HYPERTENSION
From Primary Care Medicine: Principles and Practices, University of California, San Francisco, School of Medicine
Eliseo J. Perez-Stable, MD, Professor of Medicine, University of California, San Francisco, School of Medicine
| MODERN MANAGEMENT OF HYPERTENSION
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| Prevalence and control: prevalence increasing in United States; blacks have highest rate, at 33.5%; 30% of people
with hypertension unaware of disease, and 60% undergo treatment; control of blood pressure (BP) achieved in 31% of
patients (rates higher than most European countries); BP more often uncontrolled in women, Hispanic patients, and
older adults; predictors of awareness and control—age (lower awareness in older adults); consistency of medical
care; marital status; motivation to use lifestyle modification
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| Treating hypertension in older adults: randomized study looked at patients >80 yr of age (mostly women); medical
treatment reduced rate of stroke from 10.8% to 7.5% (number needed to treat, 30); reduction in cardiovascular events
and congestive heart failure (CHF) also occurred; indirect evidence suggests treatment of hypertension reduces risk
for cognitive dysfunction by 35% to 40%
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| Chronic renal disease: retrospective cohort study found risk of developing chronic renal disease increases at systolic
BP of 120 to 129 mm Hg and diastolic BP of 80 to 84 mm Hg; risk increases up to 4-fold when BP reaches 210/120
mm Hg
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| Monitoring of BP: ambulatory monitoring independently predicts cardiovascular events (useful when deciding to treat
patients with borderline hypertension); study found self-monitoring of BP at home led to less intense medical treatment
and less control of BP, but no difference in well-being; meta-analysis of 18 studies showed reductions in systolic BP in patients
who perform systematic monitoring at home; although at-home monitoring beneficial, speaker recommends using
measurements taken in office as basis for treatment decisions
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| Classification: prehypertension (systolic BP 120-139 mm Hg) common and represents important opportunity to intervene
with lifestyle modifications; all patients with stage 2 hypertension require medical treatment; all patients with
stage 1 hypertension and cardiovascular morbidity require medical treatment; for patients with diastolic BP >90 mm
Hg, medical treatment required if lifestyle modifications insufficient; medical treatment considered for patients with
systolic BP 140 to 159 mm Hg (no clinical trials have examined outcome, but epidemiologic evidence suggests benefit)
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| Lifestyle modifications: obesity—most important factor for hypertension in United States; loss of 10 kg can reduce
BP up to 20 mm Hg; alcohol—limit to 0.5 oz daily in women and thin men, 1.0 oz daily in other men; sodium—
average adult in United States consumes twice recommended sodium intake; diet with no added salt can reduce daily
intake by half; physical activity—30 min of activity, most days or everyday, has independent effect on BP; diet—
Dietary Approaches to Stop Hypertension (DASH) diet (high intake of fruits, vegetables, and fiber; low intake of fats)
and low-sodium diet affect BP; combining these reduces BP by 8 to 14 mm Hg (effect not completely additive); increasing
dietary fiber mildly beneficial in patients >40 yr of age; habitual consumption of tea found to decrease incident
hypertension in Chinese patients; consumption of 2 alcoholic drinks per day increases relative risk of developing
hypertension to 1.3; coffee not associated with elevations in BP in adults; note—although important, changes in lifestyle
less effective than medical management for lowering BP
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| General approach to medical treatment: thiazide diuretics often preferred, but all available drugs lower BP; most
patients need >1 drug to control BP; sample regimen—start with low-dose thiazide; switch class or add low dose of
second drug in nonresponders (consider combination formulations); substitute or add β-blocker, angiotensin-converting
enzyme (ACE) inhibitor, or angiotensin-II receptor blocker (ARB) if necessary; add calcium channel blocker if
further reduction needed
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| Special indications: heart failure— β-blockers, ACE inhibitors, and ARBs may prolong life; aldosterone antagonists
also have role; myocardial infarction (MI)—medications lower BP and potentially prolong life; risk for coronary artery
disease (CAD)—thiazide diuretics reduce cardiovascular events (MI and cardiovascular death), but β-blockers and
ACE inhibitors sometimes preferred; calcium channel blockers reduce angina; diabetes—ACE inhibitors recommended
only for patients with proteinuria or chronic renal disease; thiazide diuretics and β-blockers recommended more generally;
renal disease—ARB or ACE inhibitor indicated; stroke—thiazide diuretics superior for prevention, followed by ACE
inhibitors
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| Antihypertensive Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT): thiazide diuretics
reduced incidence of heart failure by 50%, compared to α1 -blockers; implications—avoid monotherapy with α1 -
blockers, even in men with benign prostatic hyperplasia (BPH); trial—>33,000 patients (50% women; 33% black;
16% Hispanic), 55 yr of age, with hypertension and 1 other risk factor for coronary heart disease (CHD); treatment arms
included chlorthalidone, amlodipine, and lisinopril (no placebo arm); thiazide diuretics, calcium channel blockers, and
ACE inhibitors had similar effects on primary and secondary outcomes; implications—drug choice based on safety
and cost; thiazide diuretics recommended as first-line medical treatment
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| β-blockers: putative adverse effects include depression, fatigue, and sexual dysfunction, but claims not supported by
data; meta-analysis of 15 trials using 9 β-blockers found association with fatigue (placebo groups also had high rates)
but no association with depression; diabetes and hypertension—study found metoprolol led to worsening levels of hemoglobin
(Hb)A1c by 0.15% (virtually no change with carvedilol); insulin sensitivity improved with carvedilol; no difference
in control of BP; association between HbA1c and large vessel disease not well established; carvedilol more
expensive and difficult to use
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| ACE inhibitors: Heart Outcomes Prevention Evaluation (HOPE)—randomized trial compared ACE inhibitor
(ramipril) with placebo in 10,000 patients with vascular disease or diabetes plus 1 risk factor but normal ejection fractions;
patients followed for 5 yr; ramipril led to statistically significant reductions in all endpoints, including cardiovascular
death, MI, and stroke; ramipril reduced incidence of stroke by 32% and fatal stroke by 61%, independent of
reductions in BP; patients also had fewer cognitive impairments; chronic renal disease independently increases risk for
cardiovascular events; Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) trial—
comparison of ACE inhibitor (trandolapril) with placebo in 8000 patients with stable CAD and normal left ventricular
function; no differences in outcome found at 5 yr, bringing HOPE data into question; renal disease in blacks—
ramipril superior to amlodipine in patients with chronic renal disease and proteinuria; other studies—retrospective
cohort study looked at risk for rehospitalization and mortality among patients undergoing treatment with ACE inhibitors;
ramipril associated with lowest rates of cardiovascular events and mortality
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| Angiotensin-II receptor blockers: efficacy similar to that of ACE inhibitors; fewer adverse effects (particularly
cough and angioedema); note—use caution when combining with ACE inhibitor (some combinations harmful); seek
consultation with nephrologist when using combination therapy in patients with chronic renal disease; losartan—
superior to atenolol ( β-blocker) for preventing cardiovascular events and incident diabetes and for reducing mortality
and left ventricular hypertrophy (LVH)
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| Left ventricular hypertrophy: decrease in left ventricular mass independently associated with reduced mortality and
risk for stroke and MI; all BP medications, except direct vasodilators, help reverse LVH; thiazide diuretics, ACE inhibitors,
and β-blockers have similar effects
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| Calcium channel blockers: study found decreases in cardiovascular events and mortality; effects generally similar to
those of other drug classes (but CHD events somewhat higher with calcium channel blockers); dihydropyridines good
for treating systolic hypertension in elderly patients; good second drug for older patients with established coronary
disease; combination with ACE inhibitor has similar effect as β-blocker plus thiazide in patients with CAD; Women’s
Health Initiative observational study showed higher rates of cardiovascular mortality, both in monotherapy and combination
therapy
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| Other drug options: central nervous system (CNS) sympatholytics—clonidine preferred over methyldopa; α1 -
blockers—acceptable in combination therapy; not suitable for monotherapy; direct vasodilators—for treatment of
severe hypertension, particularly in patients with chronic renal disease; hydralazine preferred; loop diuretics usually
required; peripheral adrenergic antagonists—rarely needed; consider as fourth or fifth drug
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| RACE, ETHNICITY, AND HEALTH DISPARITIES: IMPLICATIONS FOR PRIMARY CARE PRACTICE
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| Overview: disparities in health care (most rigorously studied in blacks and whites) exist across broad spectrum, from patient-doctor
communication to system-wide problems of access; marked differences include access to technical procedures
(eg, coronary artery bypass grafting [CABG], angioplasty), cancer surgery (eg, lung), and renal transplantation
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| Seminal study (at Duke University): looked at large data set and compared vessel disease between whites and
blacks; no significant differences in treatment between ethnic groups among patients with single-vessel disease; however,
among patients with more advanced disease, white patients had more revascularization and lower rates of mortality,
when adjusted for predictors of coronary disease; differences in outcome correlated with differences in treatment;
greatest difference seen in access to CABG; subsequent study using videotapes of actors having chest pain found physicians
referred fewer women to cardiologist (black women had lowest rate of referral); additional studies have established
existence of disparities in procedures, medications, and outcomes
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| Race and ethnicity: demographic factors, useful to record; racial categories fit geographic origins of humans; ethnic
categories refer to self-identity with national origin or cultural group; admixture confounds categories (random pairing
would eliminate racial differences); in United States, race tends to correlate with social class; at all levels of income,
whites have higher measures of health and wealth; education and income insufficient to explain differences
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| Social determinants of health: socioeconomic status (people with low socioeconomic status have worse outcomes,
with exception of breast cancer and bipolar affective disorder); other correlates with adverse outcomes include single-
parent household, low functional health literacy, lack of immigration documents (ie, not eligible for Medicare), and
limited proficiency in English
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| More racial disparities: study using data set from Medicare compared measures of quality in health care for black and
white patients; black patients undergo fewer screens for breast cancer and fewer eye examinations (among diabetic patients),
and receive fewer prescriptions for β-blockers after MI and less follow-up after hospitalization for mental illness;
behavioral differences—eg, smoking, alcohol consumption, nutritional and exercise habits, violence, medical compliance;
may explain some differences in health outcomes among racial groups; environmental factors—study looking at
accessibility to healthy foods for diabetic patients (fresh fruits and vegetables, 1% fat milk, diet drinks, and high-fiber
bread) found large difference related to affluence of neighborhood (East Harlem vs upper east side in New York)
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| Biologic factors: some racial differences in rates of cancer not explained by other factors; breast cancer—white
women have highest rates (not explained by detection bias); Hispanic and Asian women have rates 40% of those of
white women; although black women have lower incidence of breast cancer (compared to white women), they are more
likely to have aggressive cancer and have higher rate of mortality; other cancers—rates of lung, colon, and cervical
cancer vary significantly with race; nicotine metabolism—high rate of lung cancer among blacks possibly related to
high metabolic clearance of nicotine and cotinine, leading to higher intake of tobacco smoke per cigarette, compared to
other racial groups (study showed Hispanics and whites have similar rates of clearance; Chinese have lowest rate of
clearance)
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| Communication: racial concordance—patients tend to “feel better” and discuss preferences about end-of-life care
more often when treated by clinician of same race; cultural attitudes about patient autonomy—collective or family
orientation may affect approach; empiric study found only 50% of Koreans and 66% of Hispanics would disclose diagnosis
of terminal lung cancer to patient (90% of whites and blacks would disclose diagnosis); language
concordance—empiric studies show patients who speak only Spanish feel better and have less pain, better health outlook,
and fewer symptoms when treated by Spanish-speaking clinician; patients more likely to understand instructions,
have better compliance, and ask more questions when clinician speaks same language than when interpreter
used; use of interpreter changes dynamics between clinician and patient; professional interpreter gold standard (most
accurate), but expensive and not always available
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| Questions and answers: paternalistic approach vs patient autonomy—patient autonomy important in modern health
care, but important to consider cultural values and traditions; impact of physician opinion on decision-making
process—many patients value physician recommendations about treatment options; desired amount of information varies
with patient
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Educational Objectives
| The goal of this activity is to review clinical evidence and recommendations for the management of hypertension and to
educate the clinician about racial and ethnic disparities in care. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Identify patients at risk of developing hypertension.
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| 2. Discuss health implications of hypertension.
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| 3. Develop management plans for patients with hypertension.
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| 4. Compare different classes of medications to treat hypertension.
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| 5. Discuss existing racial and ethnic disparities within health care system.
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Discussed on This Program
Amlodipine [AmVaz, Norvasc]
Atenolol [Tenormin]
Captopril [Capoten]
Carvedilol [Coreg]
Celecoxib [Celebrex]
Chlorthalidone [Hygroton, Thalitone]
Clonidine HCl [Catapres, Duraclon]
Enalapril maleate [Vasotec, Vasotec I.V.]
Fosinopril sodium [Monopril]
Hydralazine HCl [Apresoline]
Lisinopril [Prinivil, Zestril]
Losartan potassium [Cozaar]
Methyldopa [Aldomet]
Metoprolol succinate [Lopressor, Metoprolol Tartrate, Toprol XL]
Naproxen [Aleve, Anaprox, Anaprox DS, EC-Naprosyn, Naprosyn, Naprelan]
Perindopril erbumine [Aceon]
Quinapril HCl [Accupril]
Ramipril [Altace]
Rofecoxib [Vioxx] (withdrawn from market 09/30/04)
Trandolapril [Mavik]
Verapamil HCl [Calan, Calan SR, Covera-HS, Isoptin SR, Verelan, Verelan PM]
Suggested Reading
| Ansell BJ: Evidence for a combined approach to the management of hypertension and dyslipidemia. Am J Hypertens
18:1249, 2005; Brindel P, et al: Prevalence, awareness, treatment, and control of hypertension in the elderly: the Three
City Study. J Hypertens 24:51, 2006; Fahey T, et al: Educational and organizational interventions used to improve the
management of hypertension in primary care: a systematic review. Br J Gen Pract 55:875, 2005; Foody JM, et al:
Systolic hypertension in older persons: complexities in clinical decision making. Am J Geriatr Cardiol 14:325, 2005;
Grann V, et al: Regional and racial disparities in breast cancer-specific mortality. Soc Sci Med 62:337, 2006; Hertz
RP, et al: Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 165:2098,
2005; Iribarren C, et al: Sex and racial/ethnic disparities in outcomes after acute myocardial infarction: a cohort study
among members of a large integrated health care delivery system in northern California. Arch Intern Med 165:2105,
2005; Jankowski P, et al: Determinants of poor hypertension management in patients with ischaemic heart disease.
Blood Press 14:284, 2005; Kjeldsen SE, et al: Targeting the renin-angiotensin system for the reduction of cardiovascular
outcomes in hypertension: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Expert
Opin Emerg Drugs 10:729, 2005; Konrad TR, et al: Physician-patient racial concordance, continuity of care, and patterns
of care for hypertension. Am J Public Health 95:2186, 2005; Nilsson PM, et al: Update on hypertension management:
treatment of hypertension in patients with type 2 diabetes mellitus. J Hypertens 24:208, 2006; Schulz AJ, et
al: Social and physical environments and disparities in risk for cardiovascular disease: the healthy environments partnership
conceptual model. Environ Health Perspect 113:1817, 2005; Siminoff LA, Ross L: Access and equity to cancer
care in the USA: a review and assessment. Postgrad Med J 81:674, 2005; Woodard LD, et al: Racial differences in
attitudes regarding cardiovascular disease prevention and treatment: a qualitative study. Patient Educ Couns 57:225,
2005.
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Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the
faculty reported nothing to disclose.
Dr. Perez-Stable was recorded in San Francisco at Primary Care Medicine: Principles and Practice, sponsored by University
of California, San Francisco, School of Medicine, Division of General and Internal Medicine, and held October
19-21, 2005. The Audio-Digest Foundation thanks Dr. Perez-Stable and the University of California, San Francisco,
School of Medicine for their cooperation in the production of this program.
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