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Evidence coming on best preeclampsia treatment threshold
CHICAGO – It’s clear that there’s a dose-dependent relationship between hypertension in pregnancy and poor outcomes, but, even so, treatment usually doesn’t begin until women hit 160/105 mm Hg or higher, according to Mark Santillan, MD, PhD, an assistant professor of obstetrics and gynecology – maternal fetal medicine at the University of Iowa, Iowa City.
That might soon change. The National Institutes of Health–funded CHAPS (Chronic Hypertension and Pregnancy) trial is testing whether earlier intervention improves outcomes, and it hopes to define proper treatment targets, which are uncertain at this point. Results are expected as soon as 2020.
What’s already changed is that the old treatment standby – methyldopa – has fallen out of favor for labetalol and nifedipine, which have been shown to work better. “Sometimes, we will throw on hydrochlorothiazide after we max out our beta- and calcium channel blockers,” Dr. Santillan said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension (Cochrane Database Syst Rev. 2018 Oct 1;10:CD002252).
For severe hypertension, “most of the time we start off with IV hydralazine or IV labetalol” in the hospital. “You give a dose and check blood pressure in 10 or 20 minutes,” he said. If it hasn’t dropped, “give another dose until you reach your max dose.” When intravenous access is an issue, oral nifedipine is a good option (Obstet Gynecol. 2017 Apr;129[4]:e90-e95).
Delivery date is key; babies exposed to chronic hypertension are more likely to be stillborn. For hypertension without symptoms, delivery is at around 38 weeks. For mild preeclampsia – hypertension with only minor symptoms – it’s at 37 weeks.
In more severe cases – hypertension with pulmonary edema, renal insufficiency, and other problems – “the general gestalt is to stabilize and deliver when you can. See if you can get up to at least 34 weeks,” Dr. Santillan said. However, when women “have full-on HELLP syndrome [hemolysis, elevated liver enzymes, low platelet count], we often just deliver [immediately] because there’s not a lot of stabilization” that can be done. “We give magnesium after delivery to help decrease the risk of seizure,” he added.
Guidelines still use 140/90 mm Hg to define hypertension in pregnancy. When that level is reached, “you don’t need proteinuria anymore to diagnose preeclampsia. You need to have hypertension and something that looks like HELLP,” such as impaired liver function or neurologic symptoms, he said. Onset before 34 weeks portends more severe disease.
Daily baby aspirin 81 mg is known to help prevent preeclampsia, if only a little bit, so anyone with a history of preeclampsia or twin pregnancy, chronic hypertension, diabetes, renal disease, or autoimmune disease should automatically be put on aspirin prophylaxis. Women with two or more moderate risk factors – first pregnancy, obesity, preeclamptic family history, or aged 35 years or older – also should also get baby aspirin. Vitamin C, bed rest, and other preventative measures haven’t panned out in trials.
Investigators are looking for better predictors of preeclampsia; uterine artery blood flow is among the promising markers. However, it and other options are “expensive ventures” if you’re just going to end up in the same place, giving baby aspirin, Dr. Santillan said.
Dr. Santillan reported that he holds three patents; two on copeptin to predict preeclampsia and one on vasopressin receptor antagonists to treat it.
CHICAGO – It’s clear that there’s a dose-dependent relationship between hypertension in pregnancy and poor outcomes, but, even so, treatment usually doesn’t begin until women hit 160/105 mm Hg or higher, according to Mark Santillan, MD, PhD, an assistant professor of obstetrics and gynecology – maternal fetal medicine at the University of Iowa, Iowa City.
That might soon change. The National Institutes of Health–funded CHAPS (Chronic Hypertension and Pregnancy) trial is testing whether earlier intervention improves outcomes, and it hopes to define proper treatment targets, which are uncertain at this point. Results are expected as soon as 2020.
What’s already changed is that the old treatment standby – methyldopa – has fallen out of favor for labetalol and nifedipine, which have been shown to work better. “Sometimes, we will throw on hydrochlorothiazide after we max out our beta- and calcium channel blockers,” Dr. Santillan said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension (Cochrane Database Syst Rev. 2018 Oct 1;10:CD002252).
For severe hypertension, “most of the time we start off with IV hydralazine or IV labetalol” in the hospital. “You give a dose and check blood pressure in 10 or 20 minutes,” he said. If it hasn’t dropped, “give another dose until you reach your max dose.” When intravenous access is an issue, oral nifedipine is a good option (Obstet Gynecol. 2017 Apr;129[4]:e90-e95).
Delivery date is key; babies exposed to chronic hypertension are more likely to be stillborn. For hypertension without symptoms, delivery is at around 38 weeks. For mild preeclampsia – hypertension with only minor symptoms – it’s at 37 weeks.
In more severe cases – hypertension with pulmonary edema, renal insufficiency, and other problems – “the general gestalt is to stabilize and deliver when you can. See if you can get up to at least 34 weeks,” Dr. Santillan said. However, when women “have full-on HELLP syndrome [hemolysis, elevated liver enzymes, low platelet count], we often just deliver [immediately] because there’s not a lot of stabilization” that can be done. “We give magnesium after delivery to help decrease the risk of seizure,” he added.
Guidelines still use 140/90 mm Hg to define hypertension in pregnancy. When that level is reached, “you don’t need proteinuria anymore to diagnose preeclampsia. You need to have hypertension and something that looks like HELLP,” such as impaired liver function or neurologic symptoms, he said. Onset before 34 weeks portends more severe disease.
Daily baby aspirin 81 mg is known to help prevent preeclampsia, if only a little bit, so anyone with a history of preeclampsia or twin pregnancy, chronic hypertension, diabetes, renal disease, or autoimmune disease should automatically be put on aspirin prophylaxis. Women with two or more moderate risk factors – first pregnancy, obesity, preeclamptic family history, or aged 35 years or older – also should also get baby aspirin. Vitamin C, bed rest, and other preventative measures haven’t panned out in trials.
Investigators are looking for better predictors of preeclampsia; uterine artery blood flow is among the promising markers. However, it and other options are “expensive ventures” if you’re just going to end up in the same place, giving baby aspirin, Dr. Santillan said.
Dr. Santillan reported that he holds three patents; two on copeptin to predict preeclampsia and one on vasopressin receptor antagonists to treat it.
CHICAGO – It’s clear that there’s a dose-dependent relationship between hypertension in pregnancy and poor outcomes, but, even so, treatment usually doesn’t begin until women hit 160/105 mm Hg or higher, according to Mark Santillan, MD, PhD, an assistant professor of obstetrics and gynecology – maternal fetal medicine at the University of Iowa, Iowa City.
That might soon change. The National Institutes of Health–funded CHAPS (Chronic Hypertension and Pregnancy) trial is testing whether earlier intervention improves outcomes, and it hopes to define proper treatment targets, which are uncertain at this point. Results are expected as soon as 2020.
What’s already changed is that the old treatment standby – methyldopa – has fallen out of favor for labetalol and nifedipine, which have been shown to work better. “Sometimes, we will throw on hydrochlorothiazide after we max out our beta- and calcium channel blockers,” Dr. Santillan said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension (Cochrane Database Syst Rev. 2018 Oct 1;10:CD002252).
For severe hypertension, “most of the time we start off with IV hydralazine or IV labetalol” in the hospital. “You give a dose and check blood pressure in 10 or 20 minutes,” he said. If it hasn’t dropped, “give another dose until you reach your max dose.” When intravenous access is an issue, oral nifedipine is a good option (Obstet Gynecol. 2017 Apr;129[4]:e90-e95).
Delivery date is key; babies exposed to chronic hypertension are more likely to be stillborn. For hypertension without symptoms, delivery is at around 38 weeks. For mild preeclampsia – hypertension with only minor symptoms – it’s at 37 weeks.
In more severe cases – hypertension with pulmonary edema, renal insufficiency, and other problems – “the general gestalt is to stabilize and deliver when you can. See if you can get up to at least 34 weeks,” Dr. Santillan said. However, when women “have full-on HELLP syndrome [hemolysis, elevated liver enzymes, low platelet count], we often just deliver [immediately] because there’s not a lot of stabilization” that can be done. “We give magnesium after delivery to help decrease the risk of seizure,” he added.
Guidelines still use 140/90 mm Hg to define hypertension in pregnancy. When that level is reached, “you don’t need proteinuria anymore to diagnose preeclampsia. You need to have hypertension and something that looks like HELLP,” such as impaired liver function or neurologic symptoms, he said. Onset before 34 weeks portends more severe disease.
Daily baby aspirin 81 mg is known to help prevent preeclampsia, if only a little bit, so anyone with a history of preeclampsia or twin pregnancy, chronic hypertension, diabetes, renal disease, or autoimmune disease should automatically be put on aspirin prophylaxis. Women with two or more moderate risk factors – first pregnancy, obesity, preeclamptic family history, or aged 35 years or older – also should also get baby aspirin. Vitamin C, bed rest, and other preventative measures haven’t panned out in trials.
Investigators are looking for better predictors of preeclampsia; uterine artery blood flow is among the promising markers. However, it and other options are “expensive ventures” if you’re just going to end up in the same place, giving baby aspirin, Dr. Santillan said.
Dr. Santillan reported that he holds three patents; two on copeptin to predict preeclampsia and one on vasopressin receptor antagonists to treat it.
EXPERT ANALYSIS FROM JOINT HYPERTENSION 2018
SPRINT: Pill burden affects ability to reach systolic BP control
CHICAGO –
“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.
Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.
SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.
Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.
Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.
Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.
Pharmacy review is especially a good idea in the elderly.
Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.
About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,
The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.
There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
CHICAGO –
“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.
Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.
SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.
Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.
Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.
Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.
Pharmacy review is especially a good idea in the elderly.
Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.
About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,
The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.
There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
CHICAGO –
“Five or more medications” meant total drug burden, both for hypertension and comorbidities. “When you are treating a patient for hypertension, you care about blood pressure, but you also need to care about” what else they are on, and their total drug burden, “because it affects their ability to get to their blood pressure goal, especially if you’re targeting intensive control,” said lead investigator Catherine Derington, PharmD, a postdoctoral fellow at the University of Colorado, Aurora.
Good old-fashioned exercise and weight loss remain potent non–pill options, she noted at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The take-home message is to use more combination drugs for hypertension “to get patients on fewer pills.” Also, “eliminate drugs [patients] don’t need,” said SPRINT investigator William C. Cushman, MD, professor of medicine and physiology at the University of Tennessee, Memphis, when asked what he thought of the new findings.
SPRINT [Systolic Blood Pressure Intervention Trial] found that targeting systolic blood pressures below 120 mm Hg, as compared with less than 140 mm Hg, led to lower rates of MI, stroke, heart failure, and death from any cause.
Medication burden had no effect on patients in the 140 mm Hg group; they achieved a mean systolic blood pressure (SBP) of 136 mm Hg at 1 year, whether they were on fewer than five drugs a day or more. Hitting that target took an average of 1.8 hypertension medications.
Reaching 120 mm Hg generally took one extra drug (an average of 2.8), and the overall pill burden did matter; 2,463 patients in the intensive arm on fewer than five medications dropped their mean SBP 20 mm Hg at one year, while 1,698 taking more than five had a 15–mm Hg reduction. The group with the lower pill burden had a mean SBP of 120.6 mm Hg and those taking five or more had a mean SBP of 122.5 mm Hg. It’s a small difference but likely important.
Comorbidities in SPRINT included kidney and cardiovascular disease, among others, but the trial excluded patients with diabetes. Many patients were on statins and aspirin.
Pharmacy review is especially a good idea in the elderly.
Patients on five or more medications had higher rates of significant adverse events in the post hoc analysis (about 50% versus about 30%), including hypotension, syncope, electrolyte abnormalities, and acute kidney injury, regardless if they were in the 120–mm Hg or 140–mm Hg group.
About 45% in the intensive arm reported high adherence (Morisky Medication Adherence Scale-8 score greater than 8 at 12 months); medication burden made no difference. Oddly, in the standard-treatment arm, more patients on five or more drugs reported high adherence, 44.5% versus 38.1% among patients taking fewer,
The post hoc analysis was based on pill bottle review at baseline. Medication count did not affect hypertension treatment satisfaction, which was about 84% in the intensive and 77% in the standard arm.
There was no industry funding for the work. Dr. Derington didn’t have any disclosures.
REPORTING FROM JOINT HYPERTENSION 2018
Key clinical point: Consider overall pill burden when managing hypertension.
Major finding: Patients in the SPRINT trial were less likely to meet the intensive treatment goal – systolic blood pressure below 120 mm Hg – if they were taking five or more medications a day.
Study details: Post hoc analysis of the SPRINT trial
Disclosures: There was no industry funding, and the lead investigator didn’t have any disclosures.
Source: Derington C et al. Joint Hypertension 2018, Abstract P208.
CKD children need office blood pressures below the 75th percentile
CHICAGO – according to a review of 690 pediatric patients in the Chronic Kidney Disease in Children Cohort Study.
Hypertensive children with CKD were less likely to progress to dialysis or kidney transplant or have a 30% decline in estimated glomerular filtration rate (eGFR) when kept in that range, compared with children above or below it. “Achieved office [blood pressure] between the 50th and 75th percentiles appeared to offer the greatest protection against CKD progression in this cohort,” said investigators led by Joseph Flynn, MD, chief of the nephrology division at Seattle Children’s Hospital.
“We needed to have some [evidence] on what to do based on office blood pressure,” something that had been missing in the literature until now. “I think this is going to be very impactful on the care of children with CKD. Right now, the guidelines say to keep” pressures below the 90th percentile for age and height. “The guidelines [might] need to be changed,” said Dr. Flynn, also the lead author of the American Academy of Pediatrics 2017 blood pressure guidelines for children and adolescents (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
There was “no evidence to go below the 50th percentile; the 50th-75th seems to be the sweet spot for office blood pressure,” he said at the joint scientific sessions of the AHA Council on Hypertension, the AHA Council on Kidney in Cardiovascular Disease, and the American Society of Hypertension.
The 476 children with nonglomerular CKD actually did worse when their blood pressures were pushed below the 50th percentile, perhaps because of renal hypoperfusion. The 476 children with glomerular CKD did no better or worse below the 50th percentile than they did in the 50th-75th.
Children at or above the 90th percentile had the highest risk of progression, with about 80% needing renal replacement therapy or having a 30% drop in eGFR at 5-8 years of follow-up. Compared with children with glomerular CKD who were in the 90th percentile, the risk hazard (RH) for progression over 3 years was 0.10-0.30 (P less than 0.001) among those children with glomerular CKD who were kept in the 50th-75th percentile. Compared with children with nonglomerular CKD who were in the 90th percentile, the RH over 8 years among those in the 50th-75th percentile was 0.48 (P less than 0.001). Risk of progression in both glomerular and nonglomerular patients in the sweet spot was less than 50% at 5-8 years of follow-up.
When glomerular and nonglomerular patients were considered together, those with pressures below the 50th percentile were less likely to progress than children with pressures between the 75th and 90th, but they were more likely to progress than the 50th-75th percentile group.
Research nurses took three blood pressures by auscultation a minute apart after 5 minutes of rest. Most of the children were treated at first with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, per recommendations. Dihydropyridine calcium channel blockers (for example, amlodipine and nifedipine) were most likely to be used next.
It was a curious finding because dihydropyridines have been show to worsen proteinuria in adults with CKD. The team is investigating to see whether they have the same effect in children. If so, “we’ll be able to tell people to stop using them,” Dr. Flynn said.
The median age in the study was 11.3 years, and almost two-thirds of the subjects were boys. The median duration of disease was 8 years. Some children in the ongoing cohort have been followed for almost 10 years. The analysis is based on children who entered the cohort with hypertension or developed it after enrollment.
The nationwide Chronic Kidney Disease in Children Cohort Study is funded by the National Institutes of Health. Dr. Flynn is an advisor for Ultragenyx and Silvergate Pharmaceuticals.
CHICAGO – according to a review of 690 pediatric patients in the Chronic Kidney Disease in Children Cohort Study.
Hypertensive children with CKD were less likely to progress to dialysis or kidney transplant or have a 30% decline in estimated glomerular filtration rate (eGFR) when kept in that range, compared with children above or below it. “Achieved office [blood pressure] between the 50th and 75th percentiles appeared to offer the greatest protection against CKD progression in this cohort,” said investigators led by Joseph Flynn, MD, chief of the nephrology division at Seattle Children’s Hospital.
“We needed to have some [evidence] on what to do based on office blood pressure,” something that had been missing in the literature until now. “I think this is going to be very impactful on the care of children with CKD. Right now, the guidelines say to keep” pressures below the 90th percentile for age and height. “The guidelines [might] need to be changed,” said Dr. Flynn, also the lead author of the American Academy of Pediatrics 2017 blood pressure guidelines for children and adolescents (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
There was “no evidence to go below the 50th percentile; the 50th-75th seems to be the sweet spot for office blood pressure,” he said at the joint scientific sessions of the AHA Council on Hypertension, the AHA Council on Kidney in Cardiovascular Disease, and the American Society of Hypertension.
The 476 children with nonglomerular CKD actually did worse when their blood pressures were pushed below the 50th percentile, perhaps because of renal hypoperfusion. The 476 children with glomerular CKD did no better or worse below the 50th percentile than they did in the 50th-75th.
Children at or above the 90th percentile had the highest risk of progression, with about 80% needing renal replacement therapy or having a 30% drop in eGFR at 5-8 years of follow-up. Compared with children with glomerular CKD who were in the 90th percentile, the risk hazard (RH) for progression over 3 years was 0.10-0.30 (P less than 0.001) among those children with glomerular CKD who were kept in the 50th-75th percentile. Compared with children with nonglomerular CKD who were in the 90th percentile, the RH over 8 years among those in the 50th-75th percentile was 0.48 (P less than 0.001). Risk of progression in both glomerular and nonglomerular patients in the sweet spot was less than 50% at 5-8 years of follow-up.
When glomerular and nonglomerular patients were considered together, those with pressures below the 50th percentile were less likely to progress than children with pressures between the 75th and 90th, but they were more likely to progress than the 50th-75th percentile group.
Research nurses took three blood pressures by auscultation a minute apart after 5 minutes of rest. Most of the children were treated at first with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, per recommendations. Dihydropyridine calcium channel blockers (for example, amlodipine and nifedipine) were most likely to be used next.
It was a curious finding because dihydropyridines have been show to worsen proteinuria in adults with CKD. The team is investigating to see whether they have the same effect in children. If so, “we’ll be able to tell people to stop using them,” Dr. Flynn said.
The median age in the study was 11.3 years, and almost two-thirds of the subjects were boys. The median duration of disease was 8 years. Some children in the ongoing cohort have been followed for almost 10 years. The analysis is based on children who entered the cohort with hypertension or developed it after enrollment.
The nationwide Chronic Kidney Disease in Children Cohort Study is funded by the National Institutes of Health. Dr. Flynn is an advisor for Ultragenyx and Silvergate Pharmaceuticals.
CHICAGO – according to a review of 690 pediatric patients in the Chronic Kidney Disease in Children Cohort Study.
Hypertensive children with CKD were less likely to progress to dialysis or kidney transplant or have a 30% decline in estimated glomerular filtration rate (eGFR) when kept in that range, compared with children above or below it. “Achieved office [blood pressure] between the 50th and 75th percentiles appeared to offer the greatest protection against CKD progression in this cohort,” said investigators led by Joseph Flynn, MD, chief of the nephrology division at Seattle Children’s Hospital.
“We needed to have some [evidence] on what to do based on office blood pressure,” something that had been missing in the literature until now. “I think this is going to be very impactful on the care of children with CKD. Right now, the guidelines say to keep” pressures below the 90th percentile for age and height. “The guidelines [might] need to be changed,” said Dr. Flynn, also the lead author of the American Academy of Pediatrics 2017 blood pressure guidelines for children and adolescents (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
There was “no evidence to go below the 50th percentile; the 50th-75th seems to be the sweet spot for office blood pressure,” he said at the joint scientific sessions of the AHA Council on Hypertension, the AHA Council on Kidney in Cardiovascular Disease, and the American Society of Hypertension.
The 476 children with nonglomerular CKD actually did worse when their blood pressures were pushed below the 50th percentile, perhaps because of renal hypoperfusion. The 476 children with glomerular CKD did no better or worse below the 50th percentile than they did in the 50th-75th.
Children at or above the 90th percentile had the highest risk of progression, with about 80% needing renal replacement therapy or having a 30% drop in eGFR at 5-8 years of follow-up. Compared with children with glomerular CKD who were in the 90th percentile, the risk hazard (RH) for progression over 3 years was 0.10-0.30 (P less than 0.001) among those children with glomerular CKD who were kept in the 50th-75th percentile. Compared with children with nonglomerular CKD who were in the 90th percentile, the RH over 8 years among those in the 50th-75th percentile was 0.48 (P less than 0.001). Risk of progression in both glomerular and nonglomerular patients in the sweet spot was less than 50% at 5-8 years of follow-up.
When glomerular and nonglomerular patients were considered together, those with pressures below the 50th percentile were less likely to progress than children with pressures between the 75th and 90th, but they were more likely to progress than the 50th-75th percentile group.
Research nurses took three blood pressures by auscultation a minute apart after 5 minutes of rest. Most of the children were treated at first with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, per recommendations. Dihydropyridine calcium channel blockers (for example, amlodipine and nifedipine) were most likely to be used next.
It was a curious finding because dihydropyridines have been show to worsen proteinuria in adults with CKD. The team is investigating to see whether they have the same effect in children. If so, “we’ll be able to tell people to stop using them,” Dr. Flynn said.
The median age in the study was 11.3 years, and almost two-thirds of the subjects were boys. The median duration of disease was 8 years. Some children in the ongoing cohort have been followed for almost 10 years. The analysis is based on children who entered the cohort with hypertension or developed it after enrollment.
The nationwide Chronic Kidney Disease in Children Cohort Study is funded by the National Institutes of Health. Dr. Flynn is an advisor for Ultragenyx and Silvergate Pharmaceuticals.
REPORTING FROM JOINT HYPERTENSION 2018
Key clinical point: It’s best to aim for an office blood pressure between the 50th and 75th percentiles in children with CKD.
Major finding: The risk of CKD progression was less than 50% in children kept in that range, which was better than children both above or below it.
Study details: Review of 690 pediatric patients in the Chronic Kidney Disease in Children Cohort Study.
Disclosures: The nationwide Chronic Kidney Disease in Children Cohort Study is funded by the National Institutes of Health. Dr. Joseph Flynn is an advisor for Ultragenyx and Silvergate Pharmaceuticals.
Get on top of home BP monitoring now
CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.
The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.
There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).
“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.
In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.
He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.
He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).
Dr. Bosworth reported no relevant disclosures.
CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.
The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.
There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).
“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.
In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.
He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.
He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).
Dr. Bosworth reported no relevant disclosures.
CHICAGO – Home BP monitoring has proved its worth, and it’s now time to integrate it into health care and get insurers to pay for it, according to Hayden Bosworth, PhD, a population health sciences professor and health services researcher at Duke University, Durham, N.C.
The devices are on the shelves of pharmacies and discount stores nationwide, sometimes for less than $50, but what to do with them in the clinic hasn’t been worked out. It’s likely patients are soon going to want help interpreting the results, if they aren’t already, but a leap in technology has left clinicians and payors scratching their heads.
There’s more than enough evidence of benefit. Dr. Bosworth has been involved with several trials of home BP monitoring with good results. He was one of the many authors on a recent meta-analysis that found when patients check their BP at home, it can lead to a “clinically significant” reduction “which persists for at least 12 months” (PLoS Med. 2017 Sep 19;14[9]:e1002389).
“Are we talking about efficacy or proof of concept? I think we are beyond that. Now we have to think about how we put it into the system, how do we integrate it, what’s the best way of delivery. I think that’s where the future is,” he said in an interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Home monitoring came up far more often at this year’s joint sessions than in 2017, which might indicate growing interest, but reimbursement remains a challenge. American Medical Association staff said at this year’s meeting that they are working with the Centers for Medicare & Medicaid Services for coverage of the devices and their use. It seemed likely to them.
In the meantime, Dr. Bosworth had some useful advice for those who are thinking about incorporating home BP monitoring into their practices.
He shared his tips on how to pick out a device – there’s actually a journal called Blood Pressure Monitoring that can help – as well as his thoughts on how often people should monitor themselves and what to do with the numbers.
He envisions a future when patients routinely check their BP at home; it’s even possible they could adjust their medications based on the results, much like diabetes patients track their blood glucose and adjust their insulin. It’s been shown to work in Britain (JAMA. 2014 Aug 27;312[8]:799-808).
Dr. Bosworth reported no relevant disclosures.
EXPERT ANALYSIS FROM JOINT HYPERTENSION 2018
Short sleep linked to elevated blood pressure
CHICAGO – Consider 24-hour ambulatory blood pressure monitoring when patients complain about not getting enough sleep. You might catch hypertension early, according to researchers from the University of Pennsylvania, Philadelphia, and elsewhere.
They found a less than 7 hours a night and a mean in the study of 5.5 hours. Every 2-2.5 minutes of lost sleep was associated with an increase of 1 mm Hg in 24-hour mean systolic blood pressure and a increase of 1 beat per minute in heart rate.
The relationship was independent of office BP, nocturnal dipping status, and BP variability. It held in both the obese and nonobese, and in patients with and without obstructive sleep apnea (OSA). However, the relationship was found only among subjects who were not on antihypertensive medications.
“Adults with shorter sleep duration may benefit from screening with 24-hour ambulatory BP monitoring to promote earlier detection of hypertension and potentially mitigate the” the risk of cardiovascular disease. “This may be particularly important in screening for masked hypertension,” meaning normal pressures in the office, but elevated pressures at home, said investigators led by Jordana Cohen, MD, of the department of medicine at the University of Pennsylvania in a presentation at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Dr. Cohen suggested that perhaps the sympathetic and endothelial derangements that drive hypertension in OSA also affect people with insufficient sleep. It may be that the normal morning surge in blood pressure persists longer into the day, she suggested. The investigative team analyzed data from two studies. The first, LIMBS (Lifestyle Modification in BP Lowering Study), was a phase 2 trial assessing yoga for blood pressure lowering. It was conducted in West Philadelphia and excluded people with diabetes, hypertension, OSA, and kidney or cardiovascular disease. The new analysis included 66 LIMBS subjects who had 24-hour blood pressure monitoring and kept sleep diaries to record their sleep duration (J Clin Hypertens (Greenwich). 2016 Aug;18[8]:809-16).
The team also analyzed 153 subjects from the PISA (Penn Icelandic Sleep Apnea) cohort, an ongoing project assessing continuous positive airway pressure for OSA, among other things. PISA includes patients with OSA, diabetes, hypertension, and kidney or cardiovascular disease. Sleep duration in the 153 subjects was again self-reported, but corroborated by actigraphy (J Sleep Res. 2015 Jun;24[3]:328-38).
The new findings were driven mostly by higher daytime systolic BP among short sleepers in LIMBS, and higher systolic pressures during both day and night among short sleepers in PISA, compared with subjects who slept at least 7 hours, and a mean of 8.5 hours, with napping included in overall sleep duration assessment.
In LIMBS, the mean 24-hour systolic BP was 12.7 mm Hg higher and the average heart rate 8 bpm faster among short sleepers; in PISA, the mean 24-hour systolic BP was 4.7 mm Hg higher and the heart rate 2 bpm faster.
Every 2.57 minutes of sleep lost in LIMBS and every 1.99 minute of lost sleep in PISA was associated with a 1–mm Hg gain in mean systolic BP and about a 1-bpm increase in heart rate. The findings were statistically significant and adjusted for age, race, body mass index, nocturnal dipping status, and office systolic blood pressure.
Baseline characteristics were generally well matched between short and long sleepers in both studies. However, while mean office systolic BP in LIMBS was the same in both sleep groups at about 139 mm Hg, the mean office systolic BP among long sleepers in PISA was 130 mm Hg versus 136 mm Hg among short sleepers, a significant difference.
It’s unclear why some people slept less, Dr. Cohen said, and the use of sleeping pills wasn’t considered in the analysis. Patients were an average of about 50 years old, with a body mass index of about 30 mg/m2. The same model of 24-hour blood pressure monitor was used in both studies.
The work was funded by the National Institutes of Health. The investigators had no disclosures.
CHICAGO – Consider 24-hour ambulatory blood pressure monitoring when patients complain about not getting enough sleep. You might catch hypertension early, according to researchers from the University of Pennsylvania, Philadelphia, and elsewhere.
They found a less than 7 hours a night and a mean in the study of 5.5 hours. Every 2-2.5 minutes of lost sleep was associated with an increase of 1 mm Hg in 24-hour mean systolic blood pressure and a increase of 1 beat per minute in heart rate.
The relationship was independent of office BP, nocturnal dipping status, and BP variability. It held in both the obese and nonobese, and in patients with and without obstructive sleep apnea (OSA). However, the relationship was found only among subjects who were not on antihypertensive medications.
“Adults with shorter sleep duration may benefit from screening with 24-hour ambulatory BP monitoring to promote earlier detection of hypertension and potentially mitigate the” the risk of cardiovascular disease. “This may be particularly important in screening for masked hypertension,” meaning normal pressures in the office, but elevated pressures at home, said investigators led by Jordana Cohen, MD, of the department of medicine at the University of Pennsylvania in a presentation at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Dr. Cohen suggested that perhaps the sympathetic and endothelial derangements that drive hypertension in OSA also affect people with insufficient sleep. It may be that the normal morning surge in blood pressure persists longer into the day, she suggested. The investigative team analyzed data from two studies. The first, LIMBS (Lifestyle Modification in BP Lowering Study), was a phase 2 trial assessing yoga for blood pressure lowering. It was conducted in West Philadelphia and excluded people with diabetes, hypertension, OSA, and kidney or cardiovascular disease. The new analysis included 66 LIMBS subjects who had 24-hour blood pressure monitoring and kept sleep diaries to record their sleep duration (J Clin Hypertens (Greenwich). 2016 Aug;18[8]:809-16).
The team also analyzed 153 subjects from the PISA (Penn Icelandic Sleep Apnea) cohort, an ongoing project assessing continuous positive airway pressure for OSA, among other things. PISA includes patients with OSA, diabetes, hypertension, and kidney or cardiovascular disease. Sleep duration in the 153 subjects was again self-reported, but corroborated by actigraphy (J Sleep Res. 2015 Jun;24[3]:328-38).
The new findings were driven mostly by higher daytime systolic BP among short sleepers in LIMBS, and higher systolic pressures during both day and night among short sleepers in PISA, compared with subjects who slept at least 7 hours, and a mean of 8.5 hours, with napping included in overall sleep duration assessment.
In LIMBS, the mean 24-hour systolic BP was 12.7 mm Hg higher and the average heart rate 8 bpm faster among short sleepers; in PISA, the mean 24-hour systolic BP was 4.7 mm Hg higher and the heart rate 2 bpm faster.
Every 2.57 minutes of sleep lost in LIMBS and every 1.99 minute of lost sleep in PISA was associated with a 1–mm Hg gain in mean systolic BP and about a 1-bpm increase in heart rate. The findings were statistically significant and adjusted for age, race, body mass index, nocturnal dipping status, and office systolic blood pressure.
Baseline characteristics were generally well matched between short and long sleepers in both studies. However, while mean office systolic BP in LIMBS was the same in both sleep groups at about 139 mm Hg, the mean office systolic BP among long sleepers in PISA was 130 mm Hg versus 136 mm Hg among short sleepers, a significant difference.
It’s unclear why some people slept less, Dr. Cohen said, and the use of sleeping pills wasn’t considered in the analysis. Patients were an average of about 50 years old, with a body mass index of about 30 mg/m2. The same model of 24-hour blood pressure monitor was used in both studies.
The work was funded by the National Institutes of Health. The investigators had no disclosures.
CHICAGO – Consider 24-hour ambulatory blood pressure monitoring when patients complain about not getting enough sleep. You might catch hypertension early, according to researchers from the University of Pennsylvania, Philadelphia, and elsewhere.
They found a less than 7 hours a night and a mean in the study of 5.5 hours. Every 2-2.5 minutes of lost sleep was associated with an increase of 1 mm Hg in 24-hour mean systolic blood pressure and a increase of 1 beat per minute in heart rate.
The relationship was independent of office BP, nocturnal dipping status, and BP variability. It held in both the obese and nonobese, and in patients with and without obstructive sleep apnea (OSA). However, the relationship was found only among subjects who were not on antihypertensive medications.
“Adults with shorter sleep duration may benefit from screening with 24-hour ambulatory BP monitoring to promote earlier detection of hypertension and potentially mitigate the” the risk of cardiovascular disease. “This may be particularly important in screening for masked hypertension,” meaning normal pressures in the office, but elevated pressures at home, said investigators led by Jordana Cohen, MD, of the department of medicine at the University of Pennsylvania in a presentation at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
Dr. Cohen suggested that perhaps the sympathetic and endothelial derangements that drive hypertension in OSA also affect people with insufficient sleep. It may be that the normal morning surge in blood pressure persists longer into the day, she suggested. The investigative team analyzed data from two studies. The first, LIMBS (Lifestyle Modification in BP Lowering Study), was a phase 2 trial assessing yoga for blood pressure lowering. It was conducted in West Philadelphia and excluded people with diabetes, hypertension, OSA, and kidney or cardiovascular disease. The new analysis included 66 LIMBS subjects who had 24-hour blood pressure monitoring and kept sleep diaries to record their sleep duration (J Clin Hypertens (Greenwich). 2016 Aug;18[8]:809-16).
The team also analyzed 153 subjects from the PISA (Penn Icelandic Sleep Apnea) cohort, an ongoing project assessing continuous positive airway pressure for OSA, among other things. PISA includes patients with OSA, diabetes, hypertension, and kidney or cardiovascular disease. Sleep duration in the 153 subjects was again self-reported, but corroborated by actigraphy (J Sleep Res. 2015 Jun;24[3]:328-38).
The new findings were driven mostly by higher daytime systolic BP among short sleepers in LIMBS, and higher systolic pressures during both day and night among short sleepers in PISA, compared with subjects who slept at least 7 hours, and a mean of 8.5 hours, with napping included in overall sleep duration assessment.
In LIMBS, the mean 24-hour systolic BP was 12.7 mm Hg higher and the average heart rate 8 bpm faster among short sleepers; in PISA, the mean 24-hour systolic BP was 4.7 mm Hg higher and the heart rate 2 bpm faster.
Every 2.57 minutes of sleep lost in LIMBS and every 1.99 minute of lost sleep in PISA was associated with a 1–mm Hg gain in mean systolic BP and about a 1-bpm increase in heart rate. The findings were statistically significant and adjusted for age, race, body mass index, nocturnal dipping status, and office systolic blood pressure.
Baseline characteristics were generally well matched between short and long sleepers in both studies. However, while mean office systolic BP in LIMBS was the same in both sleep groups at about 139 mm Hg, the mean office systolic BP among long sleepers in PISA was 130 mm Hg versus 136 mm Hg among short sleepers, a significant difference.
It’s unclear why some people slept less, Dr. Cohen said, and the use of sleeping pills wasn’t considered in the analysis. Patients were an average of about 50 years old, with a body mass index of about 30 mg/m2. The same model of 24-hour blood pressure monitor was used in both studies.
The work was funded by the National Institutes of Health. The investigators had no disclosures.
REPORTING FROM JOINT HYPERTENSION 2018
Key clinical point: Ambulatory blood pressure monitoring in patients complaining about lack of sleep could detect hypertension.
Major finding: Every 2-2.5 minutes of lost sleep was associated with a 1–mm Hg increase in 24-hour mean systolic blood pressure and a 1-bpm increase in heart rate.
Study details: Post-hoc review of 219 patients in two trials
Disclosures: The work was funded by the National Institutes of Health. The investigators didn’t have any disclosures.
Pediatric hypertension linked to troubling MRI changes
CHICAGO – There’s another reason to worry about hypertension in children: cognitive decline later in life.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In a pilot study, Marc Lande, MD, a professor of pediatric nephrology at the University of Rochester (N.Y.), and his colleagues found similar to what’s found in adults with cognitive impairment from hypertension.
The work is ongoing, but it helps explain the subtle deficits on cognitive testing that have been previously demonstrated in children with hypertension.
“The fact that we are finding anything at this very early stage of disease is striking and somewhat bothersome. The hope is that, by improving blood pressure in children, you can improve subsequent cognition and maybe even delay the onset of dementia further down the road,” Dr. Lande said.
For now, the findings underscore the need to diagnose and manage hypertension in children, but there might be additional treatment implications in the future, especially if blood pressure targets are found that ameliorate the problem.
Dr. Lande explained the issues and the emerging evidence in a video interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
CHICAGO – There’s another reason to worry about hypertension in children: cognitive decline later in life.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In a pilot study, Marc Lande, MD, a professor of pediatric nephrology at the University of Rochester (N.Y.), and his colleagues found similar to what’s found in adults with cognitive impairment from hypertension.
The work is ongoing, but it helps explain the subtle deficits on cognitive testing that have been previously demonstrated in children with hypertension.
“The fact that we are finding anything at this very early stage of disease is striking and somewhat bothersome. The hope is that, by improving blood pressure in children, you can improve subsequent cognition and maybe even delay the onset of dementia further down the road,” Dr. Lande said.
For now, the findings underscore the need to diagnose and manage hypertension in children, but there might be additional treatment implications in the future, especially if blood pressure targets are found that ameliorate the problem.
Dr. Lande explained the issues and the emerging evidence in a video interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
CHICAGO – There’s another reason to worry about hypertension in children: cognitive decline later in life.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In a pilot study, Marc Lande, MD, a professor of pediatric nephrology at the University of Rochester (N.Y.), and his colleagues found similar to what’s found in adults with cognitive impairment from hypertension.
The work is ongoing, but it helps explain the subtle deficits on cognitive testing that have been previously demonstrated in children with hypertension.
“The fact that we are finding anything at this very early stage of disease is striking and somewhat bothersome. The hope is that, by improving blood pressure in children, you can improve subsequent cognition and maybe even delay the onset of dementia further down the road,” Dr. Lande said.
For now, the findings underscore the need to diagnose and manage hypertension in children, but there might be additional treatment implications in the future, especially if blood pressure targets are found that ameliorate the problem.
Dr. Lande explained the issues and the emerging evidence in a video interview at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
REPORTING FROM JOINT HYPERTENSION 2018
Years after ALLHAT, alpha-blocker use still common, risky
CHICAGO – The risk of cardiovascular and hypotension-related events is higher with alpha-blockers than with other hypertension drugs, but almost 20 years after the pivotal ALLHAT trial first raised safety concerns, they are still widely used, according to investigators from the University of Ottawa.
ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) linked the alpha-blocker doxazosin (Cardura) to an increased risk of heart failure and stroke, which led to the early cessation of the doxazosin arm. Guidelines no longer include alpha-blockers among the primary options for hypertension (JAMA. 2000;283[15]:1967-75).
However, there’s been some doubt about ALLHAT; doxazosin patients had diuretics withdrawn as part of the study, which might have contributed to the increased risks. “A lot of arguments have been made that perhaps alpha-blockers aren’t that bad and maybe should still be used, so we took a second look,” said lead investigator and nephrologist Swapnil Hiremath, MD, an assistant professor of medicine at the University of Ottawa.
What he and his team found “confirmed and expanded on the findings of ALLHAT.” Apart from a few specific situations, “don’t prescribe alpha-blockers. If a patient is on an alpha-blocker, consider prescribing an alternative,” Dr. Hiremath said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The drugs are still widely used, according to the team’s review of Ontario health data. From 1995 to 2015, nearly 81,000 patients were prescribed alpha-blockers for hypertension, sometimes as monotherapy, with no real downward trend in prescriptions over time.
There are some selected indications for alpha-blockers, including intolerance of other antihypertensives, pheochromocytoma management, and resistant hypertension. “So I thought maybe there would be 5,000 or 10,000. The fact that we found almost 81,000 was an eye-opener. I’m pretty sure 81,000 patients in Ontario don’t have resistant hypertension,” Dr. Hiremath said.
Patients with benign prostatic hypertrophy, another indication, were excluded from the study.
Before ALLHAT, alpha-blockers were considered first-line drugs, so maybe prescribers are just “sticking with something they know and are familiar with,” he said.
To assess the risks of continued use, the investigators used propensity scoring to match 69,092 patients prescribed alpha-blockers to 69,092 who were prescribed other antihypertensives, based on age, comorbidities, date of treatment, and a slew of other potential confounders. Patients were considered to be on an alpha-blocker only when they were filling prescriptions for the drugs. If they were not filling prescriptions they flipped into the unexposed arm.
The incident rates of ED visits and hospitalizations for hypotension and related complications – syncope, falls, and fractures – were markedly higher among alpha-blocker users. After adjusting for the total number of antihypertensives patients were on, those on alpha-blockers were 34% more likely to go to the ED or be hospitalized for hypotension, 49% more likely for syncope, 27% more likely for falls, and 41% more likely for fractures. First-dose effects don’t explain the findings; patients were often on alpha-blockers for years beforehand.
Alpha-blocker patients were also 26% more likely to have a major cardiovascular event, including heart failure and MI. The risks were greatest in those older than age 85 years. The results were all statistically significant.
About 9,000 alpha-blocker patients had a fracture versus 3,351 matched patients on other antihypertensives; “9,000 patients out of 70,000 is a huge number. These drugs are useful in some situations, but be careful,” Dr. Hiremath said.
“This is observational data, but it’s consistent with ALLHAT, and the outcomes are even worse. We didn’t in [subsequent] guidelines say that you should [never] use an alpha-blocker in hypertension. Maybe we should have,” said ALLHAT investigator William Cushman, MD, a professor of medicine and physiology at the University of Tennessee, Memphis.
There was no industry funding for the work, and the investigators reported having no financial disclosures. Dr. Cushman wasn’t involved in the work.
SOURCE: Hiremath S et al. Joint Hypertension 2018, Abstract P375.
CHICAGO – The risk of cardiovascular and hypotension-related events is higher with alpha-blockers than with other hypertension drugs, but almost 20 years after the pivotal ALLHAT trial first raised safety concerns, they are still widely used, according to investigators from the University of Ottawa.
ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) linked the alpha-blocker doxazosin (Cardura) to an increased risk of heart failure and stroke, which led to the early cessation of the doxazosin arm. Guidelines no longer include alpha-blockers among the primary options for hypertension (JAMA. 2000;283[15]:1967-75).
However, there’s been some doubt about ALLHAT; doxazosin patients had diuretics withdrawn as part of the study, which might have contributed to the increased risks. “A lot of arguments have been made that perhaps alpha-blockers aren’t that bad and maybe should still be used, so we took a second look,” said lead investigator and nephrologist Swapnil Hiremath, MD, an assistant professor of medicine at the University of Ottawa.
What he and his team found “confirmed and expanded on the findings of ALLHAT.” Apart from a few specific situations, “don’t prescribe alpha-blockers. If a patient is on an alpha-blocker, consider prescribing an alternative,” Dr. Hiremath said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The drugs are still widely used, according to the team’s review of Ontario health data. From 1995 to 2015, nearly 81,000 patients were prescribed alpha-blockers for hypertension, sometimes as monotherapy, with no real downward trend in prescriptions over time.
There are some selected indications for alpha-blockers, including intolerance of other antihypertensives, pheochromocytoma management, and resistant hypertension. “So I thought maybe there would be 5,000 or 10,000. The fact that we found almost 81,000 was an eye-opener. I’m pretty sure 81,000 patients in Ontario don’t have resistant hypertension,” Dr. Hiremath said.
Patients with benign prostatic hypertrophy, another indication, were excluded from the study.
Before ALLHAT, alpha-blockers were considered first-line drugs, so maybe prescribers are just “sticking with something they know and are familiar with,” he said.
To assess the risks of continued use, the investigators used propensity scoring to match 69,092 patients prescribed alpha-blockers to 69,092 who were prescribed other antihypertensives, based on age, comorbidities, date of treatment, and a slew of other potential confounders. Patients were considered to be on an alpha-blocker only when they were filling prescriptions for the drugs. If they were not filling prescriptions they flipped into the unexposed arm.
The incident rates of ED visits and hospitalizations for hypotension and related complications – syncope, falls, and fractures – were markedly higher among alpha-blocker users. After adjusting for the total number of antihypertensives patients were on, those on alpha-blockers were 34% more likely to go to the ED or be hospitalized for hypotension, 49% more likely for syncope, 27% more likely for falls, and 41% more likely for fractures. First-dose effects don’t explain the findings; patients were often on alpha-blockers for years beforehand.
Alpha-blocker patients were also 26% more likely to have a major cardiovascular event, including heart failure and MI. The risks were greatest in those older than age 85 years. The results were all statistically significant.
About 9,000 alpha-blocker patients had a fracture versus 3,351 matched patients on other antihypertensives; “9,000 patients out of 70,000 is a huge number. These drugs are useful in some situations, but be careful,” Dr. Hiremath said.
“This is observational data, but it’s consistent with ALLHAT, and the outcomes are even worse. We didn’t in [subsequent] guidelines say that you should [never] use an alpha-blocker in hypertension. Maybe we should have,” said ALLHAT investigator William Cushman, MD, a professor of medicine and physiology at the University of Tennessee, Memphis.
There was no industry funding for the work, and the investigators reported having no financial disclosures. Dr. Cushman wasn’t involved in the work.
SOURCE: Hiremath S et al. Joint Hypertension 2018, Abstract P375.
CHICAGO – The risk of cardiovascular and hypotension-related events is higher with alpha-blockers than with other hypertension drugs, but almost 20 years after the pivotal ALLHAT trial first raised safety concerns, they are still widely used, according to investigators from the University of Ottawa.
ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) linked the alpha-blocker doxazosin (Cardura) to an increased risk of heart failure and stroke, which led to the early cessation of the doxazosin arm. Guidelines no longer include alpha-blockers among the primary options for hypertension (JAMA. 2000;283[15]:1967-75).
However, there’s been some doubt about ALLHAT; doxazosin patients had diuretics withdrawn as part of the study, which might have contributed to the increased risks. “A lot of arguments have been made that perhaps alpha-blockers aren’t that bad and maybe should still be used, so we took a second look,” said lead investigator and nephrologist Swapnil Hiremath, MD, an assistant professor of medicine at the University of Ottawa.
What he and his team found “confirmed and expanded on the findings of ALLHAT.” Apart from a few specific situations, “don’t prescribe alpha-blockers. If a patient is on an alpha-blocker, consider prescribing an alternative,” Dr. Hiremath said at the joint scientific sessions of the American Heart Association Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The drugs are still widely used, according to the team’s review of Ontario health data. From 1995 to 2015, nearly 81,000 patients were prescribed alpha-blockers for hypertension, sometimes as monotherapy, with no real downward trend in prescriptions over time.
There are some selected indications for alpha-blockers, including intolerance of other antihypertensives, pheochromocytoma management, and resistant hypertension. “So I thought maybe there would be 5,000 or 10,000. The fact that we found almost 81,000 was an eye-opener. I’m pretty sure 81,000 patients in Ontario don’t have resistant hypertension,” Dr. Hiremath said.
Patients with benign prostatic hypertrophy, another indication, were excluded from the study.
Before ALLHAT, alpha-blockers were considered first-line drugs, so maybe prescribers are just “sticking with something they know and are familiar with,” he said.
To assess the risks of continued use, the investigators used propensity scoring to match 69,092 patients prescribed alpha-blockers to 69,092 who were prescribed other antihypertensives, based on age, comorbidities, date of treatment, and a slew of other potential confounders. Patients were considered to be on an alpha-blocker only when they were filling prescriptions for the drugs. If they were not filling prescriptions they flipped into the unexposed arm.
The incident rates of ED visits and hospitalizations for hypotension and related complications – syncope, falls, and fractures – were markedly higher among alpha-blocker users. After adjusting for the total number of antihypertensives patients were on, those on alpha-blockers were 34% more likely to go to the ED or be hospitalized for hypotension, 49% more likely for syncope, 27% more likely for falls, and 41% more likely for fractures. First-dose effects don’t explain the findings; patients were often on alpha-blockers for years beforehand.
Alpha-blocker patients were also 26% more likely to have a major cardiovascular event, including heart failure and MI. The risks were greatest in those older than age 85 years. The results were all statistically significant.
About 9,000 alpha-blocker patients had a fracture versus 3,351 matched patients on other antihypertensives; “9,000 patients out of 70,000 is a huge number. These drugs are useful in some situations, but be careful,” Dr. Hiremath said.
“This is observational data, but it’s consistent with ALLHAT, and the outcomes are even worse. We didn’t in [subsequent] guidelines say that you should [never] use an alpha-blocker in hypertension. Maybe we should have,” said ALLHAT investigator William Cushman, MD, a professor of medicine and physiology at the University of Tennessee, Memphis.
There was no industry funding for the work, and the investigators reported having no financial disclosures. Dr. Cushman wasn’t involved in the work.
SOURCE: Hiremath S et al. Joint Hypertension 2018, Abstract P375.
REPORTING FROM JOINT HYPERTENSION 2018
Key clinical point:
Major finding: Patients on alpha-blockers, versus other antihypertensives, were 26% more likely to have a major cardiovascular event, including heart failure and MI.
Study details: A propensity score matching study involving about 140,000 patients.
Disclosures: There was no industry funding for the work, and the investigators reported having no financial disclosures.
Source: Hiremath S et al. Joint Hypertension 2018, Abstract P375.