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Developing an Advanced Practice Credential for Registered Dietitian Nutritionists in Clinical Nutrition Practice
Journal of the American Society of Hypertension 9(4S) (2015) e63–e72
EPIDEMIOLOGY/SPECIAL POPULATIONS P-95 Hypokalemic metabolic alkalosis and hypertension in white and black patients Arif Asif, Daniel Sedhom, Krishnakumar Hongalgi, Roy Matthew, Shamim Haqqie. Albany Medical Center, Albany, NY, United States Hypertension presenting with metabolic alkalosis with hypokalemia is not uncommon. In this analysis, we present the management of such a scenario in white and black patients. Six patients (white¼4 [1 females, 2 males, age¼24-62]; blacks¼2 [1male, 1 female, age¼32, 40]) with hypokalemia (2.9-3.3 mEq/L), metabolic alkalosis (28-32 mm Eq/L) and hypertension (155-180/90-105 mmHg) were seen in hypertension clinic. All had a BMI of >32 and metabolic syndrome. None had clinical evidence of sleep apnea. All had been on adequate dosage of at least three BP meds (calcium channel blocker, ACE-I/ARB, metoprolol/carvedilol). All had a negative Doppler ultrasound for renal artery stenosis. Their serum aldosterone to renin ratio was 15-18 (normal¼less than 20). Urinary aldosterone in the six patients ranged from 10-12 ng/l (reference abnormal¼>14 ng/dl). Because of normal aldosterone to renin ration, CT scan was not obtained in these patients. Nonetheless, considering obesity and aldosterone production by adipocytes (high normal urinary aldosterone), treatment with spironolactone/eplerenone was initiated with normalization of blood pressure in 3/4 whites (<140/90 mmHg). The non-responder (white female age 62) was treated with amiloride with subsequent control of BP to <140/90 mmHg. Two black patients also responded better to amiloride compared to spironolactone/eplerenone bring them to the goal (<140/90 mmHg). While aldosterone is an important mediator of hypertension in obese individuals, over-activity of sodium channel in the distal tubule (ENaC) must be considered in the management uncontrolled hypertension with hypokalemic metabolic alkalosis, particularly in blacks. It has been suggested before that amiloride provides better BP control in resistance hypertension in blacks compared to white patients providing validity to ENaC over-activity. Genetic testing was not performed in our cohort to investigate the presence of Liddle’s syndrome. Keywords: Hypertension; white; black P-96 Hypertension and fear of falling: results from SPRINT Dan Berlowitz,1 Tonya Breaux-Shropshire,2 Capri Foy,7 Lisa Gren,6 Lewis Kazis,1 Alan Lerner,4 Jill Newman,7 James Powell,3 Virginia Wadley,5 Julie Williams.7 1Bedford VA Hospital, Bedford, MA, United States; 2Birmingham VA Medical Center, Birmingham, AL, United States; 3Brody School of Medicine at East Carolina University, Greenville, NC, United States; 4Case Western Reserve University School of Medicine, Cleveland, OH, United States; 5University of Alabama at Birmingham, Birmingham, AL, United States; 6University of Utah School of Medicine, Salt Lake City, UT, United States; 7Wake Forest School of Medicine, Winston-Salem, NC, United States Elderly hypertension (HTN) patients often refuse medication intensification due to concerns about falling. While fear of falling (FoF) is present in up to 25% of community dwelling elderly, little is known about it in HTN. We present baseline data from the Systolic Blood Pressure Intervention Trial (SPRINT) to describe the extent of FoF in HTN patients and determine whether low BP and anti-HTN medications (MEDs) are associated with greater FoF.
SPRINT is a multicenter randomized clinical trial comparing two strategies for managing SBP in older patients: standard care (SBP<140 mmHg) vs an intensive strategy (SBP<120). Along with baseline BP and MEDs, participants completed a detailed assessment including demographics, comorbidities, and health- related quality of life with the Veterans Rand 12 item questionnaire (VR-12). A 25% subsample also completed the Falls Self-Efficacy Scale International (FES-I) which asks respondents to use a 1-4 scale to indicate their level of concern for falling in performing 7 everyday activities. FoF was operationalized as none (score of 7), mild (score 8-10) or moderate/severe (score 11-28). Bivariate associations, overall and by age (75 vs <75) were examined between BP and number of MEDs with FoF. Multivariate ordinal logistic regression examined the independent association adjusting for baseline characteristics. The mean age of the 2299 participants was 69+10.3. Mild FoF was present in 674 (29.3%) and moderate/severe in 411 (17.9%). No differences in mean SBP (140.3+15.6, p¼.92) or DBP (77.8+12.0, p¼.07) were seen among people with no, mild, or moderate/severe FoF. Neither low BP (SBP<120 and DBP<70) nor orthostatic hypotension were associated with FoF (p>.1). Participants with moderate/severe FoF were taking significantly more MEDs (2.0 vs 1.8 vs 1.8, p<.001) than participants with mild or no FoF. After adjusting for baseline factors, no associations were evident between BP, MEDs and FoF. However, comorbidities, age and lower functional status were associated (p<.05) with increased FoF. Results were similar in older and younger participants; interaction of BP with age and functional status were not significant. We conclude that FoF is common among older HTN patients. FoF is associated with poor health rather than low BP or more MEDs. Low BP had no greater impact on older, sicker participants than younger, healthier ones. Longitudinal studies will be helpful to better understand FoF in this population. Keywords: Hypertension treatment; falling; elderly
P-97 Systolic blood pressure levels and coronary heart disease, stroke, heart failure, and falls among adults 65 years and older taking antihypertensive medication Samantha G. Bromfield,6 Lisandro D. Colantonio,6 George Howard,6 Monika M. Safford,6 Daniel Lackland,4 Olugbenga Ogedegbe,5 Maciej Banach,3 C. Barrett Bowling,2 Daichi Shimbo,1 Paul Muntner.6 1 Columbia University, New York, NY, United States; 2Emory University, Atlanta, GA, United States; 3Medical University of Lodz, Lodz, Poland; 4 Medical University of South Carolina, Charleston, SC, United States; 5 New York University Langone Medical Center, New York, NY, United States; 6University of Alabama at Birmingham, Birmingham, AL, United States The 2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) raised the systolic blood pressure (SBP) threshold for treatment initiation and goal attainment to 150 mm Hg in adults 60 years and older without a history of diabetes or chronic kidney disease (CKD). Using data from the nationwide Reasons for Geographic and Racial Difference in Stroke (REGARDS) study linked with Medicare claims, we examined the association between SBP levels and coronary heart disease (CHD), stroke, cardiovascular disease (CVD), heart failure, and serious injurious fall events among adults 65 years of age taking antihypertensive medication. We excluded participants
1933-1711/$ - see front matter Ó 2015 American Society of Hypertension. All rights reserved.
EPIDEMIOLOGY/SPECIAL POPULATIONS P-95 Hypokalemic metabolic alkalosis and hypertension in white and black patients Arif Asif, Daniel Sedhom, Krishnakumar Hongalgi, Roy Matthew, Shamim Haqqie. Albany Medical Center, Albany, NY, United States Hypertension presenting with metabolic alkalosis with hypokalemia is not uncommon. In this analysis, we present the management of such a scenario in white and black patients. Six patients (white¼4 [1 females, 2 males, age¼24-62]; blacks¼2 [1male, 1 female, age¼32, 40]) with hypokalemia (2.9-3.3 mEq/L), metabolic alkalosis (28-32 mm Eq/L) and hypertension (155-180/90-105 mmHg) were seen in hypertension clinic. All had a BMI of >32 and metabolic syndrome. None had clinical evidence of sleep apnea. All had been on adequate dosage of at least three BP meds (calcium channel blocker, ACE-I/ARB, metoprolol/carvedilol). All had a negative Doppler ultrasound for renal artery stenosis. Their serum aldosterone to renin ratio was 15-18 (normal¼less than 20). Urinary aldosterone in the six patients ranged from 10-12 ng/l (reference abnormal¼>14 ng/dl). Because of normal aldosterone to renin ration, CT scan was not obtained in these patients. Nonetheless, considering obesity and aldosterone production by adipocytes (high normal urinary aldosterone), treatment with spironolactone/eplerenone was initiated with normalization of blood pressure in 3/4 whites (<140/90 mmHg). The non-responder (white female age 62) was treated with amiloride with subsequent control of BP to <140/90 mmHg. Two black patients also responded better to amiloride compared to spironolactone/eplerenone bring them to the goal (<140/90 mmHg). While aldosterone is an important mediator of hypertension in obese individuals, over-activity of sodium channel in the distal tubule (ENaC) must be considered in the management uncontrolled hypertension with hypokalemic metabolic alkalosis, particularly in blacks. It has been suggested before that amiloride provides better BP control in resistance hypertension in blacks compared to white patients providing validity to ENaC over-activity. Genetic testing was not performed in our cohort to investigate the presence of Liddle’s syndrome. Keywords: Hypertension; white; black P-96 Hypertension and fear of falling: results from SPRINT Dan Berlowitz,1 Tonya Breaux-Shropshire,2 Capri Foy,7 Lisa Gren,6 Lewis Kazis,1 Alan Lerner,4 Jill Newman,7 James Powell,3 Virginia Wadley,5 Julie Williams.7 1Bedford VA Hospital, Bedford, MA, United States; 2Birmingham VA Medical Center, Birmingham, AL, United States; 3Brody School of Medicine at East Carolina University, Greenville, NC, United States; 4Case Western Reserve University School of Medicine, Cleveland, OH, United States; 5University of Alabama at Birmingham, Birmingham, AL, United States; 6University of Utah School of Medicine, Salt Lake City, UT, United States; 7Wake Forest School of Medicine, Winston-Salem, NC, United States Elderly hypertension (HTN) patients often refuse medication intensification due to concerns about falling. While fear of falling (FoF) is present in up to 25% of community dwelling elderly, little is known about it in HTN. We present baseline data from the Systolic Blood Pressure Intervention Trial (SPRINT) to describe the extent of FoF in HTN patients and determine whether low BP and anti-HTN medications (MEDs) are associated with greater FoF.
SPRINT is a multicenter randomized clinical trial comparing two strategies for managing SBP in older patients: standard care (SBP<140 mmHg) vs an intensive strategy (SBP<120). Along with baseline BP and MEDs, participants completed a detailed assessment including demographics, comorbidities, and health- related quality of life with the Veterans Rand 12 item questionnaire (VR-12). A 25% subsample also completed the Falls Self-Efficacy Scale International (FES-I) which asks respondents to use a 1-4 scale to indicate their level of concern for falling in performing 7 everyday activities. FoF was operationalized as none (score of 7), mild (score 8-10) or moderate/severe (score 11-28). Bivariate associations, overall and by age (75 vs <75) were examined between BP and number of MEDs with FoF. Multivariate ordinal logistic regression examined the independent association adjusting for baseline characteristics. The mean age of the 2299 participants was 69+10.3. Mild FoF was present in 674 (29.3%) and moderate/severe in 411 (17.9%). No differences in mean SBP (140.3+15.6, p¼.92) or DBP (77.8+12.0, p¼.07) were seen among people with no, mild, or moderate/severe FoF. Neither low BP (SBP<120 and DBP<70) nor orthostatic hypotension were associated with FoF (p>.1). Participants with moderate/severe FoF were taking significantly more MEDs (2.0 vs 1.8 vs 1.8, p<.001) than participants with mild or no FoF. After adjusting for baseline factors, no associations were evident between BP, MEDs and FoF. However, comorbidities, age and lower functional status were associated (p<.05) with increased FoF. Results were similar in older and younger participants; interaction of BP with age and functional status were not significant. We conclude that FoF is common among older HTN patients. FoF is associated with poor health rather than low BP or more MEDs. Low BP had no greater impact on older, sicker participants than younger, healthier ones. Longitudinal studies will be helpful to better understand FoF in this population. Keywords: Hypertension treatment; falling; elderly
P-97 Systolic blood pressure levels and coronary heart disease, stroke, heart failure, and falls among adults 65 years and older taking antihypertensive medication Samantha G. Bromfield,6 Lisandro D. Colantonio,6 George Howard,6 Monika M. Safford,6 Daniel Lackland,4 Olugbenga Ogedegbe,5 Maciej Banach,3 C. Barrett Bowling,2 Daichi Shimbo,1 Paul Muntner.6 1 Columbia University, New York, NY, United States; 2Emory University, Atlanta, GA, United States; 3Medical University of Lodz, Lodz, Poland; 4 Medical University of South Carolina, Charleston, SC, United States; 5 New York University Langone Medical Center, New York, NY, United States; 6University of Alabama at Birmingham, Birmingham, AL, United States The 2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) raised the systolic blood pressure (SBP) threshold for treatment initiation and goal attainment to 150 mm Hg in adults 60 years and older without a history of diabetes or chronic kidney disease (CKD). Using data from the nationwide Reasons for Geographic and Racial Difference in Stroke (REGARDS) study linked with Medicare claims, we examined the association between SBP levels and coronary heart disease (CHD), stroke, cardiovascular disease (CVD), heart failure, and serious injurious fall events among adults 65 years of age taking antihypertensive medication. We excluded participants
1933-1711/$ - see front matter Ó 2015 American Society of Hypertension. All rights reserved.