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Treating Adult Hypertension:� �A Practical and �Non-Race-Based Approach

Himabindu Ekanadham MD, MS Epi, FAAFP

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Agenda and Learning Objectives

Understand diagnosis of hypertension and blood pressure targets based on current guidelines

Understand how race has historically been used in treating people with elevated blood pressure and alternative non-race based approaches to prescribing antihypertensive medications.

Design a treatment plan for patients with hypertension, taking into account individuals’ medical comorbidities

Understand the principles of shared decision making and validated tools that can assist in this process

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Case 1

AA is a 65yo who is a new patient in your office. Their blood pressure today is 145/90.

What do you need to know to be able to diagnose hypertension in this patient?

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Hypertension: Guidelines from the International Society of Hypertension

American Family Physician

https://www.aafp.org/pubs/afp/issues/2021/0615/p763.html

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Case 1

AA returns in one month, and their office blood pressure is 142/92. AA has no other medical history.

Their home blood pressure log confirms blood pressures consistently over 138/85.

What would you recommend in terms of lifestyle changes?

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Non-Medication Treatment

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Case 2: A Question for Discussion:

BB, who is 53 year-old male with known hypertension comes to you for a routine follow-up visit. What is his goal blood pressure?

<120/80
<130/80
<140/90
<150/90

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https://www.aafp.org/afp/2014/1001/p503.html

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Target SBP of 120 (intensive) vs 140 (standard)

Intensive group with better outcomes, but with higher rates of hypotension, syncope, electrolyte abnormalities, and acute kidney injury

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J Am Coll Cardiol. 2018 Sep 11; 72(11): 1187–1197.

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https://www.aafp.org/dam/AAFP/documents/journals/afp/AAFPHypertensionGuideline.pdf

This is an AAFP practice guideline that is hot off the presses from 11/2022

Excellent job of summarizing the trials and guidelines over the last 6 years

It includes the JNC 8, Sprint, and ACC guidelines we talked about just now….and includes AAFP’s most recent recs as of 2022

The salient punchline is that AAFP is standing ground to support overall the 140/90 threshold because of review of more comprehensive and recent evidence suggesting a lack of significant benefit in preventing death (all cause or CV) at lower targets of < 135/80.

Treating to a lower blood pressure target (less than 135/85 mm Hg) does not provide any additional mortality benefit. The Cochrane review conducted by Arguedas, et al.,(2020) evaluated the effect on total mortality between treatment to standard (less than 140/90 mm Hg) and lower blood pressure targets (less than 135/80 mm Hg).18 It included 11 RCTs with 38,688 patients and a mean follow-up of 3.7 years.1

It does qualify the recommendation slightly to say that in patient with significant number of CV risk factors, may be low quality evidence recommendation supporting lower target of < 130s/80s ..if that pt is able to partner with meeting those goal from mental, financial, community resource standpoint, reasonable to use this target

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Case 2: Proposed Answer

A 53 year-old male with known hypertension comes to you for a routine follow-up visit. What is his goal blood pressure?

<120/80
<130/80
<140/90
<150/90

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Case 3: A Question for Discussion:

A 53 year-old black male with hypertension comes to you for a routine follow-up visit. All of the following could be considered as first-line blood pressure medications to prescribe EXCEPT:

Hydrochlorothiazide (class: thiazide)
Amlodipine (class: calcium-channel blocker)
Metoprolol (class: beta blocker)
Lisinopril (class ace-inhibitor)

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https://www.aafp.org/afp/2014/1001/p503.html

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Where do these recommendations come from?

Ann Fam Med. 2007 Sep; 5(5): 444–452.

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ALLHAT reported:

However..

In comparison to black patients treated with diuretics, black patients treated with lisinopril had:

Higher blood pressures
Higher incidence of stroke
Higher incidence of combined CV disease

Did not account for benefit in black patients when used in combination with other antihypertensives
Did not account for benefit in specific morbidities such as CKD
African American Study of Kidney disease showed slowed rate of nephropathy progression in black patients on ace inhibitors

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The African- American Heart Failure Trial (A-HeFT)

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Race-based guidelines imply genetic causes for differences seen across race that are in fact more accurately explained by social factors and realities that are perpetuated by ongoing racism.

Stress levels
Social isolation
Financial insecurity
Food insecurity
Accessibility of and time for physical activity
Sodium and potassium intake
Housing insecurity
Accessibility of primary care / follow-up visits

Am Fam Physician. 2021;104(2):122-123; https://www.ucsf.edu/news/2022/01/422151/race-based-prescribing-black-people-high-blood-pressure-shows-no-benefit#:~:text=For%20example%2C%20ACEIs%20and%20ARBs,kidney%20disease%20in%20Black%20patients.

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CCB/ thiazide

ACEi/ ARB

Race Based Guidelines Limit Treatment Options

The Journal of the American Board of Family Medicine January 2022, 35 (1) 26-34; DOI: https://doi.org/10.3122/jabfm.2022.01.210276

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Punchline:

Race is a social and political construct that should not be used to guide medical treatment. Instead consider each individual’s comorbidities and social determinants of health (e.g., ability to afford medication, healthy food, access and time to exercise).

Am Fam Physician. 2021;104(2):122-123; https://www.ucsf.edu/news/2022/01/422151/race-based-prescribing-black-people-high-blood-pressure-shows-no-benefit#:~:text=For%20example%2C%20ACEIs%20and%20ARBs,kidney%20disease%20in%20Black%20patients.

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Case 3: Proposed Answer

A 53 year-old black male with hypertension comes to you for a routine follow-up visit. All of the following could be considered as first-line blood pressure medications to prescribe EXCEPT:

Hydrochlorothiazide (class: thiazide)
Amlodipine (class: calcium-channel blocker)
Metoprolol (class: beta blocker)
Lisinopril (class ace-inhibitor)

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What about the reported higher incidence of angioedema in black patients on ACEI and ARBs?

2017 prospective cohort study (n=5,878,048): incidence of angioedema among Black patients was higher compared to other racial/ethnic groups taking ACEI, ARB, and beta blockers

Limitation: compliance was measured in medication dispensing but not confirmed patient use

2018 retrospective cohort study (n=21,639) risk of angioedema among patients with heart failure started on an ACEI: no statistically significant difference was noted in risk of angioedema between Black and non-Black patients

population was all commercially insured
Small n of angioedema events
Small n of black patients (11.5%)

2008 retrospective cohort study (n=182) of ENT hospitalized patients from 1999-2004 reported Black patients were 3x more likely to develop ACE-I angioedema than all other patient groups

low powered study comparatively
link between angioedema and ACE-I was based on the patient's history and not an objective test.�

Overall SOR: C

Source: https://journals.lww.com/ebp/fulltext/2021/10000/does_the_risk_of_ace_i_induced_angioedema_differ.11.aspx

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211020/

https://iovs.arvojournals.org/article.aspx?articleid=2125851

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884750/

Theories about: Our findings indicate that blacks have a reduced NO-dependent vasodilator activity during mental stress. This difference seems related to reduced sensitivity of smooth muscle to the vasodilator effect of NO and may play some role in the increased prevalence of hypertension and its complications in blacks.

distributions of study measures by race in men and women, respectively. Median levels (interquartile range) of CRP were 1.48 (2.66) mg/L in white men, 1.99 (3.86) mg/L in black men, 1.82 (3.27) mg/L in white women, and 3.03 (5.53) mg/L in black women. Elevated CRP (>3.0 mg/L) was most prevalent in black women (50.48%) and least prevalent in white men (28.18%). Compared with whites, black participants were more likely to be younger, live in the South, and possess fewer socioeconomic resources. Black men and women had fewer overall psychosocial resources and more psychosocial risks, less favorable health behaviors, and consistently higher rates of hypertension, diabetes, and stroke.

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The problem with tailoring to the individual..

A person is a complex creature who may have high blood pressure only…

Or high blood pressure and diabetes….

Or high blood pressure and diabetes and CAD ….

Or high blood pressure and CHF…

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Case 4: A Question for Discussion

A 71 year-old white female is admitted to the hospital with Afib and RVR (HR 120s) and an exacerbation of HFrEF (ef 25%). Her blood pressure is 175/90. Her creatinine is 2.1 mg/dL and her K is 5.1. All of the following medications would be appropriate to give EXCEPT:

Furosemide (class: loop diuretic)
Diltiazem (class: calcium-channel blocker)
Metoprolol (class: beta blocker)
Isosorbide dinitrate / hydralazine (class: nitrate / vasodilator)

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Isolated HTN

CCB
ACEI/ARB
Thiazide*

*Avoid in elderly

HFrEF

BB
ACEI/ARB/ARNI
Spiro
Loop

HFpEF

Spiro
Loop

HFrEF

(ef≤40)

BB
ARNI>ACEI/ARB
MRA
Loop
Isosorbide/

Hydralazine

*AVOID NDHP CCBs

CAD

BB
ACEI/ARB

Loop

HFpEF (ef≥50)

BB= beta blocker; CCB= calcium channel blocker; NDHP = non-dihydropyridines; ACEI = ace inhibitor; ARB = aldosterone receptor blocker; MRA = mineralocorticoid antagonist; ARNI = ARB + neprilysin inhibitor; Loop = loop diuretic

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DM and CVA

ACEI/ARB

HFrEF

BB
ACEI/ARB/ARNI
Spiro
Loop

HFpEF

Spiro
Loop

ESRD on Dialysis

BB
CCB
ARB>ACEI (less dialyzed)

�*at times limited by hyperkalemia concerns

Afib

BB
CCB (NDHP)

If the agents above (1^st line) don’t work, then consider below with cardiology:

Amiodarone
Digoxin

MRA*
Loop*

*ideally in 5:2 ratio of MRA:loop

Cirrhosis

BB= beta blocker; CCB= calcium channel blocker; NDHP = non-dihydropyridines; ACEI = ace inhibitor; ARB = aldosterone receptor blocker; MRA = mineralocorticoid antagonist; ARNI = ARB + neprilysin inhibitor; Loop = loop diuretic

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	Thiazide	CCB	ACEI/ARB	BB	ARNI	Loop	MRA	Hydralazine/ Isosorbide
Isolated HTN	✅ *avoid in elderly	✅	✅
CAD			✅	✅
HFpEF (EF ≥ 50)						✅
HFrEF (EF ≤ 40)		*avoid NDHP CCBs; can cause pump failure	✅	✅	✅ *ARNI superior to ACEi/ARB	✅	✅	✅
Afib *if first line options cannot be used, discuss amiodarone, digoxin w cardiology		✅ (NDHP, e.g. diltiazem, verapamil) �		✅
DM			✅
CVA			✅
ESRD on HD		✅	✅ *ARB>ACEi (less dialyzed)	✅ *first line
Cirrhosis						✅ ✅ Optimal MRA: Loop is 5:2

Another way to look at this information..

BB= beta blocker; CCB= calcium channel blocker; NDHP = non-dihydropyridines; ACEI = ace inhibitor; ARB = aldosterone receptor blocker;

MRA = mineralocorticoid antagonist; ARNI = ARB + neprilysin inhibitor; Loop = loop diuretic

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Case 4: Proposed Answer

A 71 year-old white female is admitted to the hospital with Afib and RVR (HR 120s) and an exacerbation of HFrEF (ef 25%). Her blood pressure is 175/90. Her creatinine is 2.1 mg/dL and her K is 5.1. All of the following medications would be appropriate to give EXCEPT:

Furosemide (class: loop diuretic)
Diltiazem (class: calcium-channel blocker)
Metoprolol (class: beta blocker)
Isosorbide dinitrate / hydralazine (class: nitrate / vasodilator)

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Case 5: A Question for Discussion

A 71 year-old male comes to the clinic BP 200s/120s, HR 90s, hx diabetes, hx CAD, hx CKD with baseline creatinine around 2mg/dL. He reports running out of his medications a week ago. He has no other complaints or current symptoms. All of the following would be appropriate actions EXCEPT:

Sending to the hospital for acute blood pressure lowering

B) Prescribing home meds to pick up and take today with plan for follow up BP check

C) Have the patient rest for 30 mins in the waiting room and then recheck the blood pressure

D) Performing a physical exam

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Am Fam Physician. 2017;95(8):492-500

Do not rapidly correct asymptomatic severe HTN because doing so could cause harm: organ hypoperfusion.

If concerned for HTN emergency, reduce MAP slowly by < 25% in the first hour followed by cautious return to normotension goals after first 24hr

Exceptions where rapid lowering of BP are required include:

Aortic dissection
Hemorrhagic Stroke

Evidence-based treatment options:

Labetolol (po, iv, gtt)
Captopril (po)
Nicardipine gtt
Nitroprusside gtt
For flash pulmonary edema prioritize topical nitroglycerin or nitroglycerin gtt

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Case 5: Proposed Answer

A 71 year-old male comes to the clinic BP 200s/120s, HR 90s, hx diabetes, hx CAD, hx CKD with baseline creatinine around 2mg/dL. He reports running out of his medications a week ago. He has no other complaints or current symptoms. All of the following would be appropriate actions EXCEPT:

Sending to the hospital for acute blood pressure lowering

B) Prescribing home meds to pick up and take today with plan for follow up BP check

C) Have the patient rest for 30 mins in the waiting room and then recheck the blood pressure

D) Performing a physical exam

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Case 6: A Question for Discussion

A 63 year-old female with a known history of HTN and HFrEF comes to the clinic BP 170s/90s. Her prescribed regimen includes losartan-sacubutril, metoprolol, furosemide, and spironolactone. She reports running out of her medications despite you refilling all of them 2 weeks ago. Which of the following is the most appropriate next step?

Tell her she must pick up her meds today as these medicines are very important in keeping her alive

B) Ask her about the reason(s) for why she hasn’t picked up her meds

C) Call the pharmacy to arrange blister packing of her meds

D) Stop the losartan-sacubutril and spironolactone to ease her pill burden

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Guidelines are great… but Real Talk

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Understanding your patient(s) within the context of their community and culture

Asking about favorite dishes from one’s culture/community and modifying 1-2 ingredients within to make it healthier

Explore bodegas and supermarkets in your neighborhood, assess cost of fruits/veg, availability, quality

Explore community for walkability, parks, exercise options that are free and low cost

Explore access to smart phone and ability/interest in using apps for medication, exercise (e.g., 7 minute exercises from NYT)

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https://www.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-2.html

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Case 6: Proposed Answer

A 63 year-old female with a known history of HTN and HFrEF comes to the clinic BP 170s/90s. Her prescribed regimen includes losartan-sacubutril, metoprolol, furosemide, and spironolactone. She reports running out of her medications despite you refilling all of them 2 weeks ago. Which of the following is the most appropriate next step?

Tell her she must pick up her meds today as these medicines are very important in keeping her alive

B) Ask her about the reason(s) for why she hasn’t picked up her meds

C) Call the pharmacy to arrange blister packing of her meds

D) Stop the losartan-sacubutril and spironolactone to ease her pill burden

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Thanks For Listening! Additional Resources Below

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Answers

C
C
B
A
B