This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Native Controlling Hypertension and Risk Through Technology (Native-CHART)

Webinar Series Introduction

Gladys Rowe Partnerships for Native Health at Washington State University

Agenda

• Institute for Research and Education to Advance Community Health (IREACH) and Partnerships for Native Health Introductory Slides (5 minutes)

• Native-CHART Presentation: Hypertension: History, Impact, and Interventions, Dr. Jason Umans (45 minutes)

• Question and Answer, Closing (15 minutes)

• Post-webinar survey link: $30.00 gift card drawing

Institute for Research and Education to Advance

Community Health

We challenge the status quo and advance community health through partnerships and collaboration.

IREACH

IREACH

Rural Health and

Health Networks

Partnerships for

Native HealthLatinx Health

Native Hawaiian and

Pacific Islander Health

Behavioral Health

Innovations

• Achieving health equity

• Community outreach and engagement

• Training and education

• ~160 partners: tribal colleges, Native organizations, tribes, and universities

Partnerships for Native Health

• Community-based research and education to improve health and reduce health disparities among American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders

Native-CHART

The Center aims to improve control of blood pressure and other risk factors for cardiovascular disease in American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders with diagnosed hypertension. It comprises three community-based intervention projects and four supporting Cores.

IREACH.WSU.EDU/NCHART

Native Controlling Hypertension and Risk Through Technology

• Post-webinar evaluation: enter to win a $30 gift card

• The webinar recording and presentation slides will be available at ireach.wsu.edu/nchart

• Please enter questions for Dr. Umans in the Q&A box

Native-CHART Webinar

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

HYPERTENSION: History, Impact, Interventions

Practice and Guidelines

Jason G. Umans, MD, PhDNative-CHART Methods CoreGeorgetown-Howard Universities Center for Clinical and Translational Science and MedStar Health Research Institute

•What is hypertension?

•Is it bad for you?

•How should we measure BP?

•What goes wrong in patients with high BP?

•Which patients should be treated, and how?

•How do we pick our BP treatment targets, and how do we get there?

Key questions we will address in this (fly-by) talk

•1896-1905-noninvasive BP measurement

•1913- high BP associated with stroke, CHF, renal failure

•Association, but no evidence of causality

•1925-Society of Actuaries report on >0.5 million men: high BP increases mortality

•They didn’t really care about causality, just prediction

•1939-62-Actuaries, Life Insurance Industry and Metropolitan Life tables: Progressive increases in mortality (along with stroke, cardiovascular and renal disease) with increases in either SBP or DBP

Hypertension: A Brief and Selective History

Relative Increase in CVD Deaths With BP

1941 Life Insurance Data

Diastolic BP → 54-83 84-93 94-116

Systolic BP

108-132 86 101 116

133-142 108 137 171

143-177 175 201 293

Target Organ Damage “Malignant” Hypertension

500 Untreated Hypertensives-1955 % Pts Survival-mo

Enlarged Heart (by CXR) 74 8

CHF/Pulmonary Edema 50 4

Angina Pectoris 16 5

Encephalopathy 2 1

Stroke 12 4

Proteinuria 42 5

Azotemia 18 1

Accelerated Hypertension 7 1

Stroke and IHD Mortality vs Usual Sys BP by Age

IHD=ischemic heart disease

Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.

Mo

rtality

(Flo

ati

ng

Ab

so

lute

Ris

k a

nd

95%

CI)

Usual Systolic BP (mm Hg)

50-59 years

60-69 years

70-79 years

80-89 years

Stroke Age at risk:

256

128

64

32

16

8

4

2

1

0

120 140 160 180

IHD

Usual Systolic BP (mm Hg)

50-59 years

60-69 years

70-79 years

80-89 years

Age at risk:

40-49 years

256

128

64

32

16

8

4

2

1

0

120 140 160 180

10090-99

80-8975-79

70-74<70 <120

120-

139

140-

159

160

48

3735 44

38

81

31

2625

2525

25

24

17

1413

1312

21

1012

99

9

Effect of Systolic and Diastolic BP on CHD Mortality: MRFIT Screenees (N=316,099)*

*Men aged 35 to 57 years followed up for a mean of 12 years.

Adapted from: Neaton et al. Arch Intern Med. 1992;152:56-64.

Death rate

per 10,000

person-years

Diastolic BP

(mm Hg)Systolic BP

(mm Hg)

•1945- FDR dies of stroke with (due to?) uncontrolled hypertension

•1948- Beginning of Framingham study

•1940s-50s-First treatments, from Kempner rice diet or sympathectomy to early sympatholytic drugs

•1967-VA Cooperative Trial 1 (3 drugs for DBP >115 saves lives-trial stopped early-this trial made hypertension into a real disease

•1989-Beginning of the Strong Heart Study-this study showed that American Indians were not (somehow) immune to CVD and that hypertension was a powerful risk factor

Hypertension: A Brief and Selective History

The VA Cooperative Study I (DBP>115)Assessable Morbid/Fatal Events

Placebon=70

Active Rx*n=73

Accelerated

hypertension12 0

Stroke 4 1

Coronary event 2 0

CHF 2 0

Renal damage 2 0

Deaths 4 0

VA Cooperative Study Group. JAMA. 1967;202:1028-1034.

*P<0.001 active drug therapy vs placebo

Placebon=194

Active Rx*n=186

Accelerated hypertension 4 0

Stroke 20 5

Total coronary event 13 11

Fatal coronary event 11 6

Congestive heart failure 11 0

Renal damage 3 0

Deaths 19 8

The VA Cooperative Study II (DBP 90-115) Assessable Morbid/Fatal Events

VA Cooperative Study Group. JAMA. 1970;213:1143-1152.*P<0.001

Hypertension Treatment Effect Mirrors Observational Data

0

2

4

6

8

10

12

CV

D I

ncid

en

ce

120 140 160 180 200 220

Systolic BP (mmHg)

•Hypertension is both a marker and cause of CVD

•Risk increases with the severity of hypertension

•Benefits of BP lowering (treatment) mirror the risks of hypertension severity in observational studies

•Recent and ongoing trials seek answers to specific treatment questions in well defined patient groups

Summary

•How much hypertension is out there?

•Are we “on top” of it?

•How do we define and grade it?

•How does it interact with other co-morbid risk factors?

•How is it actually going to kill us?

Hypertension: Definitions and Burden

Hypertension Prevalence by Age and Ethnicity in Men and Women: NHANES 1999-2000

95% CIs. Weighted to the US population. Hajjar et al. JAMA. 2003;290:199-206.

100

80

60

40

20

0Hyp

ert

en

sio

n P

revale

nce,

%

Non-

Hispanic

White

Non-

Hispanic

Black

Mexican

American

Men Women

18-39 40-59 60

Non-

Hispanic

White

Non-

Hispanic

Black

Mexican

American

2

Zhang Y, Moran A, Hypertension. 70:736-742, 2017

Prevalence,

Awareness,

Treatment, and

Control of

Hypertension,

1999 to 2014

Framingham Heart Study, CVD

outcomes by BP (2001)

Optimal <120/<80

Normal 120-129

High Normal 130-139

In JNC7 (SysBP only),

Optimal became “normal”

Normal became “PreHtn”

High Normal became “PreHtn”

In new guidelines (SysBP only),

Optimal is “normal”

Normal is “elevated”

High Normal is “Stage 1 Htn”

Additive Effect of Cholesterol and Systolic BP on Risk of CHD Death

Neaton et al. Arch Intern Med. 1992;152:56-64.

34

21

17

13

12

23

12

810

6

17.7

10.9

8.6

6.3

5.5

17

88

6

4

14

56

33

142+

125-131

<182

182-202

203-220

221-244

<118

118-124

132-141

Deaths /10,000 pt-yr

245+

Microalbuminuria increases CHD risk of high BP

Borch-Johnsen K, et al. Arterioscler Thromb Vasc Biol. 1999;19(8):1992-1997.

Prehypertension, Diabetes, and Cardiovascular Disease Risk in a Population-Based

Sample, Volume: 47, Issue: 3, Pages: 410-414, DOI:

(10.1161/01.HYP.0000205119.19804.08)

Prehypertension, Diabetes (120-139/80-89) and CVD in the SHS (2006)

Lower BP Targets in high risk

patients are because of

SPRINT (2015)

Sys BP <140 vs <120; 9361

older pts with Sys BP 130-180

and elevated CVD risk

We should have already

known this from SANDS

(2008). 499 AIs with DM,

randomized to sysBP <115 vs

<130 and tight vs very tight

LDL and non-HDL-C:

improved IMT and LVMI

•UKPDS (<85 DBP) 2.7

•ABCD (<75 DBP) 2.8

•MDRD (<92 MAP) 3.6

•HOT (<80 DBP) 3.3

•AASK (<92 MAP) 3.8

•ACCORD (<120 SBP) 3.4

•SPRINT (<120 SBP) 2.8

•SANDS (<130 SBP) 1.6

•SANDS (<115 SBP) 2.3

Number of Antihypertensive Drugs Needed to Reach BP Goals in Prospective Trials

JAMA. 2018;320(17):1760-1763. doi:10.1001/jama.2018.16068

Yano, CARDIA Study; Sun, 2.5M Korean young adults, both with mean age in 30s

Hypertension Definitions: Evolution and Disagreement

•There is still a lot of unrecognized and under-treated hypertension (by any definition)

•Hypertension is a major cardiovascular risk and its effect is multiplied by other risk factors

•Treatment (which almost always requires more than one drug) should be tailored to severity of hypertension and co-morbidities

•Risk increases with even modestly abnormal BP

•Hypertension (and what we used to call prehypertension) tends to keep bad company

Summary

•Sphygmomanometry (with auscultation)-importance of proper technique

•Home (automated, oscillometric) BP monitors• Home (BPs, if confirmed to be accurate, predict CVD outcomes and

verify control much better than office BPs

•ABPM-might it be important?• Only method that gets at nocturnal pressures

• What goes for home BPs is even better in ABPM

•Problems with devices and their use, both in the clinic and in research

BP Measurement

2

% +/-

(mm Hg)

≦5 ≦10 ≦15 Mean

Diff

SysBP 62% 87% 95% 0+/-7

DiaBP 58% 90% 98% -4+/-5

Validation of the HEM-907

1-This is the ~$700 device used in SPRINT Trial

2-Compared to Hg/Auscultation Gold Std

3-Two observers had 100% agreement

4-For comparison treatment effect size in most

BP clinical trials is 2-6 mm Hg

El Assaad et al, Bl Press Mon. 7:237-241, 2002

•A lot of unsuspected hypertension is diagnosed by proper careful BP measurement

•A lot of hypertension is cured by proper careful BP management

•Home BP management can be an important adjunct to diagnosis and treatment, but accuracy has to be assessed in each patient before trusting the values

Key Messages on BP Measurement

•Diet interventions work, but with real problems and unknowns regarding persistence—i.e., needs research•DASH, Low Sodium

• Interaction of Na and K

•On average, equivalent to ~1 BP drug (recalling that most patients need 2 or more drugs except for mild hypertension

•Not just limited adherence by patients but also therapeutic inertia and lack of aggressive titration by clinicians lead to poor control---i.e., needs research

Two Key Messages on BP Control of Relevance to Native-CHART

BP Control by

DASH Diet and

Salt Restriction

DASH lowers BP by

~6mm Hg when on

(usual) high salt diet. A

low salt diet has a similar

effect.

With both DASH and

lower salt intake, BP

goes down more but the

incremental benefit of

DASH decreases

Pettiti. N Engl J Med. 2001;344:1717.

-7

-6

-5

-4

-3

-2

-1

0

1

0 5 10 15 20 25 30 35 40

PREMIER, 2003

DASH-Sodium, 2001

TOHP-II, 1997

TOHP-I, 1992

HPT, 1990

Months of Intervention

Diffe

ren

ce

in

SB

P (

mm

Hg

)

Na+ Restriction and BP Trials

In a large VA hypertension clinic patients were not followed more closely if BP

was uncontrolled, did not have BP measured at every visit, and did not

routinely have medications adjusted or testing performed if response was

suboptimal N Engl J Med 1998; 339:1957-1963

Physicians Conspire with Patients to Avoid BP Control

• Nonadherence of patients to prescribed medication is a challenge in all chronic conditions, with typical adherence rates at 1 year:

• About 50% for drugs

• About 10% for lifestyle changes

• "Compliance" of physicians with treatment guidelines is also suboptimal, especially regarding an appropriate increase in intensity of treatment:

• In the VA system in 1997, only ~6% of patients with SBP >160 mm Hg had their BP medications increased

• In ALLHAT, ~94% of those with BP >140/90 mm Hg did not have their BP medications increased

Adherence and Compliance

Haynes et al. JAMA. 2002;288:2880-2883.

Berlowitz et al. N Engl J Med. 1998;339:1957-1963

• Hypertension kills!

• You have to measure BP (properly) to find hypertension

• The specific cause of hypertension matters• Salt sensitivity and others, not discussed

• Hypertension magnifies all other cardiovascular risks

• Antihypertensive treatment helps tremendously

• All patient groups (e.g., elderly, diabetes, kidney disease, prevalent CVD) benefit from treatment

• By extension, but with precious little data, all of these messages probably apply to Native populations, perhaps more so (e.g. SANDS)

• It is sometimes difficult to control hypertension and both physicians and patients can often share in the blame

Summary and Take Home Messages

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Thank you!

Questions?

Nonpharmacologi

-cal InterventionDose Approximate Impact on SBP

Hypertension Normotension

Weight loss Weight/body fat Best goal is ideal body weight, but aim

for at least a 1-kg reduction in body

weight for most adults who are

overweight. Expect about 1 mm Hg for

every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet DASH dietary pattern

Consume a diet rich in fruits,

vegetables, whole grains, and low-fat

dairy products, with reduced content

of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced

dietary sodium

Dietary sodium Optimal goal is <1500 mg/d, but aim

for at least a 1000-mg/d reduction in

most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced

dietary

potassium

Dietary potassium

Aim for 3500–5000 mg/d, preferably

by consumption of a diet rich in

potassium.

-4/5 mm Hg -2 mm Hg

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.

Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?

Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to.

Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

Nonpharmacologica

l Intervention

Dose Approximate Impact on SBP

Hypertension Normotension

Physical

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

-5/8 mm Hg -2/4 mm Hg

Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10

repetitions/set

-4 mm Hg -2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction, 3

sessions/wk

● 8–10 wk

-5 mm Hg -4 mm Hg

Moderation

in alcohol

intake

Alcohol

consumption

In individuals who drink alcohol,

reduce alcohol† to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

-4 mm Hg -3 mm

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz

of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%

alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60R

ela

tive r

isk (

95

% C

I)

Stroke CHD

Active Therapy vs. Placebo

CHF Death

0.63

0.46

0.68

0.87

CVD

0.75

SHEP: Cardiovascular Disease Endpoints

SHEP Research Group. JAMA. 1991;265:3255-3264.

SHEP=Systolic Hypertension in the Elderly Program

CHD=coronary disease; CHF=congestive heart failure; CVD=cardiovascular disease