Mr Patrick Gladding - GP CME North/Fri_Room11_1630... · 80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations. Office BP 190/90 on an ACEi/thiazide

Mr Patrick GladdingSpecialist

General Cardiology and Internal Medicine

Auckland

16:30 - 17:25 WS #60: Individualising Hypertension Treatment - Intensive or Not?

17:35 - 18:30 WS #72: Individualising Hypertension Treatment - Intensive or Not?

(Repeated)

Individualising Hypertension Treatment: Intensive or not?

Dr. Patrick Gladding, MBChB, FRACP, PhDAscot Cardiology

Hypertension update

• New Guidelines

• Definitions and treatment thresholds

• Global risk, investigations (Pulse wave velocity) and monitoring (mHealth)

• Targets – SPRINT trial

• Lifestyle interventions (Functional Foods)

• Genomics and Personalised Care

Outline

Secondary causes of Hypertension

Cushings syndrome

Aortic coarctation

• Office BP• White coat hypertension

• Ambulatory 24-hr BP (ABPM)• Masked hypertension

• Home blood pressure monitoring• Increased granularity

• White coat hypertension

• Feedback

• Dietary/Lifestyle and drug n=1 trials

• Adherence

• Personal control

JAMA. 2014;312(8):799-808

• 552 patients• 9mmHg SBP reduction with self-Mx

• 2 emerging techniques in echo to improve detection of end-organ damage:

1) LV strain; Deformation of the LV vs EF

2) LV mass

• 76 yr old man –Supine HTN orthostatic hypotension (~50mmHg)

• Arterial stiffness indicates lower central BP

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Hypertension update

• JNC 8• Goal for people > 60 yrs should be a SBP < 150, DBP < 90

• For fit elderly patients, a high DBP (>90 mm Hg) was associated with a 50% increase in mortality

• By contrast, for frail elderly patients, a low DBP was associated with a 50% increased risk of dying during 15 year follow-up period

1466 older men and women

“The ultimate goal is personalized treatment so that we can avoid overtreatment of the frail, and undertreatment of the fit.”

• 9361 patients (age, ≥50) with SBP of 130 to 180 mm Hg and high cardiovascular (CV) risk

• One or more: CV disease, CKD EGFR 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75

• Patients with diabetes and stroke were excluded. • Patients were randomized to either intensive or standard treatment (systolic

BP targets, 120 or 140 mm Hg, respectively)• The trial was terminated early after median follow-up of 3.3 years• The primary composite outcome (MACE) occurred in 5.2% of intensive-

treatment patients and 6.8% of standard-treatment patients (P<0.001)

• “First, the results should not be considered a mandate for people to run out and get treated so their blood pressures are below 120.

• Second, the potential benefits of lowering blood pressure must be weighed against harms.

• Third, we need more information about the balance of risks and benefits for each person so that the choice can be personalized.”

“The ideal blood pressure for most people is likely to be below 120 mmHg systolic and 75 mmHg diastolic.”

“The 2017 AHA/ACC guideline’s recommended treatment goal is to reach office BP levels of less than 130mmHg (systolic) and less than 80 mmHg (diastolic) if pharmacotherapy is commenced.”

80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations.

Office BP 190/90 on an ACEi/thiazide combination (Inhibace plus) as well as bisoprolol 2.5mg od.She takes ASA and a statin, has no T2DM, total cholesterol of 3.9, an HDL of 1.3 mmol/L.

Creatinine 82 umol/L, caucasian, nonsmoker.

• Is she well treated?• Should treatment be intensified?• Is the SPRINT trial relevant?

Is there an app for that????

Personalised Hypertension Management

Insert title of presentation here

ABPM shows average BP 135/80 with a precipitous drop

at around 1400 (see attached) to BP 105/66, when she

often feels unwell.

Diastolic BP <65mmHg is BAD




• Is she well treated? – NO. She is overtreated.• Should treatment be intensified? – NO• Is the SPRINT trial relevant? – YES and NO

SPRINT score calculator NNT 267, NNH 30.





• Inhibace + is halved

“I’m a different person!”


iOS Android

https://itunes.apple.com/ru/app/blood-pressure-calculation/id1270845450?l=en&mt=8

https://play.google.com/store/apps/details?id=com.blood.lukas.myapplication

Guidelines – take with a grain of salt

• Increased risk of CV events with very low salt intake

• Guidelines based on averaging population

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N Engl J Med 2014

Renal denervation therapy

• SYMPLICITY-3:• Renal denervation therapy

doesn’t work, for unselected patients with HTN

• Renal artery stenosis

Age directed vs Renin directed Rx

Individualise Rx based on other comorbidities

Spironolactone for Resistant HTN

http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v3/ch013/005f.html

J Clin Pharmacol 1994;34:1173-1176

Gladding et al. Personalized Medicine Journal. June 2015 ,Vol. 12, No. 3, Pages 297-311

Personalised Medicine in practice

35

Era of Mobile Health

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Advanced ECG

• WiFi based ECG

• Ultraportable, $3,500

• Deconvolutes ECG components

• Advanced pattern recognition, artificial intelligence

• ECG biological age

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Advanced ECG for general practice

• Sensitive, high sampling frequency, accurate.

Case

• 43 year old man with dyspnoea, BP 220/140

Case

41

British Journal of General Practice 2007; 57: 191–195

BMJ 1996;312:222

• A-ECG LVSD Sensitivity 93-95%, Specificity 95%

• Southern X reimbursed

Conclusion

• Hypertension is common, often called the “Silent Killer”

• Requires personalised Care taking into account • Global risk• Age and comordities• Guidelines not always applicable to the individual patient

• Emerging technologies for investigation of end-organ disease

• Lifestyle, diet, prevention paramount• Functional foods• Feedback, mHealth, Internet of Things (IoT)

• Limited new drug treatments, or procedures though these will be targeted

• Emerging role of genomics (not yet fully advocated)

Interactive Session: Hypertension and Personalised Care

Dr. Patrick Gladding, MBChB, FRACP, PhD

Case: 26 year old with HTN on home BP monitor

• Checked BP on friend’s mother’s home BP machine

• Measurement “high”

• ABPM 169/101

• No other PMHx

• Maternal Grandparents had HTN, Gfather had ESRF and HD

• Normal diet, no illicit drugs

• Mother did not have pre-eclampsia

• Normal FBC, Cr, TSH.

46

Ubiquitous home BP monitoring


47

What investigations would you order?

1. Urinalysis – sediment, microalbumin/Cr ratio2. Renin/Aldosterone levels3. Echocardiogram4. Renal artery USS5. All of the above


48

What investigations would you order?

1. Urinalysis – sediment, microalbumin/Cr ratio2. Renin/Aldosterone levels3. Echocardiogram4. Renal artery USS5. All of the above


49

Differential diagnosis for his age

•Secondary hypertension much more likely from structural reasons e.g. coarctation, PCKD, but acute renal injury, nephritis but also endocrine (hyperaldosteronism)•FHx – PCKD? Hereditary HTN

Case: Value of ubiquitous home BP monitoring

• Checked BP on friend’s mother’s home BP machine

• Measurement “high”

• ABPM 169/101

• USS – right renal hydronephrosis

• ACEi - ?nephrectomy

50

Case: 56 year old man with longstanding hypertension

• 56 year old man with longstanding hypertension

• GORD, dyslipidaemia, TIA 2014?, abnormal LFTs - 3-4L beer/day

• Palmar desquamation reaction to indapamide

• ABPM average BP 145/87, whilst on Candesartan 16mg od

• Renal USS – no renal artery stenosis, post void residual 80mls

• Echocardiogram: Mild basal septal hypertrophy

• Renin 744 (4 – 46), Aldosterone 134 (60 – 1,000) on ARB


Case: 56 year old man

53

How would you manage him?

1. Renin directed Rx - Bb2. Add bendrofluazide3. Add amlodipine4. Counsel regarding EtOH5. 1 or 3, and 4

Spironolactone for Resistant HTN



54Spironolactone for Resistant HTN

How would you manage him?

1. Renin directed Rx - Bb2. Add bendrofluazide3. Add amlodipine4. Counsel regarding EtOH5. 1 or 3, and 4


• Renin is a red herring, cannot be relied upon whilst taking antiHTN meds, especially RAAS blockers• Renin is also elevated in chronic EtOH

• Indapamide is a “thiazide-like diuretic”, as is bendrofluazide ?Class effect with desquamation

• Age on the cusp of the NICE guidelines so could get ACEi (<55yrs) or CCHB (>55yrs) however the big problem is in the ABPM


Case: Value of 24hr ABPM and diurnal measures

Focus on alcohol

Worrying diastolic nadir 40mmHg

Case: 56 year old man abstaining from alcohol

Case: 61 year old GP

• 61 year old GP, Hx of HTN on Rx

• 12L ECG “normal” AECG abnormal/CAD and biological age

• Coronary angiogram mild-moderate CAD58

Journal of Hypertension 2014, 32:1229–1236

What are the red arrows pointing to?

1.Acute coffee intake2.Conn syndrome3.Work stress4.Normal diurnal variation5.Phaeochromocytoma

Case – 61 year old GP

What are the red arrows pointing to?

1.Acute coffee intake2.Conn syndrome3.Work stress4.Normal diurnal variation5.Phaeochromocytoma

Case: 61 year old GP

Case – 61 year old GP

• Work stress is associated with HTN

• Concurrent CAD Rx to lower target?

• Manage causes of stress, mindfulness61


Case: 56 year old wife of GP

• ABPM BP 166/97

(Grade II HTN)

• Was on Amlodipine 5mg

• Drug withheld 2 weeks:• Renin 22, Aldo N

• Green mussel extract, celery extract

Emotional stress

Journal of Hypertension 2014, 32:1222–1228J Clin Hypertens (Greenwich). 2014 Jan; 16(1): 54–62.

What is the next course of action?

1.Increase dose of CCHB2.Bb3.ACEi or ARB4.Diuretic5.Spirinolactone




What is the next course of action?

1.Increase dose of CCHB2.Bb3.ACEi or ARB4.Diuretic5.Spirinolactone




Case – 56 year old wife of GP

• Was on Amlodipine 5mg

• ABPM BP 166/97

• Renin 22, Aldo N

• Green mussel extract, celery extract

• Px Chlorthalidone12.5mg od

• Pranayama

Emotional stress


Pranayama

J Clin Hypertens (Greenwich). 2014 Jan; 16(1): 54–62.

Case: 48 year old woman

• 48 year old woman with depression on Venlafaxine 225mg

• Mild dyslipidaemia

• Prior Hx of right sided breast cancer, partial mastectomy

• FHx of premature stroke

• Office BP 145/99

• Normal Cr, ECG, renin/aldosterone ratio

66

How would you better define risk in view of BP?

•Advanced lipids Lp(a)

•CIMT

•CAC

•ETT

•CTCA67


How would you better define risk in view of BP?

•Advanced lipids Lp(a)

•CIMT

•CAC

•ETT

•CTCA68


What is the cause of her mild hypertension?

69


Case: Drug induced HTN

• 48 year old woman with depression started Venlafaxine, BP 145/99

• Genomics indicated ADE

• WiFi BP max 133/95

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Case:29 year old woman

•29 year old woman, otherwise well, father adopted

•Normal weight, no EtOH

•No added salt, good sleep quality

•Office BP 140/90 on OCP71


What would you do next?

1. Stop the OCP, alternative Rx and retest her BP

2. 24-hr ABPM

3. Renin/Aldosterone

4. Renal USS

5. Renal denervation therapy

What would you do next?

1. Stop the OCP, alternative Rx and retest her BP

2. 24-hr ABPM

3. Renin/Aldosterone

4. Renal USS

5. Renal denervation therapy

Case: Incidental genomics

• 29 year old woman, otherwise well, father adopted

• Office BP 140/90 on OCP

• ABPM 132/85

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• 3-4 cups of coffee per day associated with increased risk of MI and HTN in poor metabolisers


deltaF508 carrier

Genetic counselling

Prenatal screening

Case 54 year old man

• 54 year old man presents with MI

• HTN with known hypertensive retinopathy, mild-mod LVH on Echo• BP 217/119 in 2014, started on Felodipine 10mg od

• Smoker

• Occasional methaphetamine user

• BP 170/90 on chlorthalidone 12.5mg od

• Moderate CAD on coronary angiography

• ASA/Ticagrelor/Statin/Bb/Chlorthalidone

Case 54 year old man - Potassium

Losartan + Thiazide

MI

Atypical CP, dyspnoeaAdmitted to hospital

TnI <15

Felodipine 10mg odAtypical CP, dyspnoeaAdmitted to hospital

Dx GORD

Took P went to ED

F/up clinicChlorthalidone

stopped

3.5

3.42.9

Renin <2 (4 – 46), Aldosterone 600 (60 – 1,000)

K supp

Spironolactone

What is the diagnosis?

1.Acute coffee intake2.Surreptitious thiazide use3.Conn syndrome4.Methaphetamine related hypokalaemia5.Phaeochromocytoma


What is the diagnosis?

1.Acute coffee intake2.Surreptitious thiazide use3.Conn syndrome4.Methaphetamine related hypokalaemia5.Phaeochromocytoma

Case: Conn Syndrome

Saline suppression testRenal vein sampling

Thank you

Documents

Mr Patrick Gladding - GP CME North/Fri_Room11_1630... · 80 year old woman seen in clinic. Presenting symptom of presyncope and palpitations. Office BP 190/90 on an ACEi/thiazide