Case Discussion

1
Case Discussion

• 31 yo software engineer comes to see you because
  of elevated blood pressure. On exam bp 138/88, p
  60s, weight 200, BMI 27, exam is normal labs
  reveal normal renal function, TSH, ECG, UA
• Family history positive for hypertension
• Therapy for hypertension?

2
Lifestyle Changes Effects on Blood Pressure

• Regular low to moderate intensity exercise
• Lowers blood pressure in 75 of hypertensives
• Average SBP and DBP reductions 11 and 8 mm Hg
  respectively
• Reduces 10-yr CVD risk 25

Elley CR and Arroll B, Lancet 2005 3661248-49
3
Lifestyle Changes Effects on Blood Pressure

• Weight loss (10 kg sustained for 2 yrs)
• ? 6.0/4.6 mm
• Sodium restriction 50
• ? 5/3 mm Hg
• Diet
• ? 7 mm Hg (SBP) in association with DASH diet

Kaplan NM and Opie LH, Lancet 2006 367168-76
4
High-Normal BP and Risk of CVD

• Framingham Heart Study
• N 6,859 free of hyper-tension and CVD
• SBP 130-139 / DBP 85-89 mmHg
• Risk-factor-adjusted hazard ratio for CVD over 10
  yrs

Vasan RS et al. NEJM 2001 3451291-7
5
TROPHY

• 809 patients with pre-hypertension randomized to
  placebo or candesartan 16 mg daily. After two
  years, both received placebo for another two
  years
• Mean bp 133 mm Hg at entry
• Mean age 48 yrs
• 60 male

6
JNC 7 BP Classification
7
Blood Pressure in the Two Study Groups
Julius, S. et al. N Engl J Med 20063541685-1697
8
Kaplan-Meier Analysis of New-Onset Clinical
Hypertension
Julius, S. et al. N Engl J Med 20063541685-1697
9
Case Discussion

• 53 yo man referred to you for treatment of poorly
  controlled hypertension
• 5 year history of hypertension treated with HCTZ,
  strong family history of hypertension
• BP 150/90 on HCTZ 25 mg daily
• HCTZ stopped by primary MD, atenolol added at 50
  mg daily, increased to 100 mg
• Modestly overweight, no regular exercise, lipids
  with HDLc 38 mg/dL, LDLc 150 mg/dL
• BP still 150/100. What would you do now?

10
Beta-blockers As Third-line Agents For
Hypertension

• Only modest stroke reduction
• Increased risk of DM compared to other agents
• Side effects including adverse lipid changes
• ASCOT-BPLA

Kaplan NM and Opie LH, Lancet 2006
367168-76 ASCOT-BPLA Lancet 2005 366895-906
11
LIFE Design Dosing
Titration to target blood pressure lt140 / lt90
mmHg
Losartan 100 mg HCTZ 12.5-25 mg others
Losartan 100 mg HCTZ 12.5 mg
Losartan 50 mg HCTZ 12.5 mg
Losartan 50 mg
Placebo
Atenolol 50 mg
Atenolol 50 mg HCTZ 12.5 mg
Atenolol 100 mg HCTZ 12.5 mg
Atenolol 100 mg HCTZ 12.5-25 mg others
Day ?14
Day ?7
Day 1
Mth 1
Mth 2
Mth 4
Mth 6
Yr 1
Yr 1.5
Yr 2
Yr 2.5
Yr 3
Yr 3.5
Yr 4
Yr 5
Other antihypertensives excluding ACEIs, AII
antagonists, beta-blockers
Dahlöf B et al Am J Hypertens 199710705?713.
12
LIFE Study Endpoints

• Primary Endpoint
• Composite of cardiovascular mortality, fatal and
  non-fatal myocardial infarction, fatal and
  non-fatal stroke

Dahlof B, et al. Lancet. 2002359995-1003.
13
LIFE Primary Endpoint
Atenolol
Losartan
Proportion of patients with first event ()
Adjusted Risk Reduction 130, p0021 Unadjusted
Risk Reduction 146, p0009
B Dahlof et al. Lancet 2002359995-1003
14
Medication Use and Blood Pressure Control
ASCOT-BPLA
BP at Goal
ASCOT-BPLA Lancet 2005 366895-906
15
Case Discussion

• 53 yo man referred to you for treatment of
  hypertension
• 5 year history of hypertension treated with HCTZ,
  strong family history of hypertension
• BP 150/90 on HCTZ 25 mg daily
• HCTZ stopped, atenolol added at 50 mg daily,
  increased to 100 mg
• Modestly overweight, no regular exercise, lipids
  with HDLc 38 mg/dL, LDLc 150 mg/dL
• BP 150/100. What would you do now?

16
Case Discussion

• 62 yo retired executive with dyslipidemia,
  reports a cholesterol/HDL ratio of 6 and low dose
  statin therapy for one year
• Family history with premature CAD in a paternal
  uncle (MI age 60, smoker)
• Lipids off therapy chol 242, triglycerides 125,
  HDL 43, LDL 174 mg/dL

17
Case Continued

• Lipids on therapy chol 181, HDL 38, LDL 121
• Exam bp 110/82, no cardiovascular disease
  detected
• ECG sinus bradycardia, first degree AV block
• Framingham Risk Score 8 points, 10 yr CHD risk
  16

18
Case Continued

• Patient requests noninvasive assessment for CAD
  in the hopes of stopping lipid-lowering therapy
  if negative.

Electron Beam CT reports a coronary calcium
score of 152 (50th-75th percentile for age and
sex) Should he continue lipid-lowering therapy?
19
Coronary Calcium Scan
20
Coronary Calcium Scan
21
High-risk Patients for CHD St. Francis Heart
Study
Arad Y et al. J Am Coll Cardiol 2005 46158-65
22
High-risk Patients for CHD St. Francis Heart
Study
Arad Y et al. J Am Coll Cardiol 2005 46158-65
23
CAC Scanning
Framingham 10-20 10-year risk group
CAC Score
0
1-10
11-100 and lt75th ile
gt 100 or gt 75th ile
Moderately- High Risk 10-yr risk 10- 20
Low risk
Moderate risk 10-yr risk lt10
CAD Risk Equivalent
Hecht HS et al. Am Heart J 2006 1511139-46
24
Case Discussion

• 60 yo woman is very anxious about having heart
  disease
• Hypertension treated for 15 yrs
• Lifestyle excellent
• Father had an MI at age 44 yrs
• HDLc 92 mg/dL, LDLc 134 mg/dL
• Framingham CHD risk 5 at 10 years

25
Case Discussion

• Coronary artery calcium score 0

Annual event rate 0.12
Hecht HS et al. Am Heart J 2006 1511139-46