Implementation of updated BP guidelines essential for special populations

SANTA ANA PUEBLO, N.M. — Proper BP control for black patients, those with diabetes and older patients is critical in reducing the risk for CV events, according to a presentation at the American Society for Preventive Cardiology Congress on CVD.

The risk for ischemic heart disease and stroke mortality is directly associated to an increase in systolic BP and increases as patients age, Keith C. Ferdinand, MD, FACC, FAHA, professor at Tulane University School of Medicine in New Orleans and a Cardiology Today Editorial Board Member, said in the presentation.

“Looking at free-living people who have blood pressure elevation, lower is better,” Ferdinand said.

The guidance provided by the updated Atherosclerotic CVD Risk Estimator Plus has been expanded to include expert advice on BP-lowering therapy, smoking cessation and aspirin use in addition to original statin initiation recommendations.

Compared with non-Hispanic white individuals, U.S. BP control rates are poor for black, Hispanic and non-Hispanic Asian individuals, which has mortality consequences, particularly for black patients, according to the presentation.

With the updated BP guidelines from the American College of Cardiology/American Heart Association, which defines elevated BP as 130 mm Hg systolic over 80 mm Hg diastolic, nearly 60% of non-Hispanic black adults have hypertension.

“I don’t think the guideline is giving people disease,” Ferdinand said. “What it’s saying is if you look at the observational data and epidemiologic data, persons who have blood pressures starting at 115 over 75 mm Hg, the higher the blood pressure, the greater the risk, and the cut point of 130 [mm Hg systolic] observationally predicts twice the risk of the 115 [mm Hg systolic]. Now this does not necessarily mean that all black adults should be on blood pressure medications, but they need to at least understand the increased risk.”

People aged 65 years and older also have this increased risk, as 75% to 80% of them are affected by hypertension, according to the presentation.

According to subgroup analyses from the SPRINT trial, the benefits of treating to a systolic BP target of 120 mm Hg vs. 140 mm Hg were consistent regardless of age, sex and race.

“It suggests to us that across the wide population depending not on sex, not depending on self-identified race, not depending on age, there’s data based on SPRINT for middle-age and older higher-risk patients within that population of more intensive blood pressure treatment,” Ferdinand said. “Because it was NIH-sponsored, unlike some industry trials, there’s an effort to make sure that the population is indeed heterogenous, and you see larger portions of blacks, and a smaller proportion, but a significant number of Hispanics, in addition to whites, but all with similar blood pressure reduction.”

Data have shown that as compared to initial combination therapy at submaximal dosages, starting one medication for BP control to maximum dosages, then stepping up by increasing to two medications at maximum levels increases the risk for side effects and complications, according to the presentation.

“If we’re going to replicate what we see in multiple cardiovascular outcomes trials — and some of those are landmark — it’s not going to be one drug,” Ferdinand said. “It’s going to be an average of 2.7 drugs to get blood pressures at the level that reintroduce the outcomes seen in those trials.”

According to the new guidelines, pharmacological therapy should be used for BP control in patients with clinical CVD or 10-year atherosclerotic CVD risk greater than 10% and including patients older than 65 years who are noninstitutionalized, ambulatory community-living adults.

The main reasons why black patients have hypertension are obesity, higher salt sensitivity, low levels of plasma renin, vascular function, attenuated nocturnal decrease in BP, inactivity, family history and greater comorbidity, especially in those with diabetes, Ferdinand said.

“At first glance, most of you would say that’s genetics, but families tend to eat and act the same, and they actually will transmit those cultural values when they move to another geographic area. Hence there are studies showing that people from the south who have higher risk of hypertension and cardiovascular risk, when they move to New York, they live like people from New Orleans,” Ferdinand said.

The updated BP guidelines recommend that clinicians treat black patients with hypertension, but without chronic kidney disease or HF, with a thiazide-type diuretic or calcium channel blocker, and that two or more antihypertensive medications are recommended to achieve BP levels less than 130 mm Hg systolic over 80 mm Hg diastolic.

Some patient characteristics of resistant hypertension are non-Hispanic black race, residents of southeastern United States, excessive dietary salt intake and comorbid conditions, according to the presentation.

Special options to treat these resistant patients include chlorothiazide and spironolactone, Ferdinand said, noting community-based BP control in a black barbershop has also been shown to reduce BP by 27 mm Hg systolic.

The prevalence of hypertension in adults with diabetes is an estimated 80%, and it is more common in patients with type 2 diabetes vs. those without diabetes. There is limited evidence to determine a precise BP target in patients with diabetes, although it is suggested to achieve 130 mm Hg systolic over 80 mm Hg diastolic, Ferdinand said, noting medications that are recommended for this patient population include ACE inhibitors, calcium channel blockers and diuretics.

Diabetes is a major risk factor for HF, with about 50% of patients with type 2 diabetes developing the condition. According to the EMPA-REG trial, a BP reduction of 4 mm Hg systolic over 2 mm Hg diastolic provided substantial benefits.

As patients get older, they have an increase in mean systolic BP, which is due to aortic stiffening and early wave reflection, according to the presentation. The new guidelines recommend that older adults with hypertension may benefit from BP lowering to prevent cognitive decline and dementia. In addition, this patient population is more likely to have a 10-year risk of greater than 10%, so the BP target is 130 mm Hg systolic over 80 mm Hg diastolic, Ferdinand said.

“Although we hear a lot about lipids, hypertension is an equally important risk factor,” he said. “Globally, in the underdeveloped or lower socioeconomic proportions of the world, hypertension is even more important than lipids as a cause of cardiovascular disease.”

Not only are adherence strategies important for these patient populations, but also strategies to promote lifestyle modification and a team-based approach to care, Ferdinand said.

“It’s that risk that needs to be important to patients so they can adhere, often using long-acting agents once daily … and that we use strategies to promote lifestyle,” he said. – by Darlene Dobkowski

Reference:

Ferdinand KC. Managing blood pressure in special populations. Presented at: American Society for Preventive Cardiology Congress on CVD; July 27-29, 2018; Santa Ana Pueblo, New Mexico.

Disclosure: Ferdinand reports he consults for Amgen, Boehringer Ingelheim, Novartis, Quantum Genomics and Sanofi.