Guideline-Driven Management of Hypertension: An Evidence-Based Update Webinar
Guideline-Driven Management of Hypertension: An Evidence-Based Update Webinar
Listen to Dr. Robert Carey from the University of Virginia and co-author of the 2017 AHA/American College of Cardiology clinical practice guidelines review important findings on the prevention, detection, and management of hypertension.
Content
1.199 -> on behalf of the american heart
2.639 -> association i would like to welcome you
4.72 -> to today's webinar guideline-driven
6.799 -> management of hypertension and
8.72 -> evidence-based update
10.559 -> my name is kristen coulson and i'm a
12.559 -> quality programs manager for the
14.4 -> american heart association
16.72 -> before we begin i'd like to quickly
18.64 -> review how to use this platform for
20.88 -> today's event
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49.52 -> throughout today's presentation you will
51.36 -> have the opportunity to submit text
53.12 -> questions for our speaker using the
55.28 -> questions feature on your attendee
57.039 -> control panel you may send in your
59.199 -> questions at any time and we will review
61.6 -> the questions during our q a at the end
64 -> of the presentation as time allows
66.64 -> by email tomorrow you will receive a
68.64 -> completion certificate and an invitation
71.28 -> to complete our feedback survey
73.36 -> this presentation will be recorded and
75.84 -> available within the coming weeks at
77.759 -> heart.org forward slash pain management
81.28 -> it is my pleasure to introduce our
82.72 -> speaker for today dr robert carey dr
85.759 -> kerry is dean emeritus and professor of
88.32 -> medicine at the university of virginia
90.479 -> school of medicine
91.92 -> his research on hormonal control of
93.759 -> blood pressure and hypertension has
96.079 -> resulted in over 450 publications and
99.36 -> has been funded continuously by the
101.2 -> national institutes of health since
103.32 -> 1973.
105.28 -> dr kerry co-chaired the 2017 american
108 -> college of cardiology american heart
110.079 -> association high blood pressure
111.92 -> guideline writing committee and chaired
113.759 -> the aha scientific writing committee on
116.24 -> resistant hypertension
118.24 -> he has received numerous awards
120.24 -> including the distinguished physician
122.719 -> and the outstanding leadership awards of
124.56 -> the endocrine society
126.32 -> the aha excellence award for
128.16 -> hypertension research
129.92 -> the aha distinguished scientist award
133.04 -> and election to the american society for
135.28 -> clinical investigation the association
138 -> of american physicians and the national
140.319 -> academy of medicine dr kerry the floor
143.04 -> is yours
144.56 -> well thank you kristen i'm delighted to
146.64 -> be able to give this
148.56 -> webinar
149.68 -> on guideline-driven management of
151.68 -> hypertension this will be an
153.92 -> evidence-based review
157.2 -> my disclosures are here and mainly
160.239 -> membership on writing committees of
162.16 -> various kinds
164.879 -> the outline of today's presentation
168.4 -> will begin with a brief review of major
170.8 -> guideline recommendations
173.68 -> and then
175.44 -> talk about
176.72 -> optimal systolic blood pressure
179.28 -> and primordial disease prevention
182.64 -> followed by some information on the
185.2 -> current state of blood pressure control
188.72 -> we will talk about
190.319 -> two kinds of secondary hypertension that
193.36 -> induced by drugs that people take
196.56 -> and the other primary aldosteronism in
199.2 -> which there's a recent
201.599 -> updated literature
205.12 -> we will then focus on the treatment of
206.959 -> hypertension in young adults at low
210 -> short-term cardiovascular disease risk
213.68 -> and then cover lifestyle management
216.56 -> and pharmacologic management of
218.4 -> hypertension
220.56 -> and then particularly focus on blood
223.04 -> pressure management of older adults and
226 -> then we'll conclude with some
228.72 -> summary comments
231.68 -> i intend to
233.519 -> structure this as a series of issues and
236 -> questions
237.2 -> we'll first review the major guideline
239.84 -> recommendations
241.84 -> and this slide on the left shows
244.64 -> systolic and diastolic blood pressures
247.28 -> in the blood pressure classifications
250.48 -> of the
252.879 -> jnc 7
255.12 -> guideline published in 2003
258.479 -> and the 2017 american college of
260.88 -> physicians and american heart
262.96 -> association guideline published in 2017
267.6 -> and um
268.88 -> for
270.4 -> this these guidelines
272.96 -> normal blood pressure
275.04 -> was unchanged from the
278.4 -> 2003 jnc 7 to the 2017 acc aha
285.68 -> guideline
287.84 -> but there was a large change in this
290.08 -> broad area of pre-hypertension
293.28 -> which
294.08 -> in the
295.12 -> jnc 7
297.04 -> report
298.56 -> went from
300.4 -> 120 over 80 to 139 over 89
305.28 -> and
306.16 -> we broke
307.44 -> that into two categories
310.16 -> elevated blood pressure and stage one
312.8 -> hypertension
314.4 -> because there was an increasing risk of
317.32 -> cardiovascular events
319.68 -> occurring
321.039 -> as one stepped up from normal to
323.28 -> elevated blood pressure to stage 1
325.12 -> hypertension
328.24 -> so
329.36 -> stage 1 hypertension currently is 130
332.32 -> 139 over 80 to 89.
336.72 -> we then
338.88 -> made stage 2 hypertension the previous
341.52 -> stage 1 hypertension
344.24 -> and that's anything over 140 over 90.
347.44 -> and
348.72 -> we i did not have any additional stages
353.039 -> in the 2017 guideline
356.08 -> of importance blood pressure
358.4 -> to be classified into one of these
360.4 -> categories needs to be
363.039 -> based on an average of at least two
365.52 -> careful readings on at least two
367.6 -> occasions
369.199 -> and if the systolic or diastolic blood
371.84 -> pressure is different in the two
373.84 -> categories the individual should be
376 -> designated as the higher blood pressure
378.319 -> category
380.88 -> now this slide shows the
383.12 -> thresholds
384.56 -> in the 2017 guideline
387.68 -> for drug treatment
390.08 -> and
391.199 -> of course we don't didn't recommend any
393.68 -> drug treatment for those with
395.919 -> normal or elevated blood pressure just
398.319 -> healthy lifestyle non-pharmacologic
400.639 -> therapy
403.12 -> for stage 1 hypertension which is
406.12 -> 130-139 over 80-89
409.84 -> the threshold was based on
412.039 -> cardiovascular disease risk
415.599 -> and the presence or absence of
417.12 -> cardiovascular disease
419.44 -> if there was no cardiovascular disease
422.88 -> or a very
424.479 -> low
425.52 -> 10-year
427.28 -> atherosclerotic cardiovascular disease
429.36 -> risk ascvd risk
431.52 -> of less than 10 percent then
433.88 -> non-pharmacologic therapy was
435.599 -> recommended
437.28 -> but if if there was cvd
439.68 -> or
440.4 -> a high ascvd risk
442.96 -> then
443.919 -> antihypertensive drug therapy was
446.24 -> recommended to be added to
447.72 -> non-pharmacologic therapy
450.72 -> and
452.56 -> the
453.52 -> patients with diabetes or chronic kidney
456 -> disease since they are at a much higher
459.12 -> risk
460.4 -> than others
461.919 -> were automatically placed in high risk
464.24 -> category and requiring
467.52 -> antihypertensive drug therapy to begin
469.919 -> with
471.52 -> for those aged greater than 65
474.879 -> years
476.479 -> the
478.08 -> blood pressure
480.24 -> category of 130 to 139
483.56 -> antihypertensive drug therapy was also
486.319 -> recommended because older people like
488.72 -> diabetics and patients with ckd have
492.08 -> high cardiovascular risk and of course
494.879 -> for stage 2 hypertension which is
497.12 -> greater than 140 over 90
500.639 -> irrespective of the cardiovascular risk
504.08 -> these patients should be
506.16 -> treated with antihypertensive drug
508.16 -> therapy
509.12 -> uh at least one if not two drugs to
512 -> begin with
514.88 -> this slide shows the
516.599 -> antihypertensive treatment targets
519.44 -> for the 2017 guideline
522 -> and of course there are no treatment
523.599 -> targets until you get into treatment
527.2 -> with
529.04 -> antihypertensive drugs
531.279 -> in which case
532.959 -> whether you have a high ascvd risk or
536.48 -> presence of cvd
538.16 -> or diabetes
540.24 -> or ckd
543.04 -> you should
544.32 -> aim for a target systolic blood pressure
547.36 -> of less than 130 diastolic blood
549.839 -> pressure less than 80.
552.32 -> if you are in the older age category
554.64 -> greater than or equal to 65
557.6 -> and your blood pressure is greater than
559.839 -> or equal to 130 the target is less than
562.959 -> 130 systolic
566.88 -> now having reviewed the classification
569.36 -> of blood pressure
571.92 -> in terms of thresholds and goals
575.2 -> there was a controversy surrounding the
577.12 -> 2017
578.959 -> guideline recommendations when they
580.88 -> initially appeared
582.64 -> have the major guideline recommendations
584.959 -> been validated
587.6 -> there are two reports the first one is a
590.56 -> comparison
591.92 -> of cvd events and death
594.48 -> prevented with adherence to two
596.56 -> guideline recommendations
598.64 -> the 2014 evidence-based panel report
603.2 -> which had
604.88 -> higher
605.839 -> thresholds
607.279 -> and goals of treatment
609.68 -> than the 2017 guideline
612.72 -> which had
614.32 -> lower thresholds and goals so again the
618.079 -> threshold for initiation of
620.079 -> antihypertensive therapy in the 2017
622.72 -> guideline was blood pressure greater
624.959 -> than 140 over 90 for the general
627.6 -> population with low icbd risk and if you
631.279 -> had high risk it was greater than or
633.44 -> equal to 130 over 80.
635.6 -> and then the goal as you saw was less
638.079 -> than 130 over 80 as compared to less
641.6 -> than 140 90 or 150 over 90 depending on
645.92 -> their age in the 2014 report
650 -> now if you compare the
652 -> cvd events that were prevented
655.839 -> by adherence to these two guidelines
658.32 -> there were
659.839 -> 000 in the 2014 evidence-based uh
663.12 -> guideline as opposed to 610 000
666.88 -> in the 2017 guideline
669.36 -> and the annual reduction in death
671.279 -> paralleled that at
673.48 -> 177 000 for the 2014 report as compared
677.839 -> to 334 000 for the 2017 acc aha
683.6 -> guideline
685.92 -> the second report was a simulated
688.56 -> population impact of achieving and
690.88 -> maintaining the
692.839 -> 2017 blood pressure goals
696.16 -> in adults greater than or equal to 45
698.64 -> years of age with hypertension compared
701.519 -> to maintaining current blood pressure
704.24 -> treatment and control goals or achieving
706.88 -> blood pressure
708.16 -> goals recommended in the
710.32 -> jnc report of 2003
714.16 -> or compared with the 2017
718 -> 8th chancey panel report
720.72 -> on blood pressure goals
722.639 -> and the estimates were made by using a
725.6 -> population
726.959 -> called regards
728.72 -> weighted to the u.s population
731.44 -> they used
732.8 -> the national health and nutrition
736.079 -> survey
737.279 -> for estimating the u.s population
740.48 -> and used a meta-analysis published by
743.6 -> josh bundy
745.44 -> it's a beautiful network meta-analysis
748.16 -> on the cvd risk reduction with blood
750.72 -> pressure lowering
752.32 -> they also estimated the
755.68 -> serious adverse events with blood
757.519 -> pressure lowering
758.959 -> based on
760.8 -> pool data from the sprint and accord
764.399 -> large clinical trials
767.2 -> and this analysis
769.839 -> showed that
771.279 -> the 2017 guideline
775.92 -> prevented
777.12 -> 3 million
778.399 -> cardiovascular disease events the jnc 7
782.16 -> 2.6 million and the jmc8 panel report
786.639 -> down to 1.6 million events prevented
790.72 -> so two wealth performed simulation
793.44 -> studies demonstrate a highly positive
796 -> population impact following the 2017
799.2 -> guideline recommendations for lowering
802.24 -> blood pressure and hypertensive persons
804.8 -> compared to other guidelines
807.44 -> the increased risk of adverse events
810.16 -> which are largely reversible with lower
812.56 -> blood pressure targets should not be
814.959 -> equated to the risk reduction of major
818.24 -> clinical events
820.639 -> significance
822.48 -> a significant reduction in all-cause
824.639 -> mortality shows that the benefits of
827.199 -> treatment truly outweigh the risks
830.56 -> and these reductions or these results
833.519 -> strongly support a lower blood pressure
836.24 -> target
837.199 -> less than 130 over 80 in the management
840.32 -> of hypertension
842.88 -> so given those reports is there any any
845.76 -> association of blood pressure levels
847.76 -> within the normal tensive range
850.16 -> with cardiovascular events or disease
853.36 -> and what do the data say about the
856.079 -> importance of primordial prevention
859.12 -> well what is primordial prevention
861.12 -> anyway
862.48 -> well that is actions that inhibit the
864.88 -> emergence of risk factors that
867.279 -> form in the form of environmental
869.76 -> economic social and behavioral
871.68 -> conditions and cultural patterns of
873.44 -> living
874.48 -> but the key is prevention of the
876.48 -> emergence of risk factors like high
879.199 -> blood pressure
882.48 -> so the 2017 guideline
885.44 -> lowered the systolic blood pressure spp
888.56 -> goal of therapy from less than 140 to
891.6 -> less than 130
893.76 -> and this recommendation focused on the
896.399 -> cut point at which there is likely to be
899.12 -> benefit from antihypertensive drug
902 -> therapy
903.279 -> but many individuals classified as low
906.079 -> risk based on their ascvd risk score
909.36 -> still have subclinical atherosclerosis
912.32 -> based on their coronary calcium scores
914.88 -> and may not be truly at low risk
917.68 -> so is there an association between sbp
921.6 -> within the normal range as currently
923.839 -> defined
925.04 -> and ascbd in persons without traditional
928.399 -> risk factors
930.639 -> so this study was conducted in 1400
933.68 -> adults
935.44 -> with 14 years of follow-up and you can
938.24 -> see the results here that these deciles
941.04 -> of blood pressure going from left to
942.72 -> right 1999 100 109 and so on up to 129
948.079 -> all
948.88 -> within the normal
951.199 -> or slightly elevated range are
953.6 -> associated with stepwise increase in
956.48 -> coronary artery calcium scores
959.68 -> and
960.959 -> in the upper right hand corner
963.519 -> the incident ascvd clinical events by
967.279 -> baseline blood pressure shows that for a
970.32 -> 10 millimeter higher
972.399 -> sbp there is a 53 percent higher uh
976.88 -> or increase in ascbd
982.16 -> so in this cohort study down
985.279 -> of 1400 participants
988.16 -> without atherosclerotic cardiovascular
990.639 -> disease beginning with a blood pressure
992.959 -> of 90
994.639 -> there was a stepwise increase in the
997.279 -> prevalence of traditional ascbd risk
999.759 -> factors coronary calcium scores and the
1002.48 -> risk of ascbd
1004.72 -> and for every 10 millimeter increase in
1006.88 -> systolic blood pressure there's a 53
1009.199 -> percent higher
1010.399 -> risk for a cvd
1012.639 -> so the results do highlight the
1015.279 -> importance of primordial prevention that
1017.519 -> is
1018.399 -> preventing the emergence of risk factors
1020.48 -> like hypertension
1022.32 -> to maintain optimal systolic blood
1024.72 -> pressure levels
1028.64 -> the next question is since the
1030.559 -> introduction of the current blood
1032.24 -> pressure guidelines are there any
1035.28 -> is there any evidence for improvement in
1037.36 -> blood pressure control
1039.679 -> and certainly there is
1042.48 -> because if we follow the nhanes data
1044.72 -> beginning back in 1999 you see this
1047.839 -> linear stepwise increase
1050.16 -> in blood pressure control among all
1052.72 -> adults with hypertension
1054.799 -> but something strange happened in 2014
1058.4 -> and since that time we've had a stepwise
1061.52 -> reduction
1062.96 -> up to the final data point that we have
1065.039 -> available
1066.48 -> one of the things that happened
1068.4 -> at that time
1069.76 -> was the
1070.88 -> publication of the 2014 evidence-based
1073.76 -> panel report
1075.679 -> which did recommend a higher blood
1078.96 -> pressure thresholds and targets as we
1081.2 -> reviewed before
1082.799 -> and whether or not this has
1085.2 -> something to do with it is conjectural
1088.08 -> at this point but certainly seems
1090.72 -> somewhat circumstantial
1092.799 -> this also applies to adults
1096.32 -> who are taking antihypertensive
1098.4 -> medication
1100 -> the control rates increased until 2014
1103.36 -> and then decreased
1106.559 -> we're going to talk now about secondary
1108.48 -> hypertension and two items the first one
1111.76 -> is what drugs should i worry about that
1114.799 -> might induce hypertension or
1117.6 -> aggravate drug uh blood pressure levels
1121.44 -> or interfere with drugs in patients with
1124.08 -> hypertension
1126.24 -> the biggest category is non-steroidal
1128.799 -> anti-inflammatory agents nsaids
1132.16 -> and this is the most important category
1134.96 -> at any dose level that controls pain
1138.24 -> blood pressure is elevated
1141.039 -> and nsaids do interfere with many of the
1144.16 -> first line antihypertensive agents such
1147.039 -> as ace inhibitors
1148.799 -> angiotensin receptor blockers diuretics
1151.2 -> and beta blockers
1154.72 -> other
1155.6 -> agents to be on the lookout for are oral
1158.16 -> contraceptives and hormonal replacement
1160.48 -> therapy
1161.88 -> immunosuppressive agents
1164.64 -> recombinant human erythropoietin
1167.28 -> tyrosine kinase inhibitors cocaine and
1170.32 -> amphetamines and antidepressants all of
1174 -> these can do
1175.919 -> the same thing as the nsaids can do
1181.76 -> the next question is is there anything
1183.919 -> new in the screening for secondary
1186.16 -> hypertension due to primary
1187.76 -> aldosteronizing
1189.84 -> and yes there is and um
1192.559 -> a very interesting study was published
1195.44 -> about a year and a half ago
1197.679 -> in which
1198.799 -> um
1199.72 -> 691 adults
1202.08 -> uh who are either normal tensive or
1204.559 -> hypertensive but had suppressed
1207.36 -> plasmarine inactivity
1210 -> these individuals were salt loaded with
1212.72 -> dietary sodium up to
1215.12 -> a urinary sodium excretion of 190
1217.679 -> millimoles per day
1220.32 -> at which point their aldosterone levels
1222.559 -> were measured in the europe
1224.559 -> and the normal cutoff for a sodium
1227.6 -> loaded individual
1229.84 -> above which is primary aldosteronism
1233.36 -> is 12 micrograms per deciliter
1236.799 -> and that's represented by the dashed
1238.64 -> line
1239.919 -> so here we have vertical lines you can
1242.32 -> just barely see them
1243.919 -> for each individual
1245.76 -> person in the study and what was
1248.799 -> remarkable was
1250.559 -> that above the
1252.4 -> line of 12 micrograms per
1254.72 -> per day
1256.559 -> 11
1258.72 -> of the untreated normal intensive
1260.88 -> population had overt primarily syrianism
1265.28 -> in stage 1 hypertension it rose to
1267.52 -> almost 16 percent
1270.48 -> in
1271.36 -> untreated stage 2 hypertension
1273.88 -> 21.6 percent and then resistant
1277.12 -> hypertension and 22 percent
1280.88 -> um and so
1282.64 -> these patients above the line all had
1286.48 -> primary aldosteronism unequivocally
1289.12 -> confirmed
1291.84 -> so a continuum of autonomous and
1294.799 -> renin-independent aldosterone production
1297.44 -> can be found across the spectrum from
1300.32 -> normal attention to resistant
1301.84 -> hypertension
1303.6 -> and the frequency of primarily syrianism
1306.559 -> by this confirmatory testing that we did
1310.08 -> uh was six to
1312 -> 12 percent in normal tenses six to 19
1315.039 -> percent in stage one
1317.52 -> 15 to 25 and stage 2
1320.559 -> and
1321.36 -> 18 to 52 percent in resistant
1324.72 -> hypertension depending on the pa
1327.2 -> definition employed
1330.159 -> so in the context of renin suppression
1333.84 -> the autonomous 24-hour aldosterone
1337.039 -> in the study was also associated with
1339.679 -> blood pressure urinary potassium
1342.159 -> excretion consistent with activation of
1345.039 -> the mineralocorticoid receptor
1348.159 -> and so
1349.12 -> unrecognized or subclinical primary
1351.52 -> aldosteronism very likely explains the
1354.64 -> pathogenesis of a substantial proportion
1358 -> of people with primary hypertension
1362.24 -> that being the case how many patients
1364.32 -> with primary hypertension are ever
1366.48 -> screened for primary aldosteronism
1369.2 -> what's very low in europe one in a
1371.36 -> thousand
1372.559 -> in this country it's not much better two
1374.799 -> percent of resistant hypertension
1378.32 -> uh in spite of that the cardio metabolic
1381.12 -> risk profile
1383.039 -> for patients with primarily steroidism
1385.52 -> without specific targeted therapy
1388.4 -> mineralocorticoid receptor antagonists
1391.76 -> is at least three-fold higher
1394.159 -> than for patients with primary
1395.76 -> hypertension mesh matched for age sex
1398.559 -> and blood pressure
1400.08 -> so we need this new simplified
1402.24 -> diagnostic approach that can be endorsed
1404.799 -> by the primary care community
1408.08 -> this is a diagram showing uh adrenal
1410.96 -> production of aldosterone autonomously
1415.84 -> salt loading which i just showed you
1418.24 -> this causes an increase in hydrogen ion
1421.12 -> and potassium secretion and loss of
1423.76 -> these ions
1425.6 -> with hypokalemic metabolic alkalosis
1428.96 -> in some
1430.48 -> and increased sodium reabsorption with
1432.559 -> extracellular volume expansion causing
1434.88 -> hypertension and suppressing the entire
1438.36 -> renin-angiotensin system
1441.84 -> so should all patients with primary or
1444.64 -> essential hypertension be screened for
1446.559 -> primary aldosteronism and if so how
1450.48 -> well this is my own idea not supported
1453.2 -> by any guidelines or scientific
1455.76 -> statements
1457.76 -> but if you start with a hypertensive
1460.159 -> individual
1462.08 -> the first step would be to quantify
1464.64 -> circulating arena
1467.12 -> and if renin is not suppressed then this
1470.159 -> is a negative screen for primary
1472.039 -> aldosteronism
1473.76 -> if renin is suppressed that is plasma
1476.64 -> marine activity lesson one directory and
1479.039 -> concentration less than eight
1481.12 -> then
1482.24 -> load the patient with a high sodium diet
1485.36 -> measure the urine sodium and check to
1487.279 -> make sure it's over 200 millimoles per
1489.679 -> day
1490.88 -> and then measure the aldosterone
1493.76 -> if the aldosterone is less than six
1496.559 -> micrograms per day it's a negative
1498.84 -> screen
1500.559 -> and just continue present plans
1503.44 -> if the
1504.96 -> eldest room is greater than 12 as we saw
1507.679 -> in the other diagram this is an overtly
1510.96 -> positive screen and the patient should
1513.2 -> be referred for work up to an expert
1515.76 -> center
1517.279 -> and my idea only at this point if the
1520.24 -> urinary aldosterone is between these two
1523.36 -> extremes i think this is a positive
1526.4 -> screen because it's inappropriate for
1528.72 -> aldosterone to be that high in the face
1531.36 -> of sodium suppression
1533.36 -> at which point i would treat the patient
1535.679 -> with spironolactone
1537.6 -> and 25 milligrams a day low dose for a
1541.279 -> month and then if the blood pressure
1543.76 -> falls by greater than 10 millimeters of
1546.799 -> mercury
1548.159 -> i would strongly suspect primarily
1550.48 -> syrianism and either continuum
1553.84 -> them on the mineralocorticoid antagonist
1557.039 -> or refer them to an expert center
1563.039 -> so the treatment of hypertension in
1564.96 -> young and low risk groups was not well
1567.36 -> covered in 2017 guidelines how should we
1570.96 -> manage low-risk adults in the absence of
1573.84 -> randomized trial evidence
1576.72 -> so we don't have randomized trials
1579.52 -> but for young adults with isolated
1581.36 -> hypertension the lifetime risk of ascbd
1584.64 -> is high but the 10-year asevd risk may
1588.48 -> be low
1590.799 -> as the overall population blood pressure
1593.12 -> level has gone down
1595.679 -> more cbd events are occurring
1598.4 -> at lower blood pressure levels
1601.12 -> this was demonstrated for young adults
1603.2 -> with hypertension who have earlier onset
1606.32 -> of a variety
1608 -> of
1609.48 -> cardiovascular disease processes
1612.08 -> requiring intervention
1614.96 -> the cardia study
1617.52 -> was a study of young people of 3 800 of
1621.6 -> them and that was followed for
1624.72 -> were followed for 18.8 years
1627.679 -> and very few were taking any
1629.36 -> hypertensive medications
1631.76 -> and it's very interesting that the
1633.52 -> hazard ratios for cardiovascular events
1636.96 -> were high
1639.039 -> there was a
1640.96 -> 67 percent increase for stage 1
1644.08 -> hypertension 75 for stage 2
1647.6 -> and a very large increase
1650 -> uh sorry for stage 1 and a very large
1653.6 -> increase for stage two compared to
1656 -> controls and this is shown on this slide
1660 -> where
1660.88 -> the cumulative incidence of
1662.32 -> cardiovascular events was very high
1665.039 -> in those with stage two hypertension
1668.08 -> was higher than
1671.36 -> controls in stage one hypertension and
1674.32 -> even with elevated blood pressure
1676.48 -> compared to normal blood pressure
1679.44 -> these were significantly different from
1681.2 -> each other and so
1683.279 -> were the all clause mortality rates
1686.399 -> in the cardia study
1688.159 -> which married the cardiovascular event
1690.32 -> rates
1693.12 -> so a panel i got together and wrote a
1696.24 -> scientific statement published last year
1699.44 -> that
1700.24 -> for
1701.039 -> young adults with low 10-year asevd risk
1704.32 -> the recommendation was to start with six
1707.039 -> months of vigorous lifestyle change
1710.559 -> and if the patient did not achieve goal
1713.44 -> less than 130 over 80 within six months
1716.399 -> and then lifestyle therapy should be
1718.88 -> continued
1720 -> and a consideration of the first line
1722.88 -> antihypertensive drug therapy should be
1725.2 -> given
1726.799 -> and special consideration for drug
1729.279 -> therapy should be given if the
1731.36 -> individual has a family history of
1733.6 -> premature cardiovascular disease
1736.48 -> a history of hypertension during
1738.399 -> pregnancy or a personal history of
1741.039 -> premature birth
1743.76 -> and then the ascbd risk scores should be
1747.2 -> assessed every four to six years in
1749.919 -> these patients
1753.12 -> and this is shown on this diagram of
1756.32 -> follow-up we're in stage one
1757.919 -> hypertension even if they're at low
1760.399 -> cardiovascular disease risk non-farm
1763.12 -> therapy for six months and then if the
1766 -> blood pressure does not achieve target
1768.399 -> add-on therapy would be considered
1773.12 -> the next question is how important is
1775.2 -> lifestyle modification in the treatment
1777.52 -> of hypertension and is there any new
1780.24 -> evidence supporting the efficacy of
1782.399 -> dietary sodium restriction
1785.679 -> so the cornerstone
1788.32 -> for prevention and treatment of
1789.6 -> hypertension is lifestyle therapy
1793.279 -> and you can see
1794.559 -> that weight loss
1796.159 -> a healthy dietary pattern reduced intake
1799.2 -> of dietary sodium
1801.039 -> increased intake of dietary potassium
1804.88 -> all lower the blood pressure by at least
1807.76 -> four to five millimeters of mercury and
1810.399 -> these are additive to each other and
1813.36 -> also are additive to the effects of
1815.36 -> pharmacologic therapy
1817.84 -> this also applies to physical activity
1820.399 -> either aerobic or
1822.64 -> dynamic or asymmetric resistance
1824.799 -> exercise
1826.08 -> and moderation of alcohol consumption
1828.72 -> all give you
1830.24 -> about the same
1831.6 -> reduction
1833.36 -> individually in systolic pressure
1838.159 -> so
1840.24 -> i wanted to emphasize a couple of things
1843.12 -> that
1844 -> even as little as a kilogram of weight
1846.559 -> loss
1847.679 -> can lower the blood pressure by one
1849.44 -> millimeter of mercury
1851.76 -> we're going to talk about sodium in a
1854 -> minute the optimal goal is less than
1856.48 -> 1500 milligrams but aiming for less than
1859.6 -> a thousand milligrams per day reduction
1862.32 -> and most adults will achieve
1864.96 -> a substantial reduction in blood
1867.679 -> pressure
1869.44 -> daily potassium intake
1872 -> is uh best at 3500 to 5000 milligrams
1876.24 -> per day
1877.6 -> preferably by consuming diet rich in
1880.48 -> potassium and not kcl supplements
1886.08 -> a comprehensive dose response
1888 -> meta-analysis of trials detailing the
1890.88 -> effects of change of dietary sodium on
1893.76 -> blood pressure
1895.519 -> was published last year using the most
1898.799 -> up-to-date statistical dose response
1901.12 -> modeling
1902.399 -> and this shows this relationship as
1904.48 -> positive and almost but not completely
1907.12 -> linear
1908.64 -> progressing progressively large
1910.72 -> reduction in blood pressure can be
1912.559 -> expected with a reduction in dietary
1915.2 -> sodium down to 1 to 1.5 grams per day
1919.039 -> no evidence for a threshold benefit
1921.84 -> and this is true for both systolic and
1924.08 -> diastolic pressure for adults with and
1926.72 -> without hypertension and during shorter
1929.519 -> and longer periods of sodium restriction
1933.12 -> and this is shown on this slide where on
1936.32 -> the left we have
1938.08 -> people with no hypertension systolic on
1941.44 -> top diastolic on the bottom and here
1944.399 -> with hypertension you can see that the
1947.279 -> blood pressure sodium curve is much
1949.6 -> steeper of course with the hypertension
1952.399 -> but you also see the linearity as sodium
1955.44 -> intake increases the blood pressure
1957.919 -> increases in linear fashion
1962.48 -> also salt substitutes with reduced
1964.799 -> sodium and increased potassium have been
1967.519 -> shown to lower blood pressure
1969.76 -> but their effects on cardiovascular
1971.679 -> disease outcomes have been uncertain
1974.88 -> until the neil study which was reported
1977.84 -> last year
1980.159 -> and this was an open label cluster
1982.48 -> randomized trial
1984 -> involving 600 villages in rural china
1987.44 -> the participants had hypertension in the
1989.519 -> history of stroke or were in the older
1992 -> age category
1994 -> villages were randomly assigned
1996.48 -> to an intervention group
1998.96 -> and this is interesting the salt
2001.2 -> substitute
2002.84 -> contained three quarters of the usual
2005.44 -> salt intake and one quarter substituted
2008.24 -> by potassium chloride
2010.799 -> or the control group which used regular
2013.36 -> 100 salt so that small difference
2017.36 -> would
2018.399 -> perhaps not be thought of as being
2021.2 -> significant but we'll see
2023.679 -> the primary outcome was stroke the
2025.6 -> secondary outcomes were major adverse
2027.76 -> cardiovascular events and death for many
2030 -> cause safety outcome hyperkalemia
2033.679 -> the salt substitute shifted the blood
2036.399 -> pressures downward
2038.399 -> compared to the regular salt intake as
2041.36 -> shown on this slide
2044 -> but much more importantly the outcomes
2047.12 -> were much better and statistically
2049.599 -> significant in the salt substitute group
2052.24 -> shown in yellow compared to the regular
2054.399 -> salt shown in blue
2056.399 -> for stroke
2058 -> for major adverse cardiovascular events
2061.359 -> and for death from any cause and these
2063.839 -> results were all highly significant
2066.56 -> and there was no significant difference
2068.879 -> in hyperkalemia
2071.28 -> with these two
2072.839 -> um methods of treatment
2078.32 -> so the next question is what are the
2080.639 -> latest principles for pharmacologic
2082.56 -> management of hypertension
2084.879 -> i made up this slide
2086.8 -> that begins with an agreement between
2088.96 -> the patient and clinician on the blood
2090.96 -> pressure goal
2092.399 -> followed by initiation of first-line
2094.639 -> therapeutic classes calcium channel
2096.879 -> blockers ace inhibitors or angiotensin
2100.32 -> receptor blockers or thiazide like or
2103.599 -> thiazide diuretics
2106.079 -> and monthly visits until blood pressure
2108.4 -> goes achieved
2110.16 -> during which
2112.48 -> you would obtain a home blood pressure
2115.28 -> readings and the minimum effective
2117.92 -> readings would be two readings in the
2120.32 -> morning and two in the afternoon for
2123.119 -> three days a week and bringing those
2125.359 -> back to the physic the clinician's
2127.68 -> office
2129.52 -> um using fixed-dose drug combinations
2132.56 -> and mighty day prescription refills if
2134.96 -> possible to promote adherence
2137.839 -> if blood pressure is not a goal then
2140.079 -> assessing social barriers that impede
2142.24 -> treatment effectiveness and
2144.16 -> non-adherence to treatment
2147.2 -> and then dose titrate or add another
2150.24 -> first line agent from a different class
2152.24 -> if needed to achieve the goal
2154.64 -> the second line
2156.079 -> therapeutic classes are shown here beta
2158.32 -> blockers are no longer considered first
2161.04 -> line except in ischemic heart disease
2163.76 -> and heart failure
2165.28 -> mineralocorticoid receptor antagonists
2167.44 -> as we stated before are preferred in low
2170.32 -> random states and resistant hypertension
2175.04 -> alpha-1 adrenergic antagonists
2178.48 -> can be used they're effective direct
2181.64 -> vasodilators should be used with
2183.52 -> diuretics and beta blockers
2186.32 -> potassium sparing diuretics are
2188.64 -> minimally effective in blood pressure
2190.4 -> reduction
2191.52 -> but do
2192.64 -> preserve
2194 -> blood potassium concentrations
2196.72 -> loop diuretics are preferred in ckd
2201.04 -> with gfr values less than 30
2204.48 -> and symptomatic heart failure
2207.2 -> and then when the patient is using the
2209.28 -> potent direct vasodilator minoxidil
2212.8 -> central alpha 2 agonists such as
2215.2 -> clonidine or last line agents due to cns
2218.4 -> effects and the potential for
2220.56 -> hypertensive crisis upon withdrawal
2224.72 -> this says effectively the same thing
2227.52 -> just in a different way so i'm going to
2229.52 -> skip over that
2230.96 -> and just show you this slide which is
2233.599 -> one of the
2235.599 -> only meta-analyses
2237.76 -> of the effects of thiazide like
2239.92 -> diuretics such as chlorthalidone or
2242.079 -> endappamide
2243.76 -> as compared to thiazide diuretics
2247.44 -> providing a significantly
2249.839 -> cardioprotective effect
2252.48 -> on cardiac events compared to thiazides
2259.839 -> intensive blood pressure lowering in
2261.839 -> hypertensive older adults has been
2263.76 -> controversial especially in light of
2265.76 -> risks such as orthostatic hypertension
2268.64 -> electrolyte abnormalities and increased
2271.28 -> renal failure
2272.72 -> is there any new evidence supporting the
2274.88 -> efficacy
2276.16 -> of intensive blood pressure lowering in
2278.24 -> older adults
2281.119 -> yes
2282.72 -> this study reported by zhang at all last
2285.359 -> year
2286.56 -> is the step study in
2289.96 -> 9600 chinese patients
2292.72 -> uh in the older age group
2295.2 -> with hypertension
2296.96 -> and also including diabetics
2299.839 -> randomized to
2301.839 -> intensive blood pressure lowering with
2304.079 -> an spp target of 110 to 130
2307.68 -> or standard blood pressure lowering
2310.16 -> target 130 to 150.
2313.2 -> primary outcome was a composite of
2315.68 -> stroke
2316.8 -> acute coronary syndrome acute
2318.8 -> decompensated heart failure coronary
2321.04 -> revascularization
2322.8 -> af or death from a cardiovascular cause
2325.92 -> main follow-up
2327.28 -> was 3.34 years and the study was stopped
2331.28 -> because of the efficacy of therapy
2335.119 -> this blood pressure diagram looks very
2337.599 -> much like sprint the blood pressures
2339.76 -> were lowered effectively immediately
2342.72 -> in the standard treatment group
2344.96 -> to about 135 and in the intensive
2348.079 -> treatment group to less than 130
2351.28 -> and they were maintained throughout the
2353.04 -> study and this diagram says it all
2357.44 -> this is the hazard ratio
2360.079 -> conveying a 26
2362.4 -> benefit
2363.839 -> for intensive treatment
2365.92 -> compared to standard treatment and you
2368.24 -> can see how the curves progressively
2370.32 -> widen
2371.599 -> over a period of 42 months
2377.72 -> 2017
2379.28 -> guideline recommends a systolic
2381.599 -> treatment goal of lesson 130
2384.24 -> for non-institutionalized
2386.48 -> ambulatory free living older adults who
2389.2 -> are
2389.839 -> over age 65
2392.32 -> and an individual team-based approach
2395.2 -> based on clinical judgment and patient
2397.119 -> preference for those with a higher
2399.28 -> burden of comorbidity and limited life
2402.079 -> expectancies
2404.16 -> concerns have been raised that the cbd
2407.599 -> event and all-course mortality rate
2410.8 -> of intensive blood pressure control
2413.28 -> can be offset
2415.68 -> by an increased rate of adverse events
2419.04 -> especially in older adults
2422.319 -> but there have been studies in the past
2424.319 -> two years that have thoroughly addressed
2426.56 -> this question and have provided evidence
2429.359 -> for protection
2430.96 -> um not only from these events but for
2433.52 -> mild cognitive impairment and dementia
2436.48 -> with intensive blood pressure lowering
2440 -> the concern about
2441.839 -> serious adverse events was put to rest
2444.319 -> by two reports from steve gerschack
2447.2 -> examining the sprint data and doing an
2450.4 -> aggregated individual patient data
2452.56 -> meta-analysis
2454.319 -> on the association of intensive blood
2456.319 -> pressure lowering with orthostatic
2458.48 -> hypotension
2460.24 -> in sprint orthostatic hypotension was
2462.8 -> more common in the standard treatment
2465.2 -> group and was not associated with a
2467.599 -> higher rate of cbd events or syncope
2470.4 -> electrolyte abnormalities injurious
2472.48 -> falls or renal failure
2474.8 -> in the meta-analysis intensive blood
2478 -> pressure lowering actually reduce the
2480.079 -> incidence of orthostatic hypotension
2482.64 -> possibly due to improved baroreceptor
2485.04 -> function
2486.24 -> so asymptomatic orthostatic hypotension
2489.68 -> during hypertensive treatment should not
2491.92 -> trigger
2492.8 -> automatic down
2494.48 -> titration of therapy even in the setting
2496.96 -> of a lower blood pressure goal
2499.68 -> this slide shows the effects in the
2502.56 -> meta-analysis
2504.079 -> of intensive blood pressure control
2507.2 -> on orthostatic hypotension and it was
2510.24 -> less significant
2512.24 -> than it was
2513.599 -> for
2514.8 -> a
2516.88 -> standard treatment this is with
2518.56 -> intensive treatment
2521.68 -> and this slide shows you the effects of
2524.72 -> an extended trial looking at
2527.04 -> myocognitive impairment and dementia
2531.68 -> in the sprint study
2533.599 -> and this shows that with further
2536.24 -> follow-up
2538 -> although dementia did not reach
2540.16 -> significant levels
2542.64 -> mild cognitive impairment
2545.52 -> was improved
2547.599 -> with
2548.64 -> intensive blood pressure therapy
2551.28 -> over standard therapy and the
2553.44 -> combination of dementia and
2556.4 -> cognitive impairment was also
2559.2 -> highly significant
2560.88 -> and the reason
2562.8 -> for this is the separation
2565.2 -> uh by treatment arm
2567.44 -> occurs much later
2569.52 -> for dementia and myocognitive impairment
2572.64 -> than it does for cardiovascular disease
2574.88 -> events
2576 -> and this is shown here there was a
2578.56 -> sub-study that demonstrated a smaller
2581.76 -> increase in cerebral white matter
2583.76 -> lesions in the intensive compared to the
2586.319 -> standard treatment group that again was
2588.72 -> highly significant
2591.599 -> so major takeaway points from this talk
2594.4 -> first are the blood pressure control
2596.56 -> rates increase steadily
2598.48 -> until 2014 after which they've declined
2602.319 -> be careful to avoid nsaids and patients
2605.119 -> with hypertension
2606.48 -> substitute other classes of agents to
2608.64 -> control pain
2610.56 -> autonomous aldosterone production almost
2612.64 -> certainly plays a role in the
2613.92 -> pathogenesis of stage 1 and 2
2616.079 -> hypertension and resistant hypertension
2619.28 -> all adults should be screened for
2621.04 -> primary aldosteronism if they have
2623.28 -> hypertension
2624.8 -> and if renin is low then consider a
2627.359 -> 24-hour urine aldosterone measurement
2630.24 -> during salt loading
2632.64 -> in the diet
2634.88 -> young adults with hypertension have
2637.2 -> earlier onset of cvd events compared to
2640 -> those with normal blood pressure
2642.8 -> thus the delay of treatment may be
2645.28 -> inappropriate even though randomized
2647.76 -> trial evidence is lacking
2650 -> and the evidence does support
2652.16 -> initial management with the lifestyle
2654 -> modification for six months to 12 months
2657.119 -> followed by
2658.319 -> antihypertensive drug therapy if the
2660.72 -> blood pressure remains above 130 over
2663.52 -> 80.
2664.96 -> lifestyle modification is the
2666.88 -> cornerstone of antihypertensive therapy
2669.28 -> each non-pharmacologic intervention is
2671.599 -> effective in lowering blood pressure
2673.68 -> concurrent use of two or more
2675.28 -> interventions results in additive
2677.2 -> effects and there's improvement in the
2679.76 -> effectiveness of pharmacologic therapy
2682.079 -> as well
2683.76 -> the relationship of dietary sodium
2685.92 -> chloride to blood pressure is positive
2688.079 -> and almost linear
2689.76 -> reductions in blood pressure can be
2691.599 -> expected with a decrease in dietary
2693.68 -> sodium down to 1 to 1.5
2696.24 -> grams per day and salt substitutes are
2699.28 -> effective in lowering blood pressure and
2701.119 -> improving outcomes
2703.2 -> intensive blood pressure control is not
2705.76 -> associated with increased
2707.28 -> hospitalization it does not increase the
2710.72 -> risk of orthostatic hypotension
2713.44 -> asymptomatic orthostatic hypertension
2716.079 -> hypotension and hypertensive adults is
2719.04 -> not associated with higher cvd or event
2722.24 -> rates
2723.2 -> or other detrimental effects and should
2726.079 -> and not be a reason to withdraw or down
2728.319 -> titrate treatment
2730.48 -> for older adults with hypertension
2732.88 -> intensive treatment with an spp target
2736.079 -> of 110 to 130 substantially lowers the
2739.839 -> incidence of cvd events
2742.16 -> over standard treatment with a target of
2744.64 -> 130 to 150
2747.28 -> also intensive blood pressure lowering
2749.28 -> may prevent or at least partially arrest
2752 -> cognitive decline with aging
2755.44 -> and finally home blood pressure
2757.52 -> self-monitoring and telemonitoring are
2759.599 -> effective in facilitating
2761.72 -> antihypertensive drug titration
2764.56 -> leading to the achievement and
2766.079 -> maintenance of blood pressure gold i
2768.56 -> thank you for your attention and look
2770.56 -> forward to our discussion
2773.2 -> thank you dr kerry for your presentation
2775.76 -> as a reminder for our participants you
2777.599 -> can still submit questions for our
2779.28 -> presenter using the questions feature in
2781.52 -> your attendee control panel
2783.599 -> we will now begin our q a
2786.24 -> dr carrier our first question for you is
2789.599 -> would addressing an individual's social
2791.839 -> determinants of health be an important
2793.76 -> part of primordial prevention
2796.56 -> you could argue that that addressing
2799.44 -> social determinants of health would be
2802.48 -> a way of primordial prevention because
2806.72 -> as
2807.52 -> i showed on the slide
2809.92 -> the
2811.119 -> social economic and cultural background
2815.28 -> that's present in our society
2817.839 -> has everything to do
2819.839 -> with the emergence of risk factors and
2822.319 -> so if we can control
2824.48 -> the social determinants of health we can
2827.599 -> certainly have an impact on those risk
2830.64 -> factors
2831.92 -> but i think things we need to think
2834.079 -> about population response
2837.359 -> to prevent some of these risk factors
2841.04 -> for example
2843.119 -> it would be very helpful
2845.2 -> to
2846.16 -> focus on dietary sodium restriction
2849.28 -> and
2850.079 -> elimination or
2852.079 -> mark reduction
2853.68 -> in the sodium content of processed foods
2858.4 -> which
2859.44 -> really load our population
2861.839 -> with sodium we have a very large
2866.24 -> population intake of sodium in our
2868.4 -> society
2869.68 -> and that's just one example but there
2872.48 -> are many other examples including
2875.28 -> better economics better education
2878.64 -> and
2880 -> better
2880.88 -> living conditions
2884.079 -> thank you dr kerry um what do you do if
2887.599 -> the random aldosterone
2889.76 -> renin ratio is high on the first screen
2892.24 -> do you repeat or proceed
2896 -> if the plasma arena activity is low uh
2900 -> less than one or green and concentration
2902.48 -> less than eight
2904.319 -> and the aldosterone
2906.72 -> uh if you're measuring it in plasma
2910.72 -> is high
2912.96 -> at least 16
2915.52 -> and gives you
2916.88 -> an elevated aldosterone to renin ratio
2920.88 -> then i would proceed with a confirmatory
2923.68 -> test
2924.64 -> and the ones that are used in this
2926.4 -> country
2927.44 -> are this dietary sodium loading test
2930.319 -> that i showed you on the slide
2932.64 -> where you would try to get the
2934.72 -> dietary sodium intake up to about
2938.559 -> 200 millimoles per day
2941.76 -> and then
2942.8 -> measure
2944.079 -> aldosterone you can measure it in either
2945.92 -> plasma or the urine
2947.599 -> urine
2949.04 -> is better
2950.8 -> because
2952.4 -> it measures the integrated aldosterone
2955.2 -> secretion rate all day long whereas the
2957.599 -> plasma just measures uh one point in
2961.28 -> time
2962.8 -> the other way of confirming is to do a
2965.92 -> formal saline suppression test where you
2968.839 -> infuse
2970.4 -> normal saline
2972.64 -> for
2973.92 -> over a four hour period two liters of
2976.559 -> normal saline
2977.92 -> and check the
2979.359 -> renin and aldosterone
2982.16 -> before and at the end of that infusion
2985.68 -> and in either case the aldosterone
2987.76 -> should be suppressed
2989.359 -> so if you get a high aldosterone with
2991.76 -> those confirmatory tests
2993.76 -> then
2995.52 -> that
2997.04 -> does uh make the diagnosis of primary
3000.079 -> allosterism and then you have to ask the
3003.119 -> question
3004.319 -> would the patient if
3007.04 -> the patient
3008.88 -> were to be found to have a unilateral
3011.92 -> cause
3013.119 -> from one adrenal of aldosterone
3015.52 -> production
3016.96 -> would the patient be willing and able to
3020.77 -> [Music]
3021.92 -> to have a unilateral adrenalectomy if
3025.359 -> that were found to be the case
3027.359 -> and if so you would then proceed with
3029.2 -> the workout
3032.559 -> thank you dr kerry
3034.559 -> earlier in your presentation you
3036.079 -> mentioned some considerations for
3039.119 -> folks with high blood pressure and and
3041.04 -> said use
3042.24 -> can you comment on what class of pain
3044 -> medications you recommend for patients
3045.839 -> with chronic pain
3049.119 -> um
3051.839 -> yeah i think um
3055.359 -> nsaids are uniformly
3058.07 -> [Music]
3060.079 -> bad for blood pressure
3062.319 -> as substitutes for pain
3064.88 -> i would think it's an acetaminophen
3067.68 -> tylenol
3069.52 -> would be good
3071.04 -> uh possibly
3072.88 -> aspirin
3074.16 -> if there are no gastrointestinal issues
3077.92 -> because those would be my go-to choices
3082.96 -> thank you
3085.04 -> our next question is
3086.72 -> is hypertension more important than
3088.72 -> other risk factors such as
3090.359 -> hyperlipidemia or diabetes
3093.839 -> yes
3095.52 -> of course i'm not biased
3098.319 -> no i'm i'm quite biased i guess but yes
3101.359 -> i think
3103.2 -> the reason the world health organization
3105.92 -> named hypertension as the world's
3108.24 -> leading risk factor is because it is
3110.96 -> more important and there have been some
3113.04 -> studies that support that
3116.079 -> for example
3117.839 -> there have been some
3119.28 -> cohort studies that show
3122 -> that
3122.839 -> hypertension in a large
3125.839 -> population of cohort studies
3128.88 -> accounts for
3130.44 -> 7.3 percent
3132.559 -> of preventable
3134.559 -> mortality
3136.72 -> whereas hyperlipidemia
3139.28 -> accounts in the same study for 0.1
3143.359 -> diabetes for 4.1
3146.48 -> and cigarette smoking by 4.4
3150.319 -> all of those data were in females
3153.599 -> similar data are available for males
3156.8 -> except that cigarette smoking
3160 -> seemed to
3162.079 -> to be equal or slightly greater than
3164.559 -> hypertension
3166.16 -> in the male population
3168.48 -> but in any event if you
3170.559 -> if you aggregate those populations
3172.48 -> together hypertension
3174.8 -> accounts for
3177.2 -> the largest fraction of preventable
3180.319 -> mortality so that's one way of looking
3183.28 -> at it
3184.96 -> and of course
3186.72 -> it is preventable
3189.52 -> and perhaps
3190.8 -> you could argue well you could argue
3192.319 -> that all of the things that i mentioned
3194.319 -> are preventable to a certain extent
3197.839 -> but we certainly can control blood
3199.68 -> pressure and we can do it in much better
3202.48 -> fashion
3204 -> than we have been
3207.359 -> thank you
3209.119 -> is there any data on hypertension
3211.2 -> subtypes isolated systolic blood
3213.599 -> pressure increases isolated diastolic
3216.079 -> blood pressure increase etc and their
3218.48 -> effects on ced events for example is
3221.599 -> isolated diastolic hypertension in a
3223.76 -> younger adult worth addressing
3227.2 -> if i heard the question correctly it's
3230.16 -> comparing excuse me comparing systolic
3232.88 -> and diastolic
3234.8 -> blood pressure um
3237.2 -> and we wrestled with that in the
3239.44 -> guideline discussions um
3242 -> quite a lot
3243.76 -> the
3244.72 -> vast majority
3246.319 -> of the um
3248.559 -> the clinical trial evidence
3251.119 -> for blood pressure lowering
3254.4 -> is on the basis of systolic blood
3256.72 -> pressure lowering
3258.559 -> um
3259.599 -> and we do have some trials that are
3262.319 -> older
3263.92 -> for example the hot trial
3266.4 -> that do use diastolic blood pressure
3269.839 -> but these are somewhat outdated and
3273.44 -> less highly regarded
3275.359 -> than the more recent trials
3277.76 -> so
3280.16 -> in the construction of the guideline
3283.04 -> we
3283.59 -> [Music]
3285.599 -> coded the evidence differently for
3288.16 -> systolic
3289.76 -> at a high level and diastolic as
3293.119 -> either expert opinion or low level
3295.839 -> evidence
3297.119 -> but we felt that it was important
3298.64 -> because
3299.52 -> most clinicians
3301.839 -> think about blood pressure in terms of
3303.68 -> both systolic and diastolic that we
3306.4 -> include diastolic numbers that roughly
3308.799 -> parallel the systolic numbers
3312.319 -> so but i think people need to realize
3314.4 -> that the evidence behind the diastolic
3317.119 -> recommendations are nowhere near
3319.68 -> as stringent as they are
3322.24 -> for systolic blood pressure
3326.48 -> thank you for that explanation
3329.04 -> um our next question is in your opinion
3331.76 -> are there major differences in the
3333.44 -> management of hypertension between males
3335.599 -> and females
3337.359 -> between what
3339.44 -> males and females
3342.24 -> thank you for that question
3345.839 -> um
3349.599 -> i i think um
3352.319 -> in general my answer to that question
3354.24 -> would be
3355.76 -> no
3357.68 -> um
3359.359 -> the
3360.72 -> hypertension efficacy trials
3364.35 -> [Music]
3365.92 -> have
3366.799 -> um
3368.64 -> large numbers of both men and women in
3372 -> the trials
3373.28 -> and when you look at the sex differences
3377.68 -> in responses
3380.88 -> to antihypertensive medication with
3383.839 -> blood pressure lowering or
3386.799 -> at the outcomes
3388.4 -> you find no significant differences
3392.559 -> recent examples include sprint and step
3396.88 -> neither of those had major differences
3400.72 -> between men and women
3404.319 -> so
3405.599 -> whereas there may be
3407.68 -> significant side effects
3410.88 -> in some men or some women with certain
3413.92 -> anti-hypertensive
3415.64 -> agents um for example mineralocorticoid
3419.839 -> receptor antagonists
3422.88 -> have major side effects in men
3425.68 -> and minor side effects in women and the
3428.4 -> reason is that the
3430.48 -> um
3432.319 -> agents available in this country are
3434.799 -> steroidal
3436.599 -> mineralocorticoid receptor antagonists
3440.72 -> and
3441.599 -> so
3442.4 -> they cross-react with the androgen
3444.839 -> receptor and cause
3446.85 -> [Music]
3448.319 -> impotence and gynecomastia in men
3452.16 -> and in women they do cause some minor
3454.48 -> menstrual irregularities but there would
3456.4 -> be
3457.76 -> an example of the difference in response
3461.2 -> to treatment
3462.64 -> what we need
3464.16 -> is
3465.76 -> to have
3467.16 -> non-steroidal mineralocorticoid receptor
3470 -> antagonists
3471.68 -> that wouldn't have these effects and
3474.079 -> thus wouldn't have those differences
3476.72 -> but those are coming along and i think
3478.799 -> in a few years we'll have them available
3483.599 -> thank you dr kerry
3485.2 -> and as we've reached the end of our time
3487.44 -> allotment for this webinar
3489.44 -> we will be accepting additional
3491.2 -> questions through our pain management
3493.92 -> heart.org email address for those of you
3496.24 -> who wanted to submit additional
3498.16 -> questions for dr carey
3500.48 -> so thank you dr kerry for this wonderful
3502.319 -> presentation and thank you to our guests
3504.319 -> for your participation in today's event
3507.04 -> you will all receive a completion
3508.88 -> certificate and an invitation to
3510.799 -> complete our feedback survey by email
3512.72 -> tomorrow
3514.24 -> thank you for your patience while we add
3515.76 -> closed captioning to today's recording
3518.16 -> the recording and slides will be
3519.52 -> available within the coming weeks at
3521.2 -> heart.org forward slash pain management
3524.4 -> on behalf of the american heart
3525.599 -> association thank you for joining us and
3527.599 -> have a wonderful day
Source: https://www.youtube.com/watch?v=zsHIvtbBxzM