Prevention, Treatment, Control and Sodium Reduction Policy Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead Division for Heart Disease and Stroke Prevention U.S. Department of Health and Human Services Centers for Disease Control and Prevention
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Prevention, Treatment, Control and Sodium Reduction Policy Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead Division for Heart.
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Prevention, Treatment, Control and Sodium Reduction Policy
Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead
Division for Heart Disease and Stroke Prevention
U.S. Department of Health and Human ServicesCenters for DiseaseControl and Prevention
Overview of this Module
Hypertension and the impact on population health
Assessment of hypertension
Challenges in hypertension control
JNC-VII treatment guidelines
System-based initiatives to improve control
Hypertension and sodium connection
Community and population based changes to promote prevention
Discrepancy Between Health Determinants and Spending of $1.7
Trillion, 2007
Source: Prevention Institute. 2007. Reducing Healthcare Costs Through Prevention. Available at http://www.preventioninstitute.org/documents/HE_HealthCareReformPolicyDraft_091507.pdf
The Magnitude of the Problem Hypertension is the single largest risk factor
for cardiovascular disease mortality, accounting for 45% of all CVD deaths1
INTERSTROKE Study concluded that hypertension provides 34.6% of the population-attributable risk (PAR) for stroke2, while INTERHEART found it provides 17.9% of the PAR for myocardial infarction3
The PAR is the reduction in incidence that would be observed if the population were entirely unexposed (did not have hypertension).
1. IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension.2. O’Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKEstudy): a case–control study. The Lancet 2010; 376:112–233. Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, Alvaro Avezum, Fernando Lanas, Matthew McQueen, Andrzej Budaj, Prem Pais, John Varigos, Liu Lisheng, on behalf of the INTERHEART Study Investigators, Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study, The Lancet, 2004: 9438, 11–17.
Focused clinical interventions for those at high risk
Lifestyle advice
Population-based strategies
Stages of CVD Intervention
Primordial – Before risk factors develop
Primary – Treatment of risk factors
Secondary – After a CVD event occurs
Primordial Prevention – Preventing Risk Factors from Developing
In 1978, Strasser introduced the concept of primordial prevention. Once a risk factor has developed, it can be difficult to reduce the risk it contributes to overall health
“Medications and lifestyle interventions cannot reduce CVD event rates to levels seen in those who maintain optimal risk factor profiles (ideal cardiovascular health) into middle and older ages.”
Lloyd-Jones DM. Improving the cardiovascular health of the US population. JAMA. 12 ;1314 -1316 .
Population Strategy
WHO, Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk., 2007
Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000.NEJM 2007; 356: 2388.
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Major Shifts in Population Risks and Expanded Treatment, U.S.
What Can You Do to Make a Difference?
Approximately 68 million U.S. adults (1 in 3) have hypertension
Only 46% of adults with hypertension had adequately controlled blood pressure. The Million Hearts™ initiative has set a goal of 65% control by 2017 overall, and 70% in the clinical setting
Valderrama A, et al. Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors. MMWR. 2011; 60(36);1248-1251.
Patient Level Strategy
A 10mmHg lower systolic blood pressure
(SBP) – or 5mmHg lower diastolic blood
pressure (DBP) – is associated with an
approximately 20–25% lower risk of
coronary heart disease (CHD) and an
approximately 40% lower risk of stroke
1. Stamler J, Stamler R, Neaton JD, Blood pressure, systolic and diastolic, and cardiovascular risks. US population data, Arch Intern Med, 1993;153:598–615. 2. Asia Pacific Cohort Studies Collaboration, Blood pressure and cardiovascular disease in the Asia Pacific region, J Hypertens, 2003;21:707–16.3. MacMahon S, Peto R, Cutler J, et al., Blood pressure, stroke and coronary heart disease. Part I, prolonged differences in blood pressure: prospective observational studies
corrected for the regression dilution bias, Lancet, 1990;335:765–74.4. http://www.touchbriefings.com/pdf/2988/giampaoli.pdf
Greenland P. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults:
Executive Summary. JACC. Vol. 56, No. 25, 2010.
Lifestyle interventions
JNC VII recommends therapeutic lifestyle change only for most people with pre-hypertension Weight reduction DASH diet Dietary sodium reduction Physical Activity Moderate alcohol consumption
Study from Colorado Kaiser Permanente, found that 1.9% of patients (1 in every 50 patients) with incident hypertension who were begun on treatment developed resistant hypertension within a median of 1.5 years from initial treatment
They found 16% of patients on 3 or more drugs continued to have resistant hypertension
Daugherty SL, et al. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation. February 29, 2012.
Epub ahead of print]
What Happens if Hypertension isn’t Controlled?
Left ventricular hypertrophy (LVH)
Heart failure
Chronic kidney failure
Stroke (cerebral hemorrhage)
Vascular dementia
Retinopathy
Slide SourceHypertension Online
www.hypertensiononline.org
<117
Systolic Blood Pressure (mm Hg)
Incidence of ESRD by Systolic Blood Pressure: Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor Intervention TrialMultiple Risk Factor Intervention Trial**
Klag MJ, et al. End-stage renal disease in African-American and white men. 16-year MRFIT findings. JAMA. 1997;277:1293-1298.
Incid
en
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f ES
RD
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00 P
ers
on
-Years
*The original cohort of 332,544 men included 11,677 men in other ethnic groupswhose data are excluded from this comparison. ESRD = end-stage renal disease
White Men (n = 300,645)
Black Men (n = 20,222)
117-123 124-130 131-140 >140
5.4
15.8
5.49.1
14.2
32.427.3 26.2
37.2
83.1
Effects of Systolic and Diastolic BloodPressures on CHD Mortality: MRFIT*
Neaton JD, et al. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152:56-64.
*Data shown only for 316,099 white men 35 to 57 yearsof age who were followed for a mean of 12 years.
PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure Percentage of patients aged 18 and older who are screened
for high blood pressure.
PQRS Measure #236 (NQF 0018): Hypertension: Controlling High Blood Pressure Percentage of patients aged 18 through 85 years of age
who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/<90) during the measurement year.
Team-based care – the Role of the Pharmacist
The Asheville Project is a community-based, pharmacist-directed, medication therapy management (MTM) program provided for several employers in the Asheville, NC area
Patients with hypertension receiving education and long-term medication therapy management services achieved significant clinical improvements that were sustained for as long as 6 years
↓ cardiovascular events
↑ adherence to medicationsBunting BA, et al. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:23–31.
Quality Improvement and Clinical Decision Support
A proven concept that improves care! Alerts Reminders Reports Templates for management Built-in access to guidelines Enhances implementation of quality
improvement initiatives
Clinical-Community Reporting Efforts
RWJF Aligning Forces for Quality Public reporting – Wisconsin Collaborative for Healthcare
Sodium intake is one of several dietary factors that increases blood pressure
Sodium is the principal cation of the extracellular fluid and functions as the osmotic determinant in regulating extracellular fluid volume and plasma volume
Sodium is stored in the blood and in the fluid surrounding the cells; kidneys control the body sodium concentration by clearing excess sodium through urine
The Effect of Sodium Intake on Blood Pressure
Sodium affects blood pressure by changing blood volume
Absorbed sodium remains in the extracellular compartments, including plasma (at [140 mmol/L]; interstitial fluid [145 mmol/L]; plasma
water [150 mmol/L]; muscle tissue [3 mmol/L]) These levels maintain blood pressure in the normal
range Increased sodium intake =increased blood volume =
Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: National
Academies Press; 2004.
Excess Sodium Intake Leads to Hypertension
Sodium, through hypertension, is a major contributor to death, disability, disparities, and costs attributable to cardiovascular diseases (CVD)
Economic burden Treatment for heart disease, stroke, and other CVD
accounts for 1 in 6 U.S. health dollars spent ($273 billion in 2008)
Globally, 8.5 million deaths could be averted over 10 years from 2006 to 2015 through a 15% reduction in sodium intake
Vital Signs: MMWR 2011; 60(4):1-3–8Heidenreich PA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123;933–944.Asaria P, et al. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044–53.
Sodium Reduction Benefits All Ranges of Blood Pressure
Evidence supports a strong, direct relationship between blood pressure and vascular mortality
No evidence of a blood pressure threshold—vascular mortality increases throughout the range of blood pressures in both nonhypertensive and hypertensive individuals
Average blood pressure was reduced by 22.7/9.1 mm Hg in patients with resistant hypertension when switched from a high to low sodium diet
In most individuals blood pressure is reduced within days to weeks of reducing sodium intake
Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: NationalAcademies Press; 2004.Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia J, Calhoun DA. Effects of dietary sodium reduction on bloodpressure in subjects with resistant hypertension: results from a randomized trial. Hypertension. 2009; 54: 475 - 481
DASH and DASH Sodium Trials
Dietary Approaches to Stop Hypertension (DASH) Trial Compared the effects of three diets – typical American diet, fruits and
vegetable diet, and a diet rich in fruits and vegetables and low fat dairy, and reduced in saturated fat, total fat, and cholesterol
All diets provided ~ 3,000 mg sodium per day Combination diet (DASH) produced the largest blood pressure
reduction after 8 weeks – average ↓ of 5.5 / 3.0 mm Hg • Participants with hypertension experienced an average blood pressure ↓
of 11.4 / 5.5 mm Hg
DASH Sodium Trial DASH diet and three levels of sodium intake – 1,150 mg, 2,300 mg,
and 3,450 mg DASH diet and a low level of sodium ↓ SBP by 7.1 mg Hg
• Participants with HTN experienced a BP ↓ of 11.5 mm Hg
Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-1124; Sacks et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. N Engl J Med 2001; 344:3-10
Sodium Intake Levels: Recommended and Actual
Recommended levels of sodium intake 2010 Dietary Guidelines for Americans Reduce sodium to < 2300 mg/day For specific populations: 1,500 mg/day
≥51 years old African Americans Have high blood pressure, diabetes, or chronic kidney
disease About half the U.S. population and the
majority of adults Actual sodium intake
Average daily sodium intake for U.S. adults is >3,300 mg/day
USDA and HHS. Dietary Guidelines for Americans, 2010. 7th edition. Washington, DC: Government Printing Office; 2010.
Vital Signs: MMWR 2012; 61(Early Release);1-7
Individual Sodium Reduction Has Population Benefits
Reducing the sodium content by 25% of the top 10 food category contributors to sodium intake could result in a 360 mg reduction in average sodium consumption in the United States
Reducing average population sodium consumption by 400 mg has been projected to avert up to 28,000 deaths from any cause and save $7 billion in health-care expenditures annually
CDC, MMWR;2012;61:1-7.Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590–9.
Reducing Sodium Intake Reduces Blood Pressure
Reducing average population sodium intake to 1,500 mg/day may Reduce cases of hypertension by 16 million Save $26 billion health care dollars Gain 459,000 Quality Adjusted Life Years (QALYs)
Even reducing sodium intake to 2,300 mg/day could Reduce cases of hypertension by 11 million Save $18 billion health care dollars Gain 312,000 QALYs
Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Eng J Med 2001;344:3–10.Palar K, et al. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot 2009;24(1):49–57.
Percent of US persons exceeding their 2010
Dietary Guidelines for Americans sodium intake recommendations*
*All people age 51 and older should reduce sodium intake to 1,500 mg/day.MMWR 2011;60:1413-1417
Age Group
%
Most of the sodium we eat comes from processed and restaurant foods
Mattes RD, et al. Relative contributions of dietary sodium sources. J AM Coll Nutr 1991;10:383–393.
44% of US sodium intake comes from ten types of foods
CDC, MMWR;2012;61:1-7.
Rank Food Types %
1 Bread and rolls 7.4
2 Cold cuts and cured meats 5.1
3 Pizza 4.9
4 Poultry 4.5
5 Soups 4.3
6 Sandwiches 4.0
7 Cheese 3.8
8 Pasta mixed dishes 3.3
9 Meat mixed dishes 3.2
10 Savory snacks 3.1
Other Guidelines and Recommendations
Institute of Medicine Reduce the sodium content of the U.S. food supply Health practitioners: commitment to incorporate
guidelines on sodium intake into prevention messages and standards of care
Million Hearts™ Reduce population sodium intake by 20% by January 1,
2017 Healthy People 2020
Reduce mean U.S. population sodium intake to 2,300 mg per day by 2020
American Heart Association Reduce population sodium intake to 1500 mg per day
Other Guidelines and Recommendations
American Medical Association Stepwise, minimum 50% reduction in sodium in processed foods,
fast-food products, and restaurant meals over the next decade Physicians and other clinicians should educate patients about the
benefits of long-term, moderate reductions in sodium intake Substantial public health benefits accrue from small reductions in
population blood pressure distribution, achievable with long-term modest reduction in sodium intake
AMA supports the National Salt Reduction Initiative Aim is to lower U.S. population sodium intake by 20% over five
years through sodium reduction in packaged, processed and restaurant foods by 25% over that time period
Dickinson B, Havas S. Reducing the Population Burden of Cardiovascular Disease by Reducing Sodium Intake A Report of the Council on Science and Public Health. Arch Intern Med. 2007;167(14):1460-1468.
Adults with Self-Reported Hypertension Who Received and Acted on Low-Salt
AMA recommends that health care providers educate patients on how to reduce sodium intake
However, nearly 70% of primary health care providers report advising their patients to remove the salt shaker from the table, and the majority reported advising patients to add less salt during cooking, even though these behaviors are unlikely to result in major sodium reduction
Havas S, Dickinson BD, Wilson M. The urgent need to reduce sodium consumption. JAMA. 2007;298:1439-41. Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1):76-78. doi:10.1001/archinternmed.2011.620. Image adapted from CDC Vital Signs Fact
Sheet, Where’s the Sodium
Health Care Providers Who Agree with Importance of Sodium Reduction for their
Patients
Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1):76-78. doi:10.1001/ archinternmed.2011.620.
Statement: “Most of my patients should reduce their sodium intake”
Health care provider
Role of the Provider Patients may be able to lower the required dose of
blood pressure medicines through reduced sodium intake
Patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction Referral to a Registered Dietitian for Counseling Education during BP screenings Downloadable CDC resource:
Reducing Sodium in Your Diet to Help Control Your Blood Pressure Advise consumption of fresh fruits and vegetables, frozen fruits
and vegetables without sauce, and no salt added canned vegetables
Current food environment makes it difficult for consumers who want or need to consumes less sodium to do so
Reduction of sodium in the food supply, coupled with consumer education and knowledgeable use of food labels, may provide greater choice and control over sodium intake, a modifiable risk factor for high blood pressure, heart disease, and stroke
Patient Education – It’s Not the Salt Shaker, It’s
the Food Choices!
www.cdc.gov/salt
COMMUNITY AND POPULATION-BASED CHANGES TO PROMOTE PREVENTION
Community Partners
Community health workers and Promotores de Salud A liaison between health and social services and the
community facilitating access to care Provides a trusted liaison through a shared culture with
the people they serve Barbershop- and beauty shop-based
interventions to improve hypertension control
Faith-based support programs
Ferdinand KC, et al. Community-based approaches to prevention and management of hypertension and cardiovascular disease.
Journal of Clinical Hypertension. 2012. Online ahead of print. DOI:10.1111/j.1751-7176.2012.00622.x
Population-Based Strategy
SBP Distributions
Stambler .Hypertension.
1991; 117-120.
After Interventio
n
Before Intervention
Reductio
n in BP
Reductions in SBP
% Reduction in Mortality
Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7
CDC Efforts Related to Hypertension Control
Community Transformation Grants
Sodium Reduction in Communities
WISEWOMAN program
State Health Departments
Million Hearts™ Initiative
Public Health
Public health approaches such as increasing physical activity and reducing trans-fats and salt in processed foods can achieve a downward shift in the distribution of a population’s blood pressure.
In addition to CDC activities on the previous slide, CDC funds many other programs to promote healthy lifestyles.
• SHEP (Systolic Hypertension in the Elderly Program)– In persons aged 60 years and over with isolated systolic hypertension, antihypertensive
stepped-care drug treatment with low-dose chlorthalidone as step 1 medication reduced the incidence of total stroke by 36%
• ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial)
– The mean systolic blood pressure was 4mm Hg higher in blacks and 2 mm Hg higher in non-blacks in the lisinopril group than in the chlorthalidone group. Blood pressure control was 8-13% better in the chlorthalidone group than in the lisinopril group for blacks. Although in the trial overall the chlorthalidone group was better controlled than the lisinopril group, this difference between the two groups among blacks is quite striking.
• MRFIT (Multiple Risk Factor Intervention Trial)– Changed protocol in clinics using primarily HCTZ to chlorthalidone due in part to an a higher
trend in mortality in clinics using predominantly hydrochlorothiazide. Changing to chlorthalidone was associated with a trend toward better outcomes.
• TROPHY (Trial of Preventing Hypertension)– Found that it is possible to prevent or delay the onset of clinical hypertension in people with
blood pressure that falls within the "prehypertension" category
Important Hypertension Trials
• TOHP (Trials of Hypertension Prevention)– Sodium reduction, previously shown to lower blood pressure, may also
reduce long term risk of cardiovascular events.
• TONE (Trial of Nonpharmacologic Interventions in the Elderly)– Reduced sodium intake and weight loss constitute a feasible, effective,
and safe nonpharmacologic therapy of hypertension in older persons.
• HYVET (Hypertension in the Very Elderly Trial)– According to Timothy Gardner, M.D., President of the American Heart
Association: ‘The results of HYVET demonstrate that effective antihypertensive treatment with indapamide (Natrilix SR) in persons aged 80 years old or older, is beneficial in reducing the risk of cardiovascular events, and thus extends the patient group in whom prevention must be pursued.’
Case Studies
From Medscape Education
Timing is Everything: 24-Hour Control of Blood Pressure William C. Cushman, MD
http://theheart.medscape.org/viewarticle/759171
How well prepared are your residents for managing hypertension?
Study from Johns Hopkins of baseline knowledge of PGY3 internal medicine residents
– Hypertension 62-66%
– Lipid Management 31-36%
– Diabetes 35-40%
– Smoking 53-54%
– Obesity 44-47%
– Total of 15 Chronic Diseases48-50%
Baseline knowledge of PGY3 did not differ from PGY1 and PGY2
Sisson SD, Dalal D. Internal Medicine residency training on topics in ambulatory care: A status report. Am Jour of Medicine. 2011;124(1):86-90.
Discussion Questions (could be used before delivering the module or
after)
You have a busy Family Medicine Practice
1. At what point would you consider referring a patient for hypertension control?
2. How does team-based care delivery for hypertension control work in your clinic?
3. Can you think of ways to improve your health information technology to improve hypertension control?
4. How do you guide your patients to reduce sodium in their diet?