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Future hypertension guidelines for older americans with multiple chronic conditions
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Abstracts / Journal of the American Society of Hypertension 10(4S) (2016) e39–e55
Physical exam; 2. ECG; 3. Chest X-Ray; 4. Full blood test; 5. Full urine test; 6. Retina exam. We also include patient education and follow-up immediately after 24h the acute presentation. We identified 2 HU populations: High-risk HU (patients with TO initially compromised that will probably evolve to HE), and low-risk HU (patiens without compromise of TO). The latter would rest for 1 h until reach BP values below 160/ 100 mmHg. High-risk HU typically present 4th sound, ventricular hypertrophy, creatinine>1.5 mg/dL or ‘‘arterial-venous’’ crosses in the retinal exam, and will receive pharmacological treatment. The antihypertensive treatment administered was labetalol 200 mg. We monitored patients for 2 h after the drug was administered, and if the goal of treatment was reached (BP <160/100) the patients would be sent home, where they would rest, be on a low-sodium diet (<1 g/day) and would be reevaluated 24 h after first medical examination. If BP stays >160/100 mmHg patients will receive a second dose of labetalol. The new guideline revealed that 33 pacients (24%) were not diagnosed with high BP before. It also allowed us to diagnose high BP in 13 of these 33 previously undiagnosed patients. From the total patients with high BP (115) only 27 (23%) were adequately managed and treated. The most frequent cause that triggered HU was the dietary transgression (excessive salt ingestion). In conclusion, these guideline for HU revealed that a high percentage of patients with high BP lack adequate diagnosis and/or management. Implementation of resting before drug administration allowed us to achieve the goal of BP<160/100 in low-risk HU patients. High-risk HU patients were best treated with labetalol 200 mg. The new guideline also secured a medical follow-up of all HU patients, decreasing their fall-off of the medical system (<10%) and improving their long-term medical management. Keywords: Hypertensive urgency; Managment; Labetalol
P-62 Cardiovascular events occur more often in treated hypertensive patients with ‘Low’ BP Brent M. Egan,4,2 Bo Kai,3 C. Shaun Wagner,1 Joseph H. Henderson,4 Archie H. Chandler,4 Angelo Sinopoli.4,.1 1Care Coordination Institute, Greenville, SC, United States; 2Care Coordination Institute, Greenville, SC, United States; 3College of Charleston, Charleston, SC, United States; 4 University of South Carolina School of Medicine, Greenville, SC, United States Background: The Systolic BP Intervention Trial (SPRINT) showed that systolic BP goal <120 reduced major CVE vs. goal <140, yet prior observational and post hoc analyses found the opposite, i.e., BP <120 systolic and/or <70 diastolic were linked with more CVE. The relationship of apparent treatment resistant hypertension (aTRH, BP high on 3 or controlled to <140/<90 on 4 BP meds) to the J-Curve is unclear. Our observational study in a primary care network addressed this issue. Methods: Electronic health data were matched to emergency and hospital health claims for stroke, acute coronary syndromes, and congestive heart failure for 2006-2012. Patients with a CVE in 2006-2008 were excluded leaving 118,356 treated hypertensives with 11,112 primary events (20082012) and 460,599 observation years. BP and med number were determined by all clinic visit means from 2008 to iCVE or end of study. Hazards regression ratios (HR) and 95% confidence intervals (CI) were obtained separately for patients with and without aTRH, while controlling for age, race, sex, diabetes, CKD, and statin use. Results: iCVE was greater in patients with than without aTRH (not shown). In treated patients with and without aTRH, iCVE was highest with BP <120 and/or <70 and lowest with BP 120-139/70-89. Conclusion: Explaining the striking difference between the relationship of low BP to iCVE in observational and prospective studies could enhance population health benefits of BP therapy. Keywords: hypertension; J-curve; treatment resistant hypertension; cardiovascular events
CVE by BP and aTRH Status Treated BP Group
aTRH
N
HR
95% CI
<70 120-139/70-89 >¼140/>¼90 <70 120-139/70-89 >¼140/>¼90
No No No Yes Yes Yes
18,305 41,043 18,329 5,302 12,320 23,057
1.71 0.58 0.99 1.88 0.70 1.32
1.59-1.84 0.54-0.62 0.92-1.07 1.70-2.07 0.65-0.76 1.21-1.44
P-63 Future hypertension guidelines for older americans with multiple chronic conditions Brent M. Egan,2 Susan E. Sutherland,2 C. Shaun Wagner,1 Douglas O. Fleming,1 Robert A. Davis,1 Sean T. Bryan,2 Peter L. Tilkemeier,2 Angelo Sinopoli.2 1Care Coordination Institute, Greenville, SC, United States; 2University of South Carolina School of Medicine, Greenville, SC, United States Background: Disease management guidelines focus primarily on a single disease and comment on relationships to other single diseases, while many patients have multiple chronic conditions. The 2001 Institute of Medicine’s landmark report, Crossing the Quality Chasm, noted limitations of disease management guidelines for single chronic conditions as a majority of healthcare dollars are spent on patients with multiple chronic conditions (MCC), which increase with age. Methods: Modified Elixhauser and Charlson conditions were used to classify 50,000 Shared Savings Program (Medicare) beneficiaries in a clinically integrated healthcare system in SC. An agglomerative hierarchical clustering approach was used to classify this patient group into 12 clusters. Results: 72% of MSSP beneficiaries had a hypertension (HTN) diagnosis. Five clusters, 27% of patients, had only a small proportion with MCC. These groups included ‘healthy’, isolated hyperlipidemia (HLP), uncomplicated HTN, osteoarthritis, and obesity. The remaining 73% of MSSP beneficiaries had MCC, which clustered into 7 dominant themes, e.g., diabetes (13%), CHF (12%), cancer (11%), vascular disease (11%), COPD (10%), CKD (9%) and behavioral health (7%). For example, in the CHF cluster, 91% of patients had 6 CC (HTN 94%, HLP 83%, vascular disease 76%, COPD 59%, DM 50%, behavioral 42% the most common); 92% were prescribed 8 long-term medications. In all 7 clusters, HTN and HLP were the 2nd and 3rd most prevalent conditions after the dominant theme. In 5 of 7 clusters, behavioral health diagnoses (depression, psychoses, alcohol or drug abuse) were present in at least 1 of 3 patients. Conclusions: HTN in older Americans typically occurs in combination with MCC including behavioral disorders. Most clinical trials have not included a representative sample of older hypertensive patients. The appropriate BP goal for many of these patients is, therefore, uncertain. There is a critical need for (i) clinical guidelines that address the complexity of older patients with hypertension and MCC encountered daily by primary care clinicians (ii) large-scale, practical clinical trials conducted in diverse, usual care settings which better reflect the patient population to which the guideline is applied. Keywords: hypertension; guideline; elderly P-64 Gender and Race Variation of Widened Pulse Pressure with Age Sushee Gadde, Donna Bennett, Ghazanfar Qureshi, Bassam Omar. University of South Alabama, Mobile, AL, United States Background: Aging causes widening of the pulse pressure (PP), which is the difference between the systolic blood pressure and the diastolic blood pressure. Although a widened PP has been associated with increased cardiovascular and neurologic events, the extent of change across gender and race has not been previously examined.
Abstracts / Journal of the American Society of Hypertension 10(4S) (2016) e39–e55
Physical exam; 2. ECG; 3. Chest X-Ray; 4. Full blood test; 5. Full urine test; 6. Retina exam. We also include patient education and follow-up immediately after 24h the acute presentation. We identified 2 HU populations: High-risk HU (patients with TO initially compromised that will probably evolve to HE), and low-risk HU (patiens without compromise of TO). The latter would rest for 1 h until reach BP values below 160/ 100 mmHg. High-risk HU typically present 4th sound, ventricular hypertrophy, creatinine>1.5 mg/dL or ‘‘arterial-venous’’ crosses in the retinal exam, and will receive pharmacological treatment. The antihypertensive treatment administered was labetalol 200 mg. We monitored patients for 2 h after the drug was administered, and if the goal of treatment was reached (BP <160/100) the patients would be sent home, where they would rest, be on a low-sodium diet (<1 g/day) and would be reevaluated 24 h after first medical examination. If BP stays >160/100 mmHg patients will receive a second dose of labetalol. The new guideline revealed that 33 pacients (24%) were not diagnosed with high BP before. It also allowed us to diagnose high BP in 13 of these 33 previously undiagnosed patients. From the total patients with high BP (115) only 27 (23%) were adequately managed and treated. The most frequent cause that triggered HU was the dietary transgression (excessive salt ingestion). In conclusion, these guideline for HU revealed that a high percentage of patients with high BP lack adequate diagnosis and/or management. Implementation of resting before drug administration allowed us to achieve the goal of BP<160/100 in low-risk HU patients. High-risk HU patients were best treated with labetalol 200 mg. The new guideline also secured a medical follow-up of all HU patients, decreasing their fall-off of the medical system (<10%) and improving their long-term medical management. Keywords: Hypertensive urgency; Managment; Labetalol
P-62 Cardiovascular events occur more often in treated hypertensive patients with ‘Low’ BP Brent M. Egan,4,2 Bo Kai,3 C. Shaun Wagner,1 Joseph H. Henderson,4 Archie H. Chandler,4 Angelo Sinopoli.4,.1 1Care Coordination Institute, Greenville, SC, United States; 2Care Coordination Institute, Greenville, SC, United States; 3College of Charleston, Charleston, SC, United States; 4 University of South Carolina School of Medicine, Greenville, SC, United States Background: The Systolic BP Intervention Trial (SPRINT) showed that systolic BP goal <120 reduced major CVE vs. goal <140, yet prior observational and post hoc analyses found the opposite, i.e., BP <120 systolic and/or <70 diastolic were linked with more CVE. The relationship of apparent treatment resistant hypertension (aTRH, BP high on 3 or controlled to <140/<90 on 4 BP meds) to the J-Curve is unclear. Our observational study in a primary care network addressed this issue. Methods: Electronic health data were matched to emergency and hospital health claims for stroke, acute coronary syndromes, and congestive heart failure for 2006-2012. Patients with a CVE in 2006-2008 were excluded leaving 118,356 treated hypertensives with 11,112 primary events (20082012) and 460,599 observation years. BP and med number were determined by all clinic visit means from 2008 to iCVE or end of study. Hazards regression ratios (HR) and 95% confidence intervals (CI) were obtained separately for patients with and without aTRH, while controlling for age, race, sex, diabetes, CKD, and statin use. Results: iCVE was greater in patients with than without aTRH (not shown). In treated patients with and without aTRH, iCVE was highest with BP <120 and/or <70 and lowest with BP 120-139/70-89. Conclusion: Explaining the striking difference between the relationship of low BP to iCVE in observational and prospective studies could enhance population health benefits of BP therapy. Keywords: hypertension; J-curve; treatment resistant hypertension; cardiovascular events
CVE by BP and aTRH Status Treated BP Group
aTRH
N
HR
95% CI
<70 120-139/70-89 >¼140/>¼90 <70 120-139/70-89 >¼140/>¼90
No No No Yes Yes Yes
18,305 41,043 18,329 5,302 12,320 23,057
1.71 0.58 0.99 1.88 0.70 1.32
1.59-1.84 0.54-0.62 0.92-1.07 1.70-2.07 0.65-0.76 1.21-1.44
P-63 Future hypertension guidelines for older americans with multiple chronic conditions Brent M. Egan,2 Susan E. Sutherland,2 C. Shaun Wagner,1 Douglas O. Fleming,1 Robert A. Davis,1 Sean T. Bryan,2 Peter L. Tilkemeier,2 Angelo Sinopoli.2 1Care Coordination Institute, Greenville, SC, United States; 2University of South Carolina School of Medicine, Greenville, SC, United States Background: Disease management guidelines focus primarily on a single disease and comment on relationships to other single diseases, while many patients have multiple chronic conditions. The 2001 Institute of Medicine’s landmark report, Crossing the Quality Chasm, noted limitations of disease management guidelines for single chronic conditions as a majority of healthcare dollars are spent on patients with multiple chronic conditions (MCC), which increase with age. Methods: Modified Elixhauser and Charlson conditions were used to classify 50,000 Shared Savings Program (Medicare) beneficiaries in a clinically integrated healthcare system in SC. An agglomerative hierarchical clustering approach was used to classify this patient group into 12 clusters. Results: 72% of MSSP beneficiaries had a hypertension (HTN) diagnosis. Five clusters, 27% of patients, had only a small proportion with MCC. These groups included ‘healthy’, isolated hyperlipidemia (HLP), uncomplicated HTN, osteoarthritis, and obesity. The remaining 73% of MSSP beneficiaries had MCC, which clustered into 7 dominant themes, e.g., diabetes (13%), CHF (12%), cancer (11%), vascular disease (11%), COPD (10%), CKD (9%) and behavioral health (7%). For example, in the CHF cluster, 91% of patients had 6 CC (HTN 94%, HLP 83%, vascular disease 76%, COPD 59%, DM 50%, behavioral 42% the most common); 92% were prescribed 8 long-term medications. In all 7 clusters, HTN and HLP were the 2nd and 3rd most prevalent conditions after the dominant theme. In 5 of 7 clusters, behavioral health diagnoses (depression, psychoses, alcohol or drug abuse) were present in at least 1 of 3 patients. Conclusions: HTN in older Americans typically occurs in combination with MCC including behavioral disorders. Most clinical trials have not included a representative sample of older hypertensive patients. The appropriate BP goal for many of these patients is, therefore, uncertain. There is a critical need for (i) clinical guidelines that address the complexity of older patients with hypertension and MCC encountered daily by primary care clinicians (ii) large-scale, practical clinical trials conducted in diverse, usual care settings which better reflect the patient population to which the guideline is applied. Keywords: hypertension; guideline; elderly P-64 Gender and Race Variation of Widened Pulse Pressure with Age Sushee Gadde, Donna Bennett, Ghazanfar Qureshi, Bassam Omar. University of South Alabama, Mobile, AL, United States Background: Aging causes widening of the pulse pressure (PP), which is the difference between the systolic blood pressure and the diastolic blood pressure. Although a widened PP has been associated with increased cardiovascular and neurologic events, the extent of change across gender and race has not been previously examined.