High blood pressure (hypertension) is widespread in Detroit, what we can do about it Oscar A. Carretero, M.D. Hypertension and Vascular Research Division.

High blood pressure (hypertension) is widespread in Detroit, what we can do

about it

Oscar A. Carretero, M.D.Hypertension and Vascular Research Division

Department of MedicineHenry Ford Health System

Detroit, Michigan

• 1) What is hypertension or high blood pressure

• 2) What causes hypertension?• 3) Why worry ?• 4) Is it widespread in Detroit ? • 5) What we can do?

Normal <120 and <80

Pre-hypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

BP Classification SBP mmHg DBP mmHg

Blood Pressure Classification

JNC 7 Hypertension 2003; 42: 1206-1252

High blood pressure (hypertension) affects nearly 65 million adults (1/3) in the United States. High blood pressure is often called a "silent killer" because many people have it, but don't know it.

Over time, people who do not get treated for high blood pressure can get very sick or even die.

• 1) What is hypertension or high blood pressure

• 2) What causes hypertension?• 3) Why worry ?• 4) Widespread in Detroit ? • 5) What we can do?

What Causes Hypertension ( the so-called Essential Hypertension)

1. Genetic variances (4-10 genes): a) If the genes contribute equally, they will be difficult to identify. b) Genes interact with multiple environmental factors that

increase Blood Pressure. 2. Environmental factors:

a) Obesity, metabolic syndrome, diabetes type 2 b) High alcohol intake c) High salt intake

3. Aging, 65 years of age or more, 2/3 have systolic hypertension probably due to arteriosclerosis and atherosclerosis

EVIDENCE FOR THE PARTICIPATION OF GENETIC FACTORS IN HYPERTENSION

1) Family studies

2) Twin studies

3) Adoption studies

4) Experimental models of hypertension including genetic and transgene models

5) Association of genotypes and BP (candidate gene probe; mapping)

0.55

0.25

0.58

0.27

0

0.1

0.2

0.3

0.4

0.5

0.6

Systolic Diastolic

Correlation coefficient

Monozygotic Dizygotic

60% 61%

0%

20%

40%

60%

80%

100%

Systolic Diastolic

Heritability estimate

Causes of Essential Hypertension1. Genetic factors

2. OBESITY and METABOLIC Syndrome

3. High Salt Intake/ diet

4. HIGH ALCOHOL INTAKE

5. Ageing

140

Interaction Among Genetic and Environmental

FactorsMultiple Genes(4-10)

EnvironmentalFactors

High calorie intake

Intermediatephenotypes

22060

0

100

50 genetic susceptibility

Phenotype: BP

Systolic Blood Pressure (mmHg)

Popu

latio

n D

istr

ibu

tio

n (%

)

obesity

Prevalence of Hypertension Relative to Percentage of Median Weight in Framingham Population

30-39 40-49 50-590

10

20

30

40

50

% H

YP

ER

TEN

SIV

E

30-39 40-49 50-5930-39 40-49 50-590

10

20

30

40

50

% H

YP

ER

TEN

SIV

E

30-39 40-49 50-59

<8585-99100-114>114

Men Women

AGE (years)

L. Landsberg, Journal of Hypertension, 10 (suppl 7), 1992

Diastolic Blood Pressure as a Function of Abdominal Circumference

(Normative Aging Study)

C. Johnston, Journal of Hypertension, 10 (suppl 7):S13-S26 1992

74

75

76

77

78

88.6 93.2 97.5 102.7Abdominal circunferente, cm (quintiles)

DB

P m

mH

g

140

Interaction Among Genetic and Environmental

FactorsMultiple Genes(4-10)

EnvironmentalFactors

IntermediatePhenotypes

22060

0

100

50

Phenotype: BP

Systolic Blood Pressure (mmHg)

Popu

latio

n D

istr

ibu

tio

n (%

)

genetic susceptibility

+ obesity

+ metabolic syndrome

What Is the Metabolic Syndrome?

McFarlane S, et al. J Clin Endocrinol Metab. 2001;86(2):713-8. Reaven GM. Diabetes. 1988;37:1595-607. Lebovitz H. Clin Chem. 1999;45(8B):1339-45. Ford ES, et al. JAMA. 2002;287:356-359. NCEP/ATP III.

• Impaired biological response to insulin:– Impairment of normal glucose uptake by muscle and/or

decrease in hepatic glycogen production– Precedes type 2 diabetes in the majority of patients

• Diagnosis defined by the concurrence of any 3 among:– Abdominal obesity (men >40 in, women >35 in)– Low HDL cholesterol (men <40 mg/dL, women <50 mg/dL)– Hypertension (130/85 mm Hg)– Hypertriglyceridemia (150 mg/dL)– High fasting glucose (110 mg/dL)– Proinflammatory (>CRP)

3

Prevalence of Metabolic Syndrome by Age Group (estimated 47 millions in the USA

Ford ES et al. JAMA. 2002;287:356-9.

Pre

vale

nce

(%

)

Age

MaleFemale

012-19 20- 29 30- 39 40- 49 50- 59 60- 69

5

10

20

50

15

25

30

35

³70

40

45

Age-Specific Prevalence in US Adolescents and Adults, 1988-1994

4

Stamler J et al. Diabetes Care. 1993;16:434-444.

Elevated systolic blood pressure increases risk of CV death almost twofold in diabetic vs non-diabetic patients

Car

dio

vasc

ula

r M

ort

alit

yR

ate

pe

r 10

,000

Pa

tien

t-Y

ears

SBP (mm Hg)

Nondiabetic patientsDiabetic patients

250

200

150

100

50

0<120 120–139 140–159 160–179 180–199 ³200

MRFIT20

Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk

Causes of Essential Hypertension

1. Genetic factors

2. Obesity and Metabolic Syndrome

3. High Salt Intake/ diet

4. HIGH ALCOHOL INTAKE

5. Ageing >65

3

9

15

3

9

15

PE

RC

EN

T

OF

G

RO

U P

W

ITH

S

YS

TO

LIC

PR

ES

SU

RE

≥1

40

m

m H

g

PE

RC

EN

T O

F

GR

OU

P

WIT

H

DIA

ST

OL

ICP

RE

SS

UR

E

≥90

m

m H

g

117 114 134 126

0 1-160 161-350 >350

ALCOHOL CONSUMPTION

(ml ethanol consumed per week)

Percentage of each drinking category with systolic or diastolic hypertension. Numbers in columns refer to total in the population subgroup.

“

“Effects of alcohol use and other aspects of lifestyle on blood pressure and prevalence of hypertension in a working population”. Arkwright et al Circulation 1982, 66:60-66.

Causes of Essential Hypertension

1. Genetic factors

2. Obesity and metabolic syndrome

3. High Salt Intake/ diet

4. High alcohol intake

5. Ageing >65

Why an Aging Population?

1. The “baby boom” following World War II2. Rise in life expectancy, 1950= 48, 2012= 783. A decline in fertility4. Better medical treatment?

Evolution of Untreated Systolic andDiastolic BP (Framingham Cohort)

Adapted from Franklin et al. Circulation 1997;96:308.

n=2036

160140-159120-139<120

Evolution of Untreated Systolic and Diastolic BP (Framingham Cohort)

Adapted from Franklin et al. Circulation 1997;96:308.

n=2036

160140-159120-139<120

Adapted from Neaton and Wentworth. Arch Intern Med 1992;152:56.

Death rate per 10,000 person-years

Diastolic BP(mm Hg)

Systolic BP(mm Hg)

10090-99

80-8975-79

70-74<70

<120

120-139

140-159

160

31

26

25

48

37

35

2525

44

38

81

Multiple Risk Factor Intervention Trial (MRFIT): Effect of BP on CHD–Related Mortality

25

25

1313

12

24

17

1421

1012

99

9

+ ageing

140

Interaction Among Genetic and Environmental

FactorsMultiple Genes(4-10)

EnvironmentalFactors

IntermediatePhenotypes

22060

0

100

50

Phenotype: BP

Systolic Blood Pressure (mmHg)

Popu

latio

n D

istr

ibu

tio

n (%

)

genetic susceptibility

+ high alcohol / d

iet

+ obesity

+ metabolic syndrome

• 1) What is hypertension or high blood pressure

• 2) What cause Hypertension?• 3) Why worry ?• 4) Widespread in Detroit ? • 5) What we can do?• 6) How to treat

Vascular Hypertrophy,Increased Matrix,

Lipid Accumulation, Arteriosclerosis and Atherosclerosis:

3) Myocardial infarction, 4) Stroke, 5) Dementia, 6) Peripheral Arterial Disease, & 7) Retinopathy

LVHHypertrophy

Increased Matrix:8) Heart Failure

HYPERTENSIONTarget Organ

Damage

Glomerular & VascularLesions:1) Nephrosclerosis2) ESRD (Dialysis or

transplant)

Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:

• 7% from heart disease

• 10% from stroke.

Kidney Disease, an Underestimated Killer90,000 a year (more than cancer of breast and prostate together)

THE NEW YORK TIMES, TUESDAY, JULY 16, 2013

• 1) What is hypertension or high blood pressure

• 2) What cause Hypertension?• 3) Why to worry ?• 4) Hypertension is widespread in

Detroit, why ? • 5) What we can do?• 6) How to treat

1. Memphis, TN-MS-AR2. Detroit-Livonia-Dearborn, MI3. Louisville-Jefferson County, KY-IN4. Birmingham-Hoover, AL5. Dayton, OH6. Pittsburgh, PA7. Buffalo-Niagara Falls, NY8. St. Louis, MO-IL9. Tampa-St. Petersburg-Clearwater,10. Indianapolis-Carmel, IN11. Oklahoma City, OK

National List of Hypertension Hotspots

Causes of Essential Hypertension1. Genetic factors?

2. Obesity and Metabolic Syndrome

3. High Salt-Sensitivity and high salt Intake / diet?

4. High alcohol intake

5. Ageing

2011 state-by-state adult obesity rates

1. Mississippi (34.9%); 2. Louisiana (33.4%); 3. West Virginia (32.4%); 4. Alabama (32.0%);

5. Michigan (31.3%);

6. Oklahoma (31.1%); 7. Arkansas (30.9%); 8. (tie) Indiana (30.8%); and South Carolina (30.8%); 10. (tie) Kentucky (30.4%); and Texas (30.4%); 12. Missouri (30.3%); 13. (tie) Kansas (29.6%); and Ohio (29.6%); 15. (tie) Tennessee (29.2%); and Virginia (29.2%); 17. North Carolina (29.1%); 18. Iowa (29.0%); 19. Delaware (28.8%); 20. Pennsylvania (28.6%); 21. Nebraska (28.4%); 22. Maryland (28.3%); 23. South Dakota (28.1%); 24. Georgia (28.0%); 25. (tie) Maine (27.8%); and North Dakota (27.8%); 27. Wisconsin (27.7%); 28. Alaska (27.4%): 29. Illinois (27.1%); 30. Idaho (27.0%); 31. Oregon (26.7%); 32. Florida (26.6%); 33. Washington (26.5%); 34. New Mexico (26.3%); 35. New Hampshire (26.2%); 36. Minnesota (25.7%); 37. (tie) Rhode Island (25.4%); and Vermont (25.4%); 39. Wyoming (25.0%); 40. Arizona (24.7%); 41. Montana (24.6%); 42. (tie) Connecticut (24.5%); Nevada (24.5%); and New York (24.5%); 45. Utah (24.4%); 46. California (23.8%); 47. (tie) District of Columbia (23.7%); and New Jersey (23.7%); 49. Massachusetts (22.7%); 50. Hawaii (21.8%); 51. Colorado (20.7%).

Age (y)

Prevalence of Hypertension in the U.S.in Men by Age and Ethnicity

Adapted from Burt et al. Hypertension 1995;25:305.

>8070-7940-49 60-6918-29 30-390

20

40

60

80

50-59

100

Pre

vale

nce

of

hype

rten

sion

(%

)

Caucasian

Hispanic

AfricanAmerican

Obesity Risk Factor for Hypertension

• How fat is Michigan? Very fat. • We are the 5th fattest state.• Three of 5 Michiganders could be obese by

2030 and health care cost will skyrocket

Diastolic Blood Pressure as a Function of Abdominal Circumference

(Normative Aging Study)

C. Johnston, Journal of Hypertension, 10 (suppl 7):S13-S26 1992

74

75

76

77

78

88.6 93.2 97.5 102.7Abdominal circunferente, cm (quintiles)

DB

P m

mH

g

Salt-Sensitivity• This is very important since individuals with salt-sensitivity, whether hypertensive or not, have a higher mortality than salt-resistant subjects.•Blacks have higher salt-sensitivity than Whites.

Cu

mu

lati

ve S

urv

ival

Follow-up (yrs)

1.0

.9

.8

.7

.6

5 10 20 30

H+RH+S

N+S

N+Rp <0.0001

M.H. Weinberger et al . Hypertension. 2001;37[part 2]:429-432

25150

Joint Effect of Race and Hypertensionon BP Response to DASH Combination Diet

Net

BP

Red

uctio

n, m

mH

g

-14

-12

-10

-8

-6

-4

-2

0

Normotensive

-14

-12

-10

-8

-6

-4

-2

0

Systolic Diastolic Systolic Diastolic

Hypertensive

Black

Non-Hispanic White

FEATURES OF HYPERTENSION IN BLACK PATIENTS

• Earlier onset• Salt sensitivity• Frequently concomitant with obesity /

diabetes• High target organ damage• Increased prevalence of ESRD• Low urinary kallikrein excretion• Low RAS

• 1) What is hypertension or high blood pressure

• 2) What cause Hypertension?• 3) Why to worry ?• 4) Widespread in Detroit ? • 5) What we can do?

Lifestyle Modification

Modification Approximate SBP reduction(range)

Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

Lowering SBP by 20 mm Hg Reduces Cardiovascular Risk by Half

*Data from a meta-analysis of 1 million adults in 61 prospective studies who had no prior vascular disease.Lewington S et al. Lancet. 2002;360:1903-1913.

% m

ort

alit

y r e

du

ctio

n f

or

e ach

2 0

mm

Hg

dro

p i

n S

BP

-70

-60

-50

-40

-30

-20

-10

0

Stroke Ischemic Heart Disease

Other vascular causes

40-4950-5960-6970-7980-89

N=958,074

Years o

f age

23

We need a team-based approach to solve the problem of hypertension in Detroit:

1. Health care systems: a) electronic health records, b) encourage the use of 90-day, antihypertensive refills, c) low or no co-pays (compliance will decrease stroke, heart attacks, heart failure, and end stage renal disease (dialysis) . We will save money and suffering. d) Provide education for patients

2. Providers: doctors, nurses, pharmacists etc: a) Counsel patients to take their medicine and make lifestyle changes, b) track their patient’s blood pressure, c) explain that hypertension is treated but not cured, d) measure progress against specific objectives, e) review records looking for patients that are not under BP control.

3. Patients: a) take the initiative to monitor blood pressure levels weekly and record, b) take medication as prescribed, and c) notify the doctor of any side effect, d) MAKE LIFESTILE CHANGES such as losing weight , eating Dash diet, low sodium diet, e) exercise (walk) and f) stop smoking

Left without health insurance in states that opted out of expanding Medicaid

Profession Poor and Uninsured %Cashiers 715,000 19

Cooks 520,00 17

Nursing aide, orderlies, attendants 420,000 11

Retail sales clerks 404,000 10

Waiters and waitresses 378,000 16

Laborers (outside const) 355,000 18Truck drivers 308,000 8

Housekeepers, maids, butlers, stewards 273,000 19

Algorithm for Treatment of Hypertension

JNC 7

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

With Compelling indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the

compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg)

indications

Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs

May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI,

ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB)

as needed

Not at Goal Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

Algorithm for Treatment of Hypertension

JNC 7

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

With Compelling indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the

compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg)

indications

Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs

May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI,

ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB)

as needed

Not at Goal Blood Pressure

Optimize dosages or add additional drugs

Algorithm for Treatment of Hypertension

JNC 7

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

With Compelling indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the

compelling (SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg)

indications

Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs

May consider ACEI, ARB, BB, CCB thiazide-type diuretic and, (diuretics, ACEI,

ARB, BB, CCB) or combination. ACEI or ARB, or BB, or CCB)

as needed

Algorithm for Treatment of Hypertension

JNC 7

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Optimize dosages or add additional drugsuntil goal blood pressure is achieved.

Consider consultation with hypertension specialist

Not at GoalBlood Pressure

Drug (s) for the compelling indications

Other antihypertensive drugs(diuretics, ACEI, ARB, BB, CCB)

With CompellingIndications

Without CompellingIndications

Stage 1 Hypertension(SBP 140-159 or DBP 90-99 mmHg

Thiazide-type diuretics for mostMay consider ACEI, ARB, BB, CCB

Stage 2 Hypertension(>SBP 160 or DBP >100 mmHg

Thiazide-type diuretics for mostMay consider ACEI, ARB, BB, CCB

Cumulative probability of survival from coronary artery disease in 686 men with hypertension and 6810 non-hypertensive men in primary prevention study.

O.K. Anderson, O. K. et al. BMJ, Vol. 317, July 1998

National List of Hypertension of not very hotspots

42. New York-White Plains-Wayne, NY-NJ43. Boston-Quincy, MA 44.San Diego-Carlsbad-San Marcos, CA 45. Minneapolis-St. Paul-Bloomington, MN-WI 46. Oakland-Fremont-Hayward, CA 47. Los Angeles-Long Beach-Glendale, CA48. Denver-Aurora, CO 49. Salt Lake City, UT50. San Francisco-San Mateo-Redwood City, CA

Simple tubular models of the systemic arterial system. Top, normal distensibility and normal pulse wave velocity.Middle, decreased distensibility but normal pulse wave velocity.Bottom, decreased distensibility with increased pulse wave velocity. Left, are the amplitude and contour of pressure waves that would be generated at the origin of these models by the same ventricular ejection (flow) waves. Decreased distensibility per se increases pressure wave amplitude, while increased wave velocity causes the reflected wave to return during ventricular systole. M. O’Rourke, Hypertension 1995; 26:2-9

Wave velocity

Wave velocity

Wave velocity