Pickering_1.ppt

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin

Determinations be Part of the Routine Evaluation of Hypertensive Patients?

Thomas Pickering MD, DPhilBehavioral Cardiovascular Health and

Hypertension ProgramColumbia Presbyterian Medical Center

New York


Determinations be Part of the Routine Evaluation of Hypertensive Patients?



New York


Determinations be Part of the Routine Evaluation of Hypertensive Patients



New York

Rationale- One Size Does Not Fit All

1. Level of risk varies greatly in hypertensive patients

2. Responsiveness to treatment varies greatly in hypertensive patients




1. Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria




1. Need tests to improve prediction of risk in individual patients, e.g. ABPM, Echocardiography, microalbuminuria

2. Need tests to improve prediction of treatment response, e.g. renin

JNC 7 Recommendations for Routine Work-up of Hypertensive Patients

Routine Tests• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,

and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and

low-density lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

1. ABPM

2. Echocardiogram

3. Renin

1. ABPM

2. Echocardiogram

3. Renin

Recommendations for Clinical Use of ABPM: JNC 7 & WHO-ISH

JNC 7 WHO-ISH

ABPM endorsed Yes Yes

Indications:

White Coat HTN Yes Yes

Labile BP Yes Yes

R/O hypotensive episodes Yes Yes

Resistant HTN Yes Yes

Autonomic dysfunction Yes No

Ambulatory BP and Cardiovascular Disease in the Elderly with Systolic Hypertension:The Syst-Eur Study (N = 808)

Active treatment

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Staessen et al. JAMA 1999; 282: 539-46.


Active treatment

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High risk group- Clinic BP underestimates risk


Active treatment

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High risk group- Clinic BP underestimates risk

Low risk group- WCH Clinic BP overestimates risk

The White Coat Effect in the Real World(Little et al, BMJ 2002; 325: 254)

• 173 hypertensive patients in 3 general practices in the UK

• Clinic (MD and RN), self-monitoring, and ABPM

• White coat effect estimated as difference between other measures of BP and daytime BP:-

Physician 19/11 mmHg

Nurse 1 5/8 mmHg

Nurse 2 5/6 mmHg

Self-monitoring in clinic 10/13 mmHg

Self-monitoring at home 5/6 mmHg

135/85 Ambulatory Pressure

140/90

Clinic Pressure Sustained

HypertensionWhite Coat Hypertension

True Normotension

Masked Hypertension


140/90



True Normotension

Masked Hypertension


140/90



True Normotension

Masked Hypertension

1. ABPM

2. Echocardiogram

3. Renin

Why Is Echocardiography Useful In Hypertensive Patients?

“No other biological variable (except advancing age) predicts cardiac risk better

than left ventricular hypertrophy”.

(De Simone et al, J Hypertens 12;1129, 1994)

How Common is LVH in Hypertensive Patients?

• ECG LVH in about 5% of ht patients

• Echo LVH in 15-30% of unselected ht patients• Echo LVH in 20 to 60% of ht patients in referral centers

Indications for Echocardiography in Hypertensive Patients

• Coexistent Heart Disease

• Resistant Hypertension

• Decision to Start Treatment Uncertain

Echocardiographic LVMI as a Predictor of CV Risk (Schillaci et al, Hypertens 2000; 35: 580)

0.85

1.66

2.24

2.86

4.34

0

1

2

3

4

5

1st 2nd 3rd 4th 5th

CV Events per 100-pt years

Quintiles of LVMI

In-Treatment LV Mass Predicts CV Events -LIFE Study. (Devereux et al JAMA 2004: 292:2350)

1. ABPM

2. Echocardiogram

3. Renin

Possible Applications of Renin Measurement

1. Better prediction of risk

Renin as a Risk Factor for MI (Alderman et al, AJH 1997; 10: 1)

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5

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2530

35

Low Normal High

Low

Moderate

High

Renin

Risk Status

Risk of MI/1000 pt-yrs

Possible Applications of Renin Measurement

1. Better prediction of risk

2. Identification of secondary hypertension

3. Prediction of drug response

Situations in which Renin Measurement May Be Helpful

• Suspected secondary hypertension, e.g. hypokalemia (measure off drugs)

• Refractory hypertension (measure on drugs)

• Intolerance to multiple drugs (measure off drugs)

Limited Efficacy of Monotherapy in Treating Hypertension (Materson NEJM 1993; 328: 914)

72

605554

50

31

0

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70

80

Placebo Captopril Prazosin HCTZ Atenolol Diltiazem

Patients Responding %

JNC 7: New Features and Key Messages (Continued)

Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.

Certain high-risk conditions are compelling indications for other drug classes.

Most patients will require two or more antihypertensive drugs to achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

Double-Blind Placebo-Controlled Comparison of 5 Classes of Antihypertensive

Drugs(Deary et al, J Hypertens 2002; 20:771)

• 34 young (47 years) hypertensives rotated between 5 drugs: A- ACEI (lisinopril); B- beta blocker( bisoprolol); C- calcium channel blocker (Amlodipine); D- diuretic (bendrofluazide); alpha blocker (doxazosin); placebo, for 6 weeks each.

• Best BP responses were to a renin-suppressing drug (A or B).

• No correlations between individual responses to different drugs, except A with B, and C with D (each r=0.71, p <0.005).

• Response to “best drug” was repeated and highly reproducible (r=0.79).

• Age and plasma renin activity did not predict BP response.

The A/B C/D RuleACEI- ARB/Beta blocker Calcium channel blocker/Diuretic

• Start with A/B or C/D drug: if poor BP response switch to other group

• Younger patients do best with A/B drugs; older patients do best with C/D drugs .

• Beta blockers may be inferior to other drugs for primary prevention.

• In younger patients preferred drug is ARB or ACEI.

• In older patients preferred drug is Diuretic or CCB.

Brown MJ. Heart 2001; 86:113

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- ABPM

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without ABPM

• Some type of out-of-office BP monitoring (home or ambulatory) is advisable in ALL patients

• ABPM is indicated when there is a discrepancy between either successive clinic readings or clinic and home readings

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions- Echocardiography

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without echocardiography

• Echocardiography is indicated if any of the following occur

– Coexistent heart disease

– Refractory hypertension

– Decision to treat uncertain

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement

Should Ambulatory Blood Pressure Monitoring, Echocardiogram, and Renin Determinations be Part of the Routine Evaluation of Hypertensive Patients?Conclusions-Renin measurement

• Many patients can be evaluated and treated by following the basic JNC 7 guidelines without renin measurement

• Renin measurement is indicated in the following situations:

- Suspected secondary hypertension

- Refractory hypertension

- Intolerance to multiple drugs

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Pickering_1.ppt