatal MI< stroke Early cessation of study by safety & monitoring committee when pre-specified thresholds for termination seen in Ace/CCB arm d/t efficacy

    Kaplan-Meier Curve:
    Time to First Primary Composite Endpoint

    Results: Primary Endpoints


    Primary endpoint at 30 months All Male Female Age >65 Age >70 +DM - DM Benazepril/ Amlodipine (%) 9.6 10.6 8.1 10.1 11 8.8 10.8 Benazepril/ HCTZ (%) 11.8 13.1 9.7 12.4 13.8 11 12.9 ARR (EER-CER) (%) 2.2 2.5 1.6 2.3 2.8 2.2 2.1 RRR (ARR/CER) (%) 19.6 19 16.4 18.5 20.2 20 16.2

    Drug Costs
    Drug name Cost for 30 day supply

    Enalapril 5 mg -20 mg
    HCTZ 12.5-25 mg Atenolol 25 mg- 100 mg Amlodipine (Norvasc) 5 mg

    $4
    $4 $4 $75

    Amlodipine (generic) 5 mg

    $21

    Adapted from Blue Cross Blue Shield of North Carolina and WalMart $4 pharmacy list

    90 supply available from Drugstore.com for $18

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