Module 1: Heart and Hypertension Managing Hypertension to

Module 1: Heart and Hypertension Managing Hypertension to

Module 1: Heart and Hypertension Managing Hypertension to Prevent Heart Failure and Atrial Fibrillation This program meets the accreditation criteria of The College of Family Physicians of Canada and has been accredited for up to 1.5 Mainpro-M1 credits. March 2012 1 Case Development & Disclosures Case Authors: Simon Kouz (MD, FRCPC,

FACC) Clinical Professor Laval University, QC Specialty: Cardiology Sheldon Tobe (MD, FRCPC, FACP, FASH) Associate Professor of Medicine, Sunnybrook Health Sciences Centre, University of Toronto Specialty: Nephrology CHEP Continuing Education Committee Richard A. Ward, MD CCFP Steven Goluboff, MD CCFP

Sol Stern, MD CCFP David Dannenbaum, MD CCFP John Hickey MD, CCFP Karen Mann, BN, MSc, PhD Additional Reviewers: Jonathan Howlett, MD George Pylypchuk, MD Guy Tremblay, MD 2 Conflict Disclosure Information Presenter 1: Grants/Research Support: _____________________ Speakers Bureau/Honoraria: ___________________

Consulting Fees:_____________________________ Other: ____________________________________ 3 Outline of Todays Activity Introduction Case Presentation Key Learnings & Questions

Wrap Up 4 Module 1: Heart and Hypertension Cliff A 76-year-old man presents to your office with a new complaint of shortness of breath and intermittent palpitations at rest. 5 Learning Objectives Upon completion of this activity, participants

should be able to: Apply the Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension in association with heart failure Explain the relationship between hypertension and heart failure, and in relation to a specific case Explain the relationship between hypertension and atrial fibrillation, and in relation to a specific case 6 Statement of Need My greatest challenge as a health care provider in the management of

patients with hypertension is ___________ 7 Proportion of Deaths Attributable to Leading Risk Factors Worldwide (2000) High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity Alcohol

Indoor smoke from solid fuels Iron deficiency 0 WHO 2000 Report. Lancet. 2002;360:1347-1360. 1 2 3 4 5

6 7 8 Attributable Mortality 8 Hypertension as a Risk Factor Hypertension is a significant risk factor for: cerebrovascular disease coronary artery disease congestive heart failure renal failure

peripheral vascular disease dementia atrial fibrillation 9 Blood Pressure and Risk of Stroke and Ischemic Heart Disease Mortality Higher blood pressure is associated with an increased risk of stroke and ischemic heart disease mortality For every 20 mmHg systolic blood pressure above 120 mmHg, the risk of dying doubles For every 10 mmHg increase in diastolic blood pressure the risk doubles

Lancet 2002;360:1903-13 10 Leading Diagnoses Resulting in Visits to Physician Offices in Canada Acute respiratory tract infection 5 Routine medical exams

10 Diabetes 15 Depression 20 Hypertension Million visits/year 25

0 Source: IMS HEALTH Canada 2002 11 History of Present Illness Cliff is a 76-year-old man who presents to your office with a new complaint of shortness of breath and intermittent palpitations at rest Present lifestyle Non-smoker, averages 2 beers/day Married; 2 children out of town 12

History of Present Illness A week ago he noted dyspnea with exertion while climbing the stairs at the theatre 3 nights ago he woke up from sleep with dyspnea and had to sit on the edge of his bed, with palpitations He noticed that he is winded after his usual walks with the dog No chest pain, no cough, no edema 13 Past History

Hypertension diagnosed and treated for 10 years Acute myocardial infarction 6 years ago (thrombolysed) preserved LV function immediately after discharge Osteoarthritis was an athlete in the past, retired physical education teacher LV = left ventricular 14 Family History Mother history of hypertension, stroke at age 75

Father Alzheimers dementia at age 81 Sisters 2 sisters, both diagnosed with diabetes Brother died at age 60 of colon cancer 15 Current Medications

Hydrochlorothiazide 50 mg OD Amlodipine 5 mg OD ECASA 81 mg OD Rosuvastatin 10 mg OD Celecoxib 200 mg OD 16 Physical Examination

Height: 172 cm Weight: 85 kg BMI: 28.7 kg/m2 BP (left arm, seated): 144/84 mmHg using an automated device Pulse: 96 regular Systolic murmur 2/6 over aortic area with no radiation Not dyspneic at rest No edema Lungs clear on chest

exam You decide to send Cliff for an ECG 17 Discussion Question 1 What are the benefits of performing an ECG in this patient? 18 Discussion Question 1) What are the benefits of performing in ECG in this patient? a) Document the patients heart rhythm b) Assessing for LVH or atrial abnormality or

previous MI c) Measure baseline QT interval that may be affected by pharmacologic therapy Note: Discussion questions do not necessarily have only one correct answer 19 a, b and c are all correct Documenting the patients heart rhythm Assessing for LVH or atrial abnormality or

previous MI Measuring baseline QT interval that may be affected by pharmacologic therapy 20 21 Findings The ECG indicates sinus rhythm, left ventricular hypertrophy and strain 22 Laboratory Investigations

Test Results Normal Values Glucose 6.5 mmol/L 4.0-8.0 mmol/L Urea 6.8 mmol/L

3.0-7.0 mmol/L Creatinine 105 mol/L eGFR 50ml/min 44-106 umol/L K 3.4 mmol/L 3.5-5.0 mmol/L

Hb 112 g/L 115-165 g/L Note that labs are done prior to the next visit. Hb: hemoglobin, K: potassium 23 Laboratory Investigations Test Results

Normal Values LDL 2.5 mmol/L <2.50 mmol/L Total Chol 3.8 mmol/L <5.20 mmol/L

TG 2.4 mmol/L <1.70 mmol/L HDL 0.8 mmol/L >0.99 mmol/L TC:HDL 4.75

High risk target: <4.0 Mod risk target: <5.0 Low risk target: <6.0 24 European Society of Hypertension Classification of Blood Pressure Category Systolic Diastolic Optimal

<120 and / or <80 Normal <130 and / or <85

High-Normal 130-139 and / or 85-89 Grade 1 (mild hypertension ) 140-159 and / or 90-99

Grade 2 (moderate hypertension) 160-179 and / or 100-109 Grade 3 (severe hypertension) 180 and / or

110 Isolated Systolic Hypertension (ISH) 140 and <90 The category pertains to the highest risk blood pressure *ISH=Isolated Systolic Hypertension. J Hypertension 2007;25:1105-87, 25

Recommended Treatment Targets Treatment consists of health behaviour pharmacological management Population SBP DBP Diabetes <130 <80

All others < 80 y.a. (including CKD) <140 <90 Very elderly ( 80 years) NA <150* *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis.

2014 Management Plan What are the nonpharmacological treatment options for this patient? 27 Management Plan Nonpharmacological Sodium restriction, consult dietitian Weight loss Exercise Reduction of alcohol intake

28 Impact of health behaviours on blood pressure Intervention Systolic BP (mmHg) Diastolic BP (mmHg) Diet and weight control -6.0

-4.8 Reduced salt/sodium intake - 5.4 - 2.8 Reduced alcohol intake (heavy drinkers) -3.4 -3.4

DASH diet -11.4 -5.5 Physical activity Relaxation therapies -3.1 -3.7 -1.8 -3.5

Multiple interventions -5.5 -4.5 Clinical Guideline : Methods, evidence and recommendations National Institute for Health and Clinical Excellence (NICE) May 2011 2014 Discussion Question 2 What are the main reasons for

dyspnea in Cliff? 30 Discussion Question 2 What are the main reasons for dyspnea in Cliff? a) b) c) d) e) Diastolic Heart failure Angina equivalent

Hypertension Anemia Valvular heart disease Note: Discussion questions do not necessarily have only one correct answer 31 a) Diastolic heart failure He has all the risk factors associated with this condition Possible atrial fibrillation, hypertension, ischemic heart disease ECG showing LVH

32 b) Angina equivalent Dyspnea can be a result of angina, especially in elderly persons 33 C) Hypertension Patients with uncontrolled hypertension will be asymptomatic until they develop target organ damage so this is unlikely 34

d) Anemia Patients with progressive anemia can manifest with shortness of breath Patient may have developed silent GI bleed or renal insufficiency as a cause Hb of 112 is unlikely to cause these symptoms even if acute 35 e) Valvular Heart Disease Clinical evaluation of possible aortic and mitral valve disease is more frequently misleading at the extremes of age (young/old) He is only 76 and has a murmur

Consider aortic stenosis 36 Discussion Question 3 What risk factors does Cliff have for developing atrial fibrillation? 37 Discussion Question 3) What risk factors does Cliff have for developing atrial fibrillation? a) b)

c) d) Hypertension LVH Age Ischemic heart disease Note: Discussion questions do not necessarily have only one correct answer 38 a, b, c and d are all correct This patient has high risk of developing atrial fibrillation (hypertension, LVH, age, ischemic

heart disease and alcohol* use) * alcohol: best evidence is for those drinking 5+ per day 39 Discussion Question 4 If there is concern about underlying atrial fibrillation, what should be performed? 40 Discussion Question 4) If there is concern about underlying atrial fibrillation, which of the following should be performed?

a) b) c) d) Comprehensive review of symptom patterns Review historical risk factors Careful physical examination CBC, electrolytes, renal function and thyroid function Note: Discussion questions do not necessarily have only one correct answer 41

a) Comprehensive review of symptom patterns Determine if the pattern is one of paroxysmal or persistent atrial fibrillation Determine past history of atrial fibrillation 42 b) Review historical risk factors Consider hypertension and medication use Alcohol abuse, thyroid disease, sleep apnea 43 c) Careful physical examination Look for evidence of LVH and risk factors for

thromboembolic disease 44 d) CBC, electrolytes, renal function and thyroid function Recommended for the evaluation of patients with atrial fibrillation 45 Discussion Question 5 The ECG shows that Cliff is in sinus rhythm with LVH and strain. Which tests will you now order?

46 Discussion Question 5 ) The ECG shows that Cliff is in sinus rhythm with LVH and strain. Which of the following tests will you now order? a) b) c) d) e) Chest Radiograph Diagnostic Holter

Echocardiography Treadmill test exercise Trans-esophageal echo Note: Discussion questions do not necessarily have only one correct answer 47 a) Chest Radiograph A normal part of assessment for patients with shortness of breath Should be performed irrespective of ECHO 48

b) Diagnostic Holter Negative test does not rule out atrial fibrillation Holter is often insufficient to diagnose paroxysmal atrial fibrillation Cardiac loop monitor over 7 days or 2 weeks is better; documents arrhythmia, assesses rate control, assesses episodes of bradycardia 49 c) Echocardiography This is the best test to: Measure size of the LA Assess LV systolic function Assess for ventricular function in including

diastolic dysfunction Assess for valvular disease Assess for LVH Also can estimate the PA pressure (right ventricular systolic Pressure) 50 d) Treadmill exercise test Indicated for those with exertional dyspnea, particularly without a cause Assesses functional capacity, BP and HR response to exercise Helps to guide care

51 e) Trans-esophageal echo Not a routine test This test helps to assess left atrial size and rule out an left atrial thrombus Invasive 52 Case Progression After the ECG and after getting booked for the stress test, the Holter and Echo, Cliff left your office before therapy could be prescribed for his hypertension as he was concerned about the parking meter. He returns 4 weeks later to review the results of his

tests. He has had occasional symptoms during that time. His exercise stress test was normal. The Holter showed premature atrial contractions, and some episodes of supraventricular ectopy. The Echo shows normal EF, mitral annular calcification, mild left atrial dilation, concentric LVH and moderate diastolic dysfunction. BP 148/78, HR is 85, SAO2 96%, RR is 16 53 Discussion Question 6 Whats Your Treatment Plan? 54 Discussion Question 6

Whats Your Treatment Plan? a) Reduce afterload with a renin-angiotensinaldosterone system (RAAS) blocker (ie ARB or ACEi) b) Add bisoprolol 5 mg/day c) Reduce HCTZ to 25 mg/day d) Stop calcium channel blocker (amlodipine) e) Stop celecoxib Note: Discussion questions do not necessarily have only one correct answer 55 a) Reduce afterload with a RAAS blocker (i.e. ARB or ACEi) This helps treat symptoms of diastolic heart failure and achieve better control of blood

pressure Helps to raise his potassium Reduces the chance of first episode of atrial fibrillation Expected results: BP 130/78, HR is 85, SAO2 96%, RR is 16 56 LIFE: New Onset Atrial Fibrillation Proportion of patients with first event 7 % HR: 0.67 [95% CI: 0.550.83], p<0.001 Adjusted HR: 0.67 [95% CI: 0.550.83], p<0.001

6 5 4 Atenolol group 3 2 Losartan group 1 0 0

6 12 18 24 30 36 42 Time (months) 48

54 60 66 Wachtell et al J Am Coll Cardiol 2005 Atrial Fibrillation and Hypertension LIFE study (2005) Studies have attempted to reduce atrial fibrillation and

cardiac events in patients with hypertension and AF using ARBs: 1.GISSI-AF (2009) 2.ACTIVE-I (2011) 3.ANTIPAF (2007, 2011) Renin angiotensin blockade seemed to be good for AF prevention, studies have not demonstrated this (for those who have had AF) 58 b) Add bisoprolol 5 mg/day Good choice to slow the heart rate and lower

blood pressure Does not address hypokalemia Expected results: BP 136/73, HR is 64, SAO2 96%, RR is 16 59 c) Reduce HCTZ to 25 mg/day Lowering the dose of HTCZ will help to reverse his hypokalemia which, in the setting of heart disease, can predispose to cardiac arrhythmias Lowering HTCZ will not address hypertension management Lowering HTCZ and adding ACEi or ARB will help to

lower his blood pressure and correct his hypokalemia Expected results: BP 152/88, HR is 90, SAO2 96%, RR is 18 60 d) Stop calcium channel blocker (amlodipine) CCBs are not to be used routinely in patients with low ejection fraction systolic heart failure. If other forms of BP or HR lowering therapy are not available or tolerated, then these can still be used if necessary However he has a normal ejection fraction Expected results: BP 158/85, HR is 78, SAO2 96%, RR is 16

61 e) Stop celecoxib NSAIDS and coxibs lead to sodium retention and heart failure and increase the risk for hyperkalemia and hyponatremia Will also reduce effectiveness of most antihypertensives Expected results: BP 142/72, HR is 84, SAO2 96%, RR is 18 62 Adjusted Medications Previous

Adjusted Hydrochlorothiazide 50 mg OD 25 mg OD Amlodipine 5 mg OD 5 mg OD

ECASA 81 mg OD 81 mg OD Rosuvastatin 10 mg OD 10 mg OD Celecoxib (previous) Perindopril (new)

200 mg OD 8 mg OD 63 Treatment of Hypertension in Patients with Left Ventricular Hypertrophy Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events. Left ventricular hypertrophy - ACEI

- ARB, - CCB - Thiazide Diuretic - BB (if age below 60)* Vasodilators: Hydralazine, Minoxidil can increase LVH 64 Case Progression Cliff tolerated therapy with an ACEi at a maximally recommended dose and a reduction of his HCTZ to 25 mg/ day. Celecoxib was stopped as well His creatinine is 123 umol/L and potassium is now 4.0

mmol/L He continues to get palpitations associated with dypsnea and fatigue and his pulse is irregular during these episodes. He comes to your office and says he is experiencing these symptoms now You perform an ECG (slide follows) BP 138/78, HR is 130, SAO2 96%, RR is 16 65 66 Atrial Fibrillation: Uncontrolled Rate You start him on bisoprolol 5 mg/day for rate

control His rate drops to 70-80 bpm but he remains in atrial fibrillation 67 Discussion Question 7 Whats Your Treatment Plan? 68 Discussion Question 7 Whats Your Treatment Plan? a) Send him to the emergency room b) Consult a cardiologist or an internist with

expertise for atrial fibrillation c) Start oral anticoagulant (e.g. warfarin 5 mg/day) and monitor INR to achieve a level of 2.0 3.0 d) Continue ECASA 81 mg/day e) Start clopidogrel 75 mg/day Note: Discussion questions do not necessarily have only one correct answer 69 a) Send him to the emergency room In the absence of symptoms to suggest an acute event or hemodynamic instability, he can be managed as an outpatient If atrial fibrillation is of duration longer than 48 hours, he should have an anticoagulant for 3

weeks prior to cardioversion 70 b) Consult a cardiologist or an internist with expertise for atrial fibrillation No survival advantage from rhythm control over rate control alone (AFFIRM study*) even in severe CHF Patient requires management while waiting for appointment *NEJM 2002;347:1825-33 *NEJM 2008;348:1284-86

71 Figure 3 Canadian Journal of Cardiology 2014 30 1114 Downloaded from CCS Web site October 2014 Copyright 2014 Canadian Cardiovascular Society c) Start oral anticoagulant (e.g. warfarin 5 mg/day or dabigatran) and monitor INR to achieve a level of 2.0 3.0 CHADS2 His risk of stroke using the CHADS2

method is scored at 2 Points Congestive Heart Failure 1 Hypertension 1 Age over 75 yrs

1 Diabetes Mellitus 1 Stroke or TIA history 2 73 CHADS2 Score CHADS2 Score

Risk of Stroke 0 Low 1 Intermediate 2 High

Appropriate Therapy ASA 81 mg po od Oral anticoagulation or ASA 81 mg po od Oral anticoagulation Note that other risk factors, such as systolic dysfunction, can also be considered when making a therapy choice with CHADS2 score of 1. CHEST 2008; 133(6):545S-92S. Figure 1

Canadian Journal of Cardiology 2014 30, 1114 Copyright 2014 Canadian Cardiovascular Society Figure 2 Management of OAC for ER visits With new onset AF Canadian Journal of Cardiology 2014 30, 1114 2014 Canadian Cardiovascular Society Copyright d) Continue ASA 81 mg/day Stop ASA* His CHADS2 score is 2, indicating moderatehigh risk of stroke

Indicates anticoagulation *Dont add ASA for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation. Lip GY BMJ 2008;336:614 77 e) Start clopidogrel 75 mg/day His CHADS2 score is 2, indicating moderatehigh risk of stroke Indicates anticoagulation 78 Case Progression Cliff was started on a NOAC and rate control with bisoprolol has

been effective. He is now back for a 2 month follow-up visit. He is feeling better. His exercise is back to baseline and is tolerating his medications. Perindopril 8 mg/day HCTZ 25 mg/day Amlodipine 5 mg/day Rosuvastatin 10 mg/day Bisoprolol 5 mg/day NOAC BP 130/78, HR is 78, SAO2 96%, RR is 16 79 Discussion Question 8 What is your plan for follow up?

80 Discussion Question 8 What is your plan for follow up? a) Review the Cliffs blood pressure in clinic 3-4 times a year b) Monitor global cardiovascular risk factors c) Refer him for a pacemaker insertion d) Continue lifestyle modifications Note: Discussion questions do not necessarily have only one correct answer 81

a) Review Cliffs blood pressure in clinic Patients with blood pressure above target are recommended to be followed at least every 2nd month Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence 82 b) Monitor global cardiovascular risk factors This patient is higher risk so he is on a statin Ensure his blood pressure remains controlled Target < 140/90 mmHg as he has chronic kidney disease, LDL <2.0 and he is on a RAAS blocker

83 c) Refer him for a pacemaker insertion Unnecessary 84 d) Continue lifestyle modifications Frequent brief interventions double the rate of lifestyle changes All hypertensives require ongoing support to initiate and maintain lifestyle changes 85

Cliffs wife who is also hypertensive asks: What can I do to prevent a similar outcome? Cliff is a 76 year old man with longstanding hypertension presenting with dyspnoea Likely a manifestation of CHF and atrial fibrillation Treated effectively with BP control and management of his atrial fibrillation How might this have been prevented? 86 Progression from Hypertension to Heart Failure Obesity Diabetes

Diastolic dysfunction LVH Hypertension Smoking Dyslipidaemia Diabetes HF MI Normal

LV LV structure and function remodelling Death Systolic dysfunction Subclinical LV dysfunction Time: decades

Overt heart failure Time: months The Major Risk Factors for the Development of Heart Failure Hypertension Myocardial infarction

Angina pectoris Diabetes Left ventricular hypertrophy Valvular disease 88 Key Learnings Keeping blood pressure controlled helps to prevent left ventricular hypertrophy and lowers the risk for developing heart failure Hypertension and heart failure are risks for the new onset of atrial fibrillation Controlling hypertension is likely the single most effective means of preventing both heart

failure and atrial fibrillation 89 The full slide set of the 2015 CHEP Recommendations is available at www.hypertension.ca 90

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