High blood pressure hypertension is widespread in Detroit

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 Medicine Henry 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?

Blood Pressure Classification BP Classification SBP mm. Hg DBP mm. Hg Normal <120 and <80 Pre-hypertension 120– 139 or 80– 89 Stage 1 Hypertension Stage 2 Hypertension 140– 159 or 90– 99 >160 or >100 JNC 7 Hypertension 2003; 42: 1206 -12

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

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)

Causes of Essential Hypertension 1. Genetic factors 2. OBESITY and METABOLIC Syndrome 3. High Salt Intake/ diet 4. HIGH ALCOHOL INTAKE 5. Ageing

Interaction Among Genetic and Environmental Factors Multiple Genes (4 -10) Intermediate phenotypes Environment al Factors High calorie intake Population Distribution (%) 100 Phenotype: BP c c ti ne us s ge 50 y it l i tib p e si e b o y t 0 60 140 220 Systolic Blood Pressure (mm. Hg)

Diastolic Blood Pressure as a Function of Abdominal Circumference (Normative Aging Study) 78 DBP mm. Hg 77 76 75 74 88. 6 93. 2 97. 5 102. 7 Abdominal circunferente, cm (quintiles) C. Johnston, Journal of Hypertension, 10 (suppl 7): S 13 -S 26 1992

Interaction Among Genetic and Environmental Factors Multiple Genes (4 -10) Intermediate Phenotypes Environment al Factors Population Distribution (%) 100 Phenotype: BP e om ity l r i d b i n t y ep s c c i s l u o s b c + a y itt e eti s n em b ge + o 50 0 60 140 220 Systolic Blood Pressure (mm. Hg)

What Is the Metabolic Syndrome? • 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/d. L, women <50 mg/d. L) – Hypertension ( 130/ 85 mm Hg) – Hypertriglyceridemia ( 150 mg/d. L) – High fasting glucose ( 110 mg/d. L) – Proinflammatory (>CRP) Mc. Farlane 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(8 B): 1339 -45. Ford ES, et al. JAMA. 2002; 287: 356 -359. NCEP/ATP III. 3

Prevalence of Metabolic Syndrome by Age Group (estimated 47 millions in the USA Age-Specific Prevalence in US Adolescents and Adults, 1988 -1994 50 Prevalence (%) 45 40 Male Female 35 30 25 20 15 10 5 0 12 -19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 ³ 70 Age Ford ES et al. JAMA. 2002; 287: 356 -9. 4

Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk Cardiovascular Mortality Rate per 10, 000 Patient-Years Elevated systolic blood pressure increases risk of CV death almost twofold in diabetic vs non-diabetic patients 250 Nondiabetic patients Diabetic patients 200 150 100 50 0 <120 120– 139 140– 159 160– 179 180– 199 ³ 200 SBP (mm Hg) Stamler J et al. Diabetes Care. 1993; 16: 434 -444. MRFIT 20

Causes of Essential Hypertension 1. Genetic factors 2. Obesity and Metabolic Syndrome 3. High Salt Intake/ diet 4. HIGH ALCOHOL INTAKE 5. Ageing >65

“ 117 114 134 126 PERCENT OF GROUP WITH DIASTOLIC PRESSURE ≥ 90 mm Hg PERCENT OF GROU P WITH SYSTOLIC PRESSURE ≥ 140 mm Hg 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. 0 1 -160 161 -350 >350 ALCOHOL CONSUMPTION (ml ethanol consumed per week)

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. 2. 3. 4. The “baby boom” following World War II Rise in life expectancy, 1950= 48, 2012= 78 A decline in fertility Better medical treatment?

Interaction Among Genetic and Environmental Factors Multiple Genes (4 -10) Intermediate Phenotypes Environment al Factors Population Distribution (%) 100 Phenotype: BP e m y t ro / ili d b i n ol t y p s oh g ce c i s l u o alc gt ein s b tic + seittya igh +d iae e n h m e e + b g o + 50 0 60 140 220 Systolic Blood Pressure (mm. Hg)

• 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

Each 2 mm. Hg rise in systolic blood pressure associated with increased risk of mortality: • 7% from heart disease • 10% from stroke.

THE NEW YORK TIMES, TUESDAY, JULY 16, 2013 Kidney Disease, an Underestimated Killer 90, 000 a year (more than cancer of breast and prostate together)

• 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

National List of Hypertension Hotspots 1. Memphis, TN-MS-AR 2. Detroit-Livonia-Dearborn, MI 3. Louisville-Jefferson County, KY-IN 4. Birmingham-Hoover, AL 5. Dayton, OH 6. Pittsburgh, PA 7. Buffalo-Niagara Falls, NY 8. St. Louis, MO-IL 9. Tampa-St. Petersburg-Clearwater, 10. Indianapolis-Carmel, IN 11. Oklahoma City, OK

Causes of Essential Hypertension 1. Genetic factors? 2. Obesity and Metabolic Syndrome 3. High Salt-Sensitivity and high salt Int / diet? 4. High alcohol intake 5. Ageing

2011 state-by-state adult obesity rates 1. 2. 3. 4. 5. Mississippi (34. 9%); Louisiana (33. 4%); West Virginia (32. 4%); Alabama (32. 0%); 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%);

Prevalence of Hypertension in the U. S. in Men by Age and Ethnicity Caucasian Hispanic African American Prevalence of hypertension (%) 100 80 60 40 20 0 18 -29 30 -39 40 -49 50 -59 60 -69 70 -79 >80 Age (y) Adapted from Burt et al. Hypertension 1995; 25: 305.

Obesity Risk Factor for Hypertension • How fat is Michigan? Very fat. • We are the 5 th 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) 78 DBP mm. Hg 77 76 75 74 88. 6 93. 2 97. 5 102. 7 Abdominal circunferente, cm (quintiles) C. Johnston, Journal of Hypertension, 10 (suppl 7): S 13 -S 26 1992

Salt-Sensitivity • This is very important since individuals with salt-sensitivity, whether hypertensive or not, have a higher mortality than salt-resistant subjects. Cumulative Survival • Blacks have higher salt-sensitivity than Whites. 1. 0 N+R . 9 p <0. 0001 . 8 N+S H+R H+S . 7. 6 0 5 10 15 20 Follow-up (yrs) 25 30 M. H. Weinberger et al. Hypertension. 2001; 37[part 2]: 429 -432

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 Approximate SBP reduction (range) Weight reduction 5– 20 mm. Hg/10 kg weight loss Adopt DASH eating plan Dietary sodium reduction Physical activity 8– 14 mm. Hg Moderation of alcohol consumption 2– 4 mm. Hg 2– 8 mm. Hg 4– 9 mm. Hg

Lowering SBP by 20 mm Hg Reduces Cardiovascular Risk by Half Stroke -10 -20 -30 -40 -50 Other vascular causes N=958, 074 40 -49 50 -59 60 -69 70 -79 80 -89 Years of age % mortality reduction for each 20 mm Hg drop in SBP 0 Ischemic Heart Disease -60 -70 *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. 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,

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 18 Truck drivers 308, 000 8 Housekeepers, maids, butlers, stewards 273, 000 19

Algorithm of. Hypertension Algorithmfor for. Treatment of Algorithm for Treatment of Hypertension JNC 77 JNC 7 Lifestyle Modifications Not at Blood Pressure (<140/90 Not. Goal at Goal Blood Pressure (<140/90 mm. Hg) (<130/80 for those with diabetes or chronic kidneymm. Hg) disease) Notmm. Hg atfor Goal Blood Pressure (<140/90 (<130/80 mm. Hg those with diabetes or chronic kidney disease) (<130/80 mm. Hg for those with diabetes or chronic kidney disease) Initial Drug Choices With Compelling Withoutindications Compelling With Compelling indications Indications With Compelling With. Indications Compelling With Compelling Indications Stage 1 Hypertension Stage 2 Hypertension (SBP 140 -159 or DBP 90 -99 mm. Hg (>SBP 160 or DBP >100 mm. Hg Stage 1 Hypertension Stage 2 Hypertension Thiazide-type diuretics for most Stage 1 Hypertension Stage 2 Hypertension (SBP 140– 159 or DBP 90– 99 mm. Hg) (SBP >160 or DBP >100 mm. Hg) May consider ACEI, ARB, BB, CCB (SBP 140– 159 or DBP 90– 99 mm. Hg) (SBP >160 or DBP >100 mm. Hg) Thiazide-type diuretics for most. 2 -drug combination for most (usually Thiazide-type diuretics for. BB, most. combination for most May consider ACEI, ARB, CCB 2 -drug thiazide-type and, (usually Notdiuretic at Goal May consider ACEI, ARB, BB, CCB thiazide-type diuretic or combination. ACEI or ARB, or BB, or and, CCB) Blood Pressure or combination. ACEI or ARB, or BB, or CCB) Drug (s) for the compelling indications Drug(s) for the compelling Other antihypertensive drugs Drug(s) indications for the compelling (diuretics, ACEI, ARB, BB, CCB) indications Other antihypertensive drugs Other antihypertensive (diuretics, ACEI, ARB, BB, drugs CCB) (diuretics, ACEI, ARB, BB, CCB) as needed Optimize add Pressure additional drugs Notdosages at Goal or Blood until goal blood pressure is achieved. Consider withadditional hypertension specialist Optimizeconsultation dosages or add drugs

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, Ju

National List of Hypertension of not very hotspots 42. New York-White Plains-Wayne, NY-NJ 43. 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, CA 48. Denver-Aurora, CO 49. Salt Lake City, UT 50. San Francisco-San Mateo-Redwood City, CA

Wave velocity 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