Paul H. Pronovost, MD, FACP, FASN; Interim Chief, Section of Nephrology, Hypertension and Kidney Transplantation at the Lewis Katz School of Medicine at Temple University discusses challenges in the medical management of hypertension. Despite the knowledge that blood-pressure-reducing medications effectively reduce the risk of patients being diagnosed with cardiovascular and kidney disease, studies show wide variations in prescribing patterns and inadequate clinical results experienced by patients. With the Temple Comprehensive Hypertension Program, hypertension experts from various clinical backgrounds work as a team to employ a broad consideration of diagnostic and advanced therapeutic options for patients with resistant or uncontrolled hypertension.
well. Hello, I'm paul. Provo. I'm a specialist in clinical hypertension in the section of the nephrology at Temple University and a member of the hypertension management program um and we welcome you to explore our new innovative program and approaches to hypertension for our community. I would like to discuss with you optimal pharmaceuticals to support blood pressure management. As you're all aware of high blood pressure is one of the strongest and most modifiable cardiovascular risks and risk of kidney disease. Blood pressure reduction with medications can effectively reduce this risk and it's been estimated that each five millimeter reduction in systolic blood pressure conveys the risk of major adverse cardiovascular event reduction by 10% reduction in the rate of strokes by 13% and all cause cardiovascular death by 5%. Even when starting with low baseline blood pressures. And although hypertension awareness treatment and control have improved since the 1980s and 90s, control rates of plateau in the past decade. Despite highly circulated guidelines with frequent updates on the treatment for elevated blood pressure but continue to see wide variations and prescribing patterns, often with associated inadequate clinical results, largely as a result of the sprint trial. We've now appreciate the need to be more stringent in our gold blood pressures so that the vast majority of people should have a targeted blood pressure below 1 30/80 whether or not they have hypertension alone or hypertension with associated comorbidities such as diabetes stroke, cerebral vascular disease, coronary artery disease or chronic kidney disease. The approach has varied uh but certain tenants remain very important in our approach to this. And the initial treatment usually uh centers around one of three classes of agents agents that block the renown angiotensin converting enzyme di hydro parody in calcium channel blockers or thighs. I diuretics. It's appreciated that each agent on average reduces blood pressure by about 10 points. And so for somebody who starts with more elevated blood pressures, certainly over 1 40 or 1 50 it's very likely that they're going to need combination medicines and that there is an increased push to initially starting with combination medicines, particularly uh in the form of a single tablet. Um When we look at these various agents, uh several observations based on randomized controlled trials and observational trials are visible. One core Saladin seems to have advantages over H C T. Z is a easy diuretic and retains efficacy and advanced kidney disease. And although di hydro parenting channel blockers seem to have more efficacy at standard doses than non dehydrate paradigms such as still ties them of rapid milk. Um certain agents have been studied more commonly than others in particular based on the results that they all had trial accomplished trial and many other trials looking at these therapeutics. Um recent other trials such as the pathway to trial has shown that spironolactone and mineral according. COIT antagonist may be superior to beta blockers or alpha blockers. Is that on therapy and as a result, spironolactone is often recommended as 1/4 line agent in conjunction with an ace or an ARB thighs side and a di hydro protein calcium channel blocker if needed. As many of you are aware ace inhibitors and ARBs are not recommended combination largely as a result of the on target trial and others which have shown an increased risk of acute kidney injury. Beta blockers in general do not have strong blood pressure reducing effects in most people. And I preferred only in those with associated uh cardiac comorbidities. And while other agents use are often limited by side effects agents such as cloNIDine had similar rates of control as spironolactone as 1/4 line agent. But many of these other agents they were left to use are added as needed and not really desirable because of significant side effects associated with them and more frequent dozing. Many of us are aware of common side effects of many of the agents. We used to lower blood pressure. Besides maybe associated with right and metabolic effects such as hyponatremia, hypoglycemia, hyper your ischemia and hyperglycemia. These effects may be more prominent in older patients and in those with associated comorbidities, calcium channel blockers of the die hard parenting type may cause non dirigible adama and often confused as primary care providers when they see swollen legs and attempt to use larger and stronger diuretics and attempt to deal with this we've all seen. Um side effects from the ace inhibitors such as cough President. About 10 to 15% of the patients and this could be easily remedied by converting these patients to an angiotensin receptor blocker. Very rarely life threatening. Side effects such as angio oedema may be seen. But thankfully these are very rare occurrences. Indeed, there's no medication without side effects, but the other ones tend to have more of an adverse side effect profile. Beta blockers may cause fatigue and bradycardia, slow heart rate, as many of you know, mineral accord accord antagonists such as spironolactone has been associated with tender gynecomastia and menstrual irregularities and hyper khalidiya when used in conjunction with an ace inhibitor. But the risk remains low and that combination is often deemed acceptable. Peripheral alpha agonists such as Cardura may be associated with the first pass effects with excessive blood pressure reduction and Ortho stasis for patients feel dizzy or lightheaded upon standing. Central alpha agonists are sympathetic, such as cloNIDine may be associated with symptoms such as fatigue, dry mouth again. Ortho static changes in blood pressure and risk of rebound hypertension, particularly when they come into the hospital. And the admitting doctor just continues this agent in favor of other agents. The direct acting Visa dilator such as hydra lysine. Very unpredictable responses in individual patients. Uh they're associated with fluid retention and reflex tachycardia and a variety of autoimmune diseases that are not infrequent, including anca associated disease a and a and even retro peritoneal fibrosis, making these less desirable. Also in part because of the frequent dozing that's needed. So when we look at agents of choice, variety of principles come to mind that we try to exercise in our program and most practitioners should keep in mind as well. First of all, the use of the medication should not be a substitute for lifestyle modifications, which can be very effective in reducing blood pressure. However, initiation of these medications should not be delayed while attempting to modify one's lifestyle and waiting for a response. It's also recognized the most blood pressure loan occurs in the moderate dose of range with a greater chance of side effects when prescribing higher doses As stated. Already, most patients whose initial blood pressure is greater than 150 are required. Going to require more than one agent to achieve control blood pressure and therefore combination medications are going to be needed. The frequency and number of pills per day are important factors affecting patient adherence. So it's preferable to use medications with once daily dose ng or single pill combinations with fixed dose combinations as needed and the choice of agents. You should have complementary mechanisms such as an ace inhibitor with a calcium channel blocker with the thighs on for example, As already alluded to consideration of agents that include acceptable side effects and of course financial concerns and encourage insurance coverage and again, treatment goals for most patients with these agents is going to be less than 130 over 80. We could see from the start trial that's starting combination therapy initially with either a variety of arbs aces and load up in As a calcium channel blocker have been shown to improve adherence because of the lower pill burden and simultaneously reduce all course cause mortality to a significant degree. An interesting concept that has come up recently is called chrono therapy. Due to the recognition that nocturnal blood pressure is correlated more strongly with cardiovascular risks than perhaps daytime blood pressure. The normal response to sleep is a 10-15% drop in systolic blood pressure And the nocturnal response of course could only be assessed by 24 ambulatory blood pressure monitoring, which we're now able to offer at our hypertension program at temple. So the absence of this nocturnal dipping, reverse dipping where the blood pressure actually even goes up, or excessive dipping. Words reduced more than 20%. All has a variety of increased cardiovascular risks attributed to it. A recent trial called the hygiene. No one suggested that taking your medications in the evening may have therapeutic advantage by providing more strict control during the nighttime and high risk period. However, method logic problems to the study and the risk of excessive reduction we just discussed allow no firm recommendations to be made as yet about the timing of blood pressure administration until the results of three ongoing randomized controlled trials are published. So Temple University's comprehensive hypertension program has its goal to partner with referring providers to obtain optimal blood pressure control. in order to reduce cardiovascular, cerebral vascular and renal disease that always attributed to elevated blood pressure. With a focus on those who have resisted hypertension meaning inadequate control blood pressure, blood pressure, not at goal. Despite three or more medications of reasonable combination, one of which being a diuretic, we use a multidisciplinary team approach with hypertension experts from a variety of clinical backgrounds in partnership with community resources, pharmacists and dietitians. This allows a broad array of consideration of diagnostic and advanced or emerging therapeutic options. We encourage the use of home blood pressure monitoring and offer ambulatory blood pressure monitoring services to our patients to achieve adequate and comprehensive control. Thank you for joining me in this discussion and thank you for partnering with us and our attempt to adequately battle one of the more common cardiovascular risk factors that plague our community. Thank you again.