High blood pressure (hypertension) is widespread in Detroit, what we can do about it

1. High blood pressure (hypertension) is widespread in Detroit, what we can do about it Oscar A. Carretero, M.D. Hypertension and Vascular Research Division Department of Medicine Henry Ford Health System Detroit, Michigan

2. 1) What is hypertension or high blood pressure • 2) What causes hypertension? • 3) Why worry ? • 4) Is it widespread in Detroit ? • 5) What we can do?

3. Blood Pressure Classification JNC 7 Hypertension 2003; 42: 1206-1252

4. High blood pressure (hypertension) affects nearly 65 million adults (1/3) in the United States. High blood pressure is often called a "silent killer" because many people have it, but don't know it. Over time, people who do not get treated for high blood pressure can get very sick or even die.

5. 1) What is hypertension or high blood pressure • 2) What causes hypertension? • 3) Why worry ? • 4) Widespread in Detroit ? • 5) What we can do?

6. What Causes Hypertension • ( the so-called Essential Hypertension) • 1. Genetic variances (4-10 genes): • a) If the genes contribute equally, they will be difficult to identify. • b) Genes interact with multiple environmental factors that increase Blood Pressure. • 2. Environmental factors: • a) Obesity, metabolic syndrome, diabetes type 2 • b) High alcohol intake • c) High salt intake • 3. Aging, • 65 years of age or more, 2/3 have systolic hypertension • probably due to arteriosclerosis and atherosclerosis

7. EVIDENCE FOR THE PARTICIPATION OF GENETIC FACTORS IN HYPERTENSION • Family studies • Twin studies • Adoption studies • Experimental models of hypertension including genetic and transgene models • Association of genotypes and BP • (candidate gene probe; mapping)

9. Causes of Essential Hypertension • Genetic factors • 2. OBESITY and METABOLIC Syndrome • 3. High Salt Intake/ diet • 4. HIGH ALCOHOL INTAKE • 5. Ageing

10. Interaction Among Genetic and Environmental Factors Multiple Genes (4-10) Phenotype: BP 100 geneticsusceptibility Intermediate phenotypes 50 obesity Population Distribution (%) 0 60 Environmental Factors High calorie intake 140 220 SystolicBlood Pressure (mmHg)

12. Diastolic Blood Pressure as a Function of Abdominal Circumference(Normative Aging Study) 78 77 76 DBP mmHg 75 74 88.6 93.2 97.5 102.7 Abdominal circunferente, cm (quintiles) C. Johnston, Journal of Hypertension, 10 (suppl 7):S13-S26 1992

13. Interaction Among Genetic and Environmental Factors + metabolic syndrome +obesity Multiple Genes (4-10) Phenotype: BP 100 geneticsusceptibility Intermediate Phenotypes 50 Population Distribution (%) 0 60 Environmental Factors 140 220 SystolicBlood Pressure (mmHg)

14. What Is the Metabolic Syndrome? • Impaired biological response to insulin: • Impairment of normal glucose uptake by muscle and/or decrease in hepatic glycogen production • Precedes type 2 diabetes in the majority of patients • Diagnosis defined by the concurrence of any 3 among: • Abdominal obesity (men >40 in, women >35 in) • Low HDL cholesterol (men <40 mg/dL, women <50 mg/dL) • Hypertension (130/85 mm Hg) • Hypertriglyceridemia (150 mg/dL) • High fasting glucose (110 mg/dL) • Proinflammatory (>CRP) McFarlane S, et al. J Clin Endocrinol Metab. 2001;86(2):713-8. Reaven GM. Diabetes. 1988;37:1595-607. Lebovitz H. Clin Chem. 1999;45(8B):1339-45. Ford ES, et al. JAMA. 2002;287:356-359. NCEP/ATP III. 3

15. Prevalence of Metabolic Syndrome by Age Group (estimated 47 millions in the USA Age-Specific Prevalence in US Adolescents and Adults, 1988-1994 50 Male 45 Female 40 35 30 Prevalence (%) 25 20 15 10 5 0 12-19 20- 29 30- 39 40- 49 50- 59 60- 69 ³70 Age 4 Ford ES et al. JAMA. 2002;287:356-9.

16. 250 Nondiabetic patients 200 Diabetic patients 150 Cardiovascular MortalityRate per 10,000 Patient-Years 100 50 0 <120 120–139 140–159 160–179 180–199 ³200 SBP (mm Hg) MRFIT Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk Elevated systolic blood pressure increases risk of CV death almost twofold in diabetic vs non-diabetic patients Stamler J et al. Diabetes Care. 1993;16:434-444. 20

17. Causes of Essential Hypertension • Genetic factors • 2.Obesity and Metabolic Syndrome • 3. High Salt Intake/ diet • 4. HIGH ALCOHOL INTAKE • 5. Ageing >65

18. Percentage of each drinking category with systolic or diastolic hypertension. Numbers in columns refer to total in the population subgroup. “ “Effects of alcohol use and other aspects of lifestyle on blood pressure and prevalence of hypertension in a working population”. Arkwright et al Circulation 1982, 66:60-66. PERCENT OF GROU P WITH SYSTOLIC PRESSURE ≥140 mm Hg 117 114 134 126 PERCENT OF GROUP WITH DIASTOLIC PRESSURE ≥90 mm Hg 0 1-160 161-350 >350 ALCOHOL CONSUMPTION (ml ethanol consumed per week)

19. Causes of Essential Hypertension • Genetic factors • 2.Obesity and metabolic syndrome • 3. High Salt Intake/ diet • 4. High alcohol intake • 5. Ageing >65

20. Why an Aging Population? • The “baby boom” following World War II • Rise in life expectancy, 1950= 48, 2012= 78 • A decline in fertility • Better medical treatment?

23. Interaction Among Genetic and Environmental Factors + metabolic syndrome +high alcohol / diet +obesity + ageing Multiple Genes (4-10) Phenotype: BP 100 geneticsusceptibility Intermediate Phenotypes 50 Population Distribution (%) 0 60 Environmental Factors 140 220 SystolicBlood Pressure (mmHg)

24. 1) What is hypertension or high blood pressure • 2) What cause Hypertension? • 3) Why worry ? • 4) Widespread in Detroit ? • 5) What we can do? • 6) How to treat

26. Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality: • 7% from heart disease • 10% from stroke.

27. THE NEW YORK TIMES, TUESDAY, JULY 16, 2013 Kidney Disease, an Underestimated Killer90,000 a year (more than cancer of breast and prostate together)

28. 1) What is hypertension or high blood pressure • 2) What cause Hypertension? • 3) Why to worry ? • 4) Hypertension is widespread in Detroit, why ? • 5) What we can do? • 6) How to treat

29. National List of Hypertension Hotspots • Memphis, TN-MS-AR • Detroit-Livonia-Dearborn, MI • Louisville-Jefferson County, KY-IN • Birmingham-Hoover, AL • Dayton, OH • Pittsburgh, PA • Buffalo-Niagara Falls, NY • St. Louis, MO-IL • Tampa-St. Petersburg-Clearwater, • Indianapolis-Carmel, IN • Oklahoma City, OK

30. Causes of Essential Hypertension • Genetic factors? • 2. Obesity and Metabolic Syndrome • High Salt-Sensitivity and high salt Intake • / diet? • 4. High alcohol intake • 5. Ageing

31. 2011 state-by-state adult obesity rates • Mississippi (34.9%); • Louisiana (33.4%); • West Virginia (32.4%); • Alabama (32.0%); • 5. Michigan (31.3%); • 6. Oklahoma (31.1%); 7. Arkansas (30.9%); 8. (tie) Indiana (30.8%); and South Carolina (30.8%); • 10. (tie) Kentucky (30.4%); and Texas (30.4%); 12. Missouri (30.3%); 13. (tie) Kansas (29.6%); • and Ohio (29.6%); 15. (tie) Tennessee (29.2%); and Virginia (29.2%); 17. North Carolina (29.1%); • 18. Iowa (29.0%); 19. Delaware (28.8%); 20. Pennsylvania (28.6%); 21. Nebraska (28.4%); • 22. Maryland (28.3%); 23. South Dakota (28.1%); 24. Georgia (28.0%); 25. (tie) Maine (27.8%); • and North Dakota (27.8%); 27. Wisconsin (27.7%); 28. Alaska (27.4%): 29. Illinois (27.1%); • 30. Idaho (27.0%); 31. Oregon (26.7%); 32. Florida (26.6%); 33. Washington (26.5%); • 34. New Mexico (26.3%); 35. New Hampshire (26.2%); 36. Minnesota (25.7%); • 37. (tie) Rhode Island (25.4%); and Vermont (25.4%); 39. Wyoming (25.0%); 40. Arizona (24.7%); • 41. Montana (24.6%); 42. (tie) Connecticut (24.5%); Nevada (24.5%); and New York (24.5%); • 45. Utah (24.4%); 46. California (23.8%); 47. (tie) District of Columbia (23.7%); and • New Jersey (23.7%); 49. Massachusetts (22.7%); 50. Hawaii (21.8%); 51. Colorado (20.7%).

32. Prevalence of Hypertension in the U.S. in Men by Age and Ethnicity Caucasian Hispanic African American Adapted from Burt et al. Hypertension 1995;25:305. 100 80 60 Prevalence of hypertension (%) 40 20 Age (y) 0 39 >80 30 - 18 - 29 50 - 59 60 - 69 70 - 79 40 - 49

33. Obesity Risk Factor for Hypertension • How fat is Michigan? Very fat. • We are the 5th fattest state. • Three of 5 Michiganders could be obese by 2030 and health care cost will skyrocket

34. Diastolic Blood Pressure as a Function of Abdominal Circumference(Normative Aging Study) 78 77 76 DBP mmHg 75 74 88.6 93.2 97.5 102.7 Abdominal circunferente, cm (quintiles) C. Johnston, Journal of Hypertension, 10 (suppl 7):S13-S26 1992

35. 1.0 N+R .9 Cumulative Survival Salt-Sensitivity • This is very important sinceindividuals with salt-sensitivity, whether hypertensive or not, have a higher mortality than salt-resistant subjects. • Blacks have higher salt-sensitivity than Whites. p <0.0001 .8 N+S .7 H+R H+S .6 10 30 20 5 0 25 15 Follow-up (yrs) M.H. Weinberger et al . Hypertension. 2001;37[part 2]:429-432

37. FEATURES OF HYPERTENSION IN BLACK PATIENTS • Earlier onset • Salt sensitivity • Frequently concomitant with obesity / diabetes • High target organ damage • Increased prevalence of ESRD • Low urinary kallikrein excretion • Low RAS

38. 1) What is hypertension or high blood pressure • 2) What cause Hypertension? • 3) Why to worry ? • 4) Widespread in Detroit ? • 5) What we can do?

39. Lifestyle Modification

40. Lowering SBP by 20 mm Hg Reduces Cardiovascular Risk by Half Other vascular causes Stroke Ischemic Heart Disease 0 -10 N=958,074 -20 40-49 50-59 -30 60-69 % mortality reduction for each 20 mm Hg drop in SBP Years of age -40 70-79 80-89 -50 -60 -70 *Data from a meta-analysis of 1 million adults in 61 prospective studies who had no prior vascular disease.Lewington S et al. Lancet. 2002;360:1903-1913. 23

41. We need a team-based approach to solve the problem of hypertension in Detroit: Health care systems: a) electronic health records, b) encourage the use of 90-day, antihypertensive refills, c) low or no co-pays (compliance will decrease stroke, heart attacks, heart failure, and end stage renal disease (dialysis) . We will save money and suffering. d) Provide education for patients Providers: doctors, nurses, pharmacists etc: a) Counsel patients to take their medicine and make lifestyle changes, b) track their patient’s blood pressure, c) explain that hypertension is treated but not cured, d) measure progress against specific objectives, e) review records looking for patients that are not under BP control. Patients: a) take the initiative to monitor blood pressure levels weekly and record, b) take medication as prescribed, and c) notify the doctor of any side effect, d) MAKE LIFESTILE CHANGES such as losing weight , eating Dash diet, low sodium diet, e) exercise (walk) and f) stop smoking

43. Left without health insurance in states that opted out of expanding Medicaid

44. Algorithm for Treatment of Hypertension JNC 7 Algorithm for Treatment of Hypertension JNC 7 Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices With Compelling indicationsWith Compelling Indications Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI, ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB) as needed Algorithm for Treatment of Hypertension JNC 7 Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices With Compelling indicationsWith Compelling Indications Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI, ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB) as needed Not at Goal Blood Pressure Optimize dosages or add additional drugs Algorithm for Treatment of Hypertension JNC 7 Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices With Compelling indicationsWith Compelling Indications Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI, ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB) as needed Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling Indications With Compelling Indications Drug (s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mmHg Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB Stage 2 Hypertension (>SBP 160 or DBP >100 mmHg Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist

45. Cumulative probability of survival from coronary artery disease in 686 men with hypertension and 6810 non-hypertensive men in primary prevention study. O.K. Anderson, O. K. et al. BMJ, Vol. 317, July 1998

46. National List of Hypertension of not very hotspots • New York-White Plains-Wayne, NY-NJ • Boston-Quincy, MA • San Diego-Carlsbad-San Marcos, CA • Minneapolis-St. Paul-Bloomington, MN-WI • Oakland-Fremont-Hayward, CA • Los Angeles-Long Beach-Glendale, CA • Denver-Aurora, CO • Salt Lake City, UT • San Francisco-San Mateo-Redwood City, CA

47. Wave velocity Wave velocity Wave velocity Simple tubular models of the systemic arterial system. Top, normal distensibility and normal pulse wave velocity. Middle, decreased distensibility but normal pulse wave velocity. Bottom, decreased distensibility with increased pulse wave velocity. Left, are the amplitude and contour of pressure waves that would be generated at the origin of these models by the same ventricular ejection (flow) waves. Decreased distensibility per se increases pressure wave amplitude, while increased wave velocity causes the reflected wave to return during ventricular systole. M. O’Rourke, Hypertension 1995; 26:2-9