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

1
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive
Patients?

• Thomas Pickering MD, DPhil
• Behavioral Cardiovascular Health and Hypertension
  Program
• Columbia Presbyterian Medical Center
• New York

2
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive
Patients?
Pro

• Thomas Pickering MD, DPhil
• Behavioral Cardiovascular Health and Hypertension
  Program
• Columbia Presbyterian Medical Center
• New York

3
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients
(Sort of)

• Thomas Pickering MD, DPhil
• Behavioral Cardiovascular Health and Hypertension
  Program
• Columbia Presbyterian Medical Center
• New York

4
Rationale- One Size Does Not Fit All

• Level of risk varies greatly in hypertensive
  patients
• Responsiveness to treatment varies greatly in
  hypertensive patients

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Rationale- One Size Does Not Fit All

• Level of risk varies greatly in hypertensive
  patients
• Responsiveness to treatment varies greatly in
  hypertensive patients
• Need tests to improve prediction of risk in
  individual patients, e.g. ABPM, Echocardiography,
  microalbuminuria

6
Rationale- One Size Does Not Fit All

• Level of risk varies greatly in hypertensive
  patients
• Responsiveness to treatment varies greatly in
  hypertensive patients
• Need tests to improve prediction of risk in
  individual patients, e.g. ABPM, Echocardiography,
  microalbuminuria
• Need tests to improve prediction of treatment
  response, e.g. renin

7
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

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• 1. ABPM
• 2. Echocardiogram
• 3. Renin

9

• 1. ABPM
• 2. Echocardiogram
• 3. Renin

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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

11
Ambulatory BP and Cardiovascular Disease in the
Elderly with Systolic Hypertension The Syst-Eur
Study (N 808)
Placebo
Active treatment
Cardiovascular disease (per 1000 patient - year)
Staessen et al. JAMA 1999 282 539-46.
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Ambulatory BP and Cardiovascular Disease in the
Elderly with Systolic Hypertension The Syst-Eur
Study (N 808)
High risk group- Clinic BP underestimates risk
Placebo
Active treatment
Cardiovascular disease (per 1000 patient - year)
Staessen et al. JAMA 1999 282 539-46.
13
Ambulatory BP and Cardiovascular Disease in the
Elderly with Systolic Hypertension The Syst-Eur
Study (N 808)
High risk group- Clinic BP underestimates risk
Placebo
Active treatment
Cardiovascular disease (per 1000 patient - year)
Low risk group- WCH Clinic BP overestimates risk
Staessen et al. JAMA 1999 282 539-46.
14
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

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Clinic Pressure
Sustained Hypertension
White Coat Hypertension
140/90
True Normotension
Masked Hypertension
135/85 Ambulatory Pressure
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20 of hypertensive population
Clinic Pressure
Sustained Hypertension
White Coat Hypertension
140/90
True Normotension
Masked Hypertension
135/85 Ambulatory Pressure
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20 of hypertensive population
Clinic Pressure
Sustained Hypertension
White Coat Hypertension
140/90
10 of GENERAL population
True Normotension
Masked Hypertension
135/85 Ambulatory Pressure
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• 1. ABPM
• 2. Echocardiogram
• 3. Renin

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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 121129, 1994)

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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

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Indications for Echocardiography in Hypertensive
Patients

• Coexistent Heart Disease
• Resistant Hypertension
• Decision to Start Treatment Uncertain

22
Echocardiographic LVMI as a Predictor of CV Risk
(Schillaci et al, Hypertens 2000 35 580)
CV Events per 100-pt years
Quintiles of LVMI
23
In-Treatment LV Mass Predicts CV Events -LIFE
Study. (Devereux et al JAMA 2004 2922350)
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• 1. ABPM
• 2. Echocardiogram
• 3. Renin

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(No Transcript)
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Possible Applications of Renin Measurement

1. Better prediction of risk

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Renin as a Risk Factor for MI (Alderman et
al, AJH 1997 10 1)
Risk of MI/1000 pt-yrs
Risk Status
Renin
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Possible Applications of Renin Measurement

1. Better prediction of risk
2. Identification of secondary hypertension
3. Prediction of drug response

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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)

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Limited Efficacy of Monotherapy in Treating
Hypertension (Materson NEJM 1993 328 914)
Patients Responding
31
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 gt20/10 mmHg above goal, initiate therapy
  with two agents, one usually should be a
  thiazide-type diuretic.

32
Double-Blind Placebo-Controlled Comparison of 5
Classes of Antihypertensive Drugs(Deary et al, J
Hypertens 2002 20771)

• 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 r0.71, p lt0.005).
• Response to best drug was repeated and highly
  reproducible (r0.79).
• Age and plasma renin activity did not predict BP
  response.

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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 86113
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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

35
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

36
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

37
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

38
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

39
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