Newsletter of the Hypertension Initiative & ASH Carolinas-Georgia ...

Newsletter of the
Hypertension Initiative &
ASH Carolinas-Georgia-
Florida Chapter
F o c u s 2 0 0 9 :
I m p r o v i n g B P
i n R e s i s t a n t
H y p e r t e n s i o n
& M u l t i p l e R i s k
F a c t o r C o n t r o l
S P E C I A L P O I N T S
O F I N T E R E S T :
• A “STITCH” in time saves .
. . An option for better BP
control
• ACCOMPLISHing better
patient outcomes with FDC
I N S I D E T H I S
I S S U E :
HTN Specialists vs
Renin-Guided Rx in
Resistant HTN
ASH Hypertension
Specialists
2
2
V O L U M E 2 # 1
Simplified Treatment Intervention To Control Hypertension (STITCH)
While the focus this year is on resistant hypertension,
a paper in the April issue of Hypertension
is especially relevant to our shared goal of
optimizing hypertension control with BP controlled
to 90 (>130/>80 if diabetic)
were enrolled during a regular visit.
STITCH began with diuretic-ACE or diuretic-
ARB fixed-dose combinations (FDC) at low
dose (Step 1), uptitration to the maximum FDC
(Step 2), addition of a CCB (Step 3), and addition
of spironolactone or an α- or β-blocker.
Baseline characteristics were similar in the
two groups of patients from 27 practices assigned
to guideline and 18 to STITCH. BP fell
more and control improved more with STITCH
care. Physicians in the STITCH group were
S P R I N G 2 0 0 9
more likely to uptitrate medications in response
to uncontrolled BP. However, dose equivalents
tended to be lower with STITCH care, which
speaks to the efficacy of FDC, even in submaximal
doses. Physicians in STITCH were more satisfied
with the care provided and more likely to
recommend it to a colleague.
The findings indicate that initial treatment
with low-dose FDC and titration using a simple
algorithm is effective for uncomplicated Stage
1—2 hypertension and accepted by providers.
Variable Usual Care STITCH P-Value
# of patients 1246 802
Baseline
SBP, mmHg 153.4 155.1 NS
DBP, mmHg 87.7 88.1 NS
Diabetic, % 15.9 15.1 NS
FDC, % 9.3 11.2 NS
BP control, % 0 0 NS
Final visit
∆ SBP, mmHg −17.5 −22.6

P A G E 2
In treated, but uncontrolled
HTN,
renin-guided Rx
(RGT) improves control
and lowers BP
equally well or better
than HTN Specialists,
indicating
that RGT provides a
reasonable strategy
in these patients
HTN Specialists vs Renin-Guided Rx
in Resistant Hypertension
As noted in the previous newsletter, clinical
trials suggest that >20% of hypertensives are
treatment resistant, which is close to the
16% rate among practices in the Initiative.
Highly scalable and effective strategies are
needed that can be applied in primary care.
With this in mind, we teamed with Drs.
Laragh and Sealey to compare HTN Specialists
(Basile, Rehman, Egan) to renin-guided
Rx in patients in 77 patients with treated and
uncontrolled hypertension. Renin samples
were drawn during a routine clinic visit, while
patients were taking their usual medications.
Without increasing the # of medications,
SBP and DBP fell in both groups, although
SBP fell more with renin-guided Rx. Thus,
renin-guided Rx emerges as an option for the resistant
HTN patient.
Variable Renin-Guided Rx (39) HTN Specialist (38)
Baseline BP
#BP Meds
Final BP
#BP Meds
Change BP
Change Meds
Renin-Guided Therapeutics in
Rx, Uncontrolled Hypertensives
157.0±2.6 / 87.1±2.0
3.1±0.3
127.9±2.3/73.1±1.8
3.1±0.2
−29.1±3.2/−14.1±1.9
+0.0±0.2
153.2±2.3 / 91.1±2.0
2.7±0.2
134.0±2.879.8±1.9
3.0±0.2
−19.2±3.2/−11.3±2.0
+0.3±0.1
p

V O L U M E 2 # 1 S P R I N G 2 0 0 9
Hemodynamic Approach to Resistant HTN
P A G E 3
Hemodynamic Profile and
Treatment Options in Hypertension
Algorithm adapted from: Smith R, et al. Hypertension. 2006;47:769-775. Taler SJ, et al.
Hypertension. 2002;39:982-988.
Impedance cardiography (IC) has been used to successfully
guide BP medication selection and improve control in
treated, uncontrolled hypertension (references above).
In brief, in uncontrolled hypertensives with a high cardiac
index, >4.2 L/m 2 , beta-blockers or non-dihyrdropyridine
CCBs (diltiazem, verapamil) are added or the doses increased.
Conversely, if systemic vascular resistance index is >2580
units/m 2 , then ACE inhibitors, ARBs, non-dihyrdropyridine
CCBs or other vasodilators are utilized.
Diuretics are increased or added if thoracic fluid content (TFC)
rises on non-diuretic therapy or fails to decrease significantly
on diuretic treatment as indicated in the algorithm above.
Addition of an Aldo Antagonist in Resistant Hypertension
In 76 subjects with resistant HTN, including
34 patients with 1 O aldo, lowdose
spironolactone (12.5 – 50 mg/d)
lowered BP 21±21/10±12 at 6 weeks
and 25±20 / 12±12 at 3 months. BP fell
similarly in subjects with and without 1 O
aldo. The authors concluded that lowdose
spironolactone provided significant
BP reduction in African American and
white subjects with resistant hypertension
with and without 1 O aldo. This paper
by Calhoun and colleagues was published
in the Am J Hyperten 2003;16:92.
In ASCOT, the effect of low-dose spironolactone
was evaluated in 1411 participants
with uncontrolled BP on three
medications. During spironolactone
therapy (mean dose 25 mg), BP fell by
21.9/9.5 mmHg, p

American Society of
Hypertension
Carolinas-Georgia-
Florida Chapter
Continuing Medical Education
The ASH Carolina-Georgia-Florida Chapter is preparing
an exciting slate of programs for 2009 and
will provide a list of programs, topics, and dates
to you as soon as planning is finalized.
ASH Hypertension Specialist Exam
The ASH Clinical Hypertension Specialist certifying
examination will take place May 9, 2009. The Chapter
will once again endeavor to maximize the number of
primary care and other physicians from the Southeast
who take and successfully complete the certifying
exam. Contact us or go to the ASH website (www.ashus.org)
to learn more about the Specialist’s Exam.
Chapter Contact Information:
Carolinas-Georgia-Florida Chapter
American Society of Hypertension
135 Cannon Street, 3rd Floor
Charleston, SC 29425
Tel: 843.876.1141
Fax: 843.876.1143
email: Lackland@musc.edu
A Partnership for Excellence in CV Health
The Hypertension Initiative and ASH Carolinas-
Georgia-Florida Chapter are partners with you
to optimize management of hypertension, hyperlipidemia
and diabetes. Through this collaborative
effort, we can help transition our
region from a leader in cardiovascular disease
to a model of heart and vascular health.
Key strategies include: (1) CME programs
(2) ensuring that Hypertension Specialists are
available in communities throughout the region
(3) practice data audit and feedback reports to
support your quality improvement efforts
(4) targeted practice-based interventions and
sharing of best practices.
For information about the Initiative contact:
Brent Egan, MD
E-mail: eganbm@musc.edu
Phone: 843-792-1715
ASH Carolinas-Georgia-Florida Chapter: Another first.
One quality improvement strategy
of the ASH Carolinas-Georgia-
Florida Chapter has been to develop
a cadre of ASH Clinical Hypertension
Specialists, so that there is
1 Specialist for every 20 primary
care physicians. To further ensure
that the expertise is present in the
local community, a related goal is
to have at least 1 Hypertension
Specialist in every county of Chapter
States. We believe that this is
the number and distribution of Hypertension
Specialists required to
have a significant impact on BP
control throughout the region encompassed
by the Chapter.
To realize this impact, Hypertension
Specialists would have a tripartite
mission including excellence in: (1)
patient care (2) education for other
practitioners and the public (3)
health-services research to develop,
demonstrate and disseminate best
practices (Am H Hypertens
2002;15:372—379; J Clin Hypertens
2006;12:879–886).
The American Society of Hypertension
subsequently endorsed these
objectives as a priority for the country.
With the leadership of Dr. Dan Lackland,
Past-President of the Chapter,
the ASH Hypertension Specialists
have endorsed a pilot program in
South Carolina. Qualified resident
physicians in training can take the
examination prior to board certification.
They can receive the designation
as an ASH Hypertension Specialist
concurrently with their
Boards given a passing score on
both exams.
We look forward to a successful
pilot that can be replicated
throughout the entire Carolinas-
Georgia-Florida Chapter and then
nationally. We’ll plan to provide
updates as this pilot ‘unfolds’.