1、ISHIB 2007 Innovating Vascular Health: Practical Applications to Clinical Practice,Critical Challenges in Cardiovascular Disease,Program Chairwoman Shawna D. Nesbitt, MD, MS Associate Professor Department of Internal Medicine Division of Hypertension University of Southwestern Texas Medical School D
2、allas, TX,CME-accredited symposium jointly sponsored by the American Society of Hypertension and CMEducation Resources, LLC Commercial Support: Sponsored by an independent educational grant from Novartis Pharmaceuticals Mission statement: Improve patient care through evidence-based education, expert
3、 analysis, and case study-based management Processes: Strives for fair balance, clinical relevance, on-label indications for agents discussed, and emerging evidence and information from recent studies COI: Full faculty disclosures provided in syllabus and at the beginning of the program,Welcome and
4、Program Overview,Program Educational Objectives,As a result of this session, physicians will be able to:Identify the importance of early treatment of patients with high blood pressure, and the importance of treating both systolic and diastolic blood pressure abnormalities.Implement clinical strategi
5、es that help patients achieve blood pressure goals as quickly as possible, using combination therapy, when indicated.Identify prescribing strategies that reduce side effects and increase the likelihood of adherence to an antihypertensive drug regimen.Characterize and distinguish among safety profile
6、s of and efficacy characteristics of antihypertensive agents used in the African American population.,Program Educational Objectives,Recognize markers of target organ damage and learn which antihypertensive agents are useful for preventing end organ complications such as CV disease and diabetic rena
7、l disease.Manage hypertension as a systematic disease, with multiple manifestations, and associations, including metabolic syndrome and associated risk factors.Address complications linked to healthcare disparities observed in specific patient populations, and the importance of providing access, tre
8、atment, and monitoring of patients with multiple risk CV risk factors.Manage African American patients with features of the metabolic syndrome, and its implications for multiple risk factor management,Program Faculty,Program Chairwoman Shawna D. Nesbitt, MD, MS Associate Professor Department of Inte
9、rnal Medicine Division of Hypertension University of Southwestern Texas Medical School Dallas, TexasKen Jamerson, MD Professor of Medicine Cardiovascular Medicine University of Michigan Health System Ann Arbor, Michigan,Jackson T. Wright, Jr., MD, PhD, FACP Professor of Medicine Program Director, Ge
10、neral Clinical Research Center Case Western Reserve University Director, Clinical Hypertension Program University Hospitals of Cleveland Chief, Case Western Reserve University Hypertension Section(Louis Stokes VAMC) Cleveland, Ohio,Program Agenda,8:00 8:25 PM HypertensionA Systemic Disease Requiring
11、 Systematic Approaches to Therapy: Recent Clinical Practice Recommendations Focusing on Combination Therapy in Difficult-to-Treat Patient Populations with High Blood Pressure and Compelling ConditionsJackson T. Wright, Jr., MD, PhD, FACP 8:25 8:55 PM The Evolving Landscape of Antihypertensive Therap
12、y: Direct Renin Inhibition, Combination Therapy, and Implications for African American and Other Ethnic Populations Shawna D. Nesbitt, MD, MS8:55 PM Questions and Interactions with the Faculty,The Current Landscape of Cardiovascular Risk Management in African Americans Where Co-morbidity Matters The
13、 Evolving Relationship Between Risk Factors, Diabetes, Hypertension, And Vascular Complications,Shawna D. Nesbitt MD, MS Associate Professor of Internal Medicine University of Texas Southwestern Dallas, Texas,Introduction and Overview,Changing TrendsHispanics are the fastest-growing segment of the p
14、opulation, and now account for 13% U.S., as do African Americans.The U.S. Asian population currently consists of 10.6 million people, and represents 4% U.S.,; however, this population group is expected to triple in size by 2050.,The U.S. Population is Becoming Increasingly Diverse,Adapted from U.S.
15、Census Bureau, 2004. Table 1a. Accessed Dec. 1, 2006.,Southern U.S. Has the Highest Concentration of African-Americans,25.0 to 60.0 12.3 to 24.9 5.0 to 12.2 0.3 to 4.9,People indicating exactly one race, Black or African American, as a percent of total population by state,Adapted from U.S. Census Bu
16、reau, 2002 Redistricting Data (PL 94-171) Summary File,Estimated Rates of US Adults With Hypertension by Sex, Race, and Ethnicity NHANES 1988-1994 to 1999-2000,Fields et al. Hypertension. 2004;44:398-404. Hajjar and Kotchen. JAMA. 2003;290:199206,All,Mexican American,Non-Hispanic White,Hypertensive
17、Adults (Rate, Percent SE),45,30,20,15,0,10,25,40,5,1999-2000,1988-1994,F,M,F,M,35,Hypertension Treatment and Control Rates by Race/Ethnicity: NHANES 2000,Hajjar and Kotchen. JAMA. 2003;290:199206.,%,63,44.6,60.1,55.6,40.3,44,0,10,20,30,40,50,60,70,Treatment,Control,African Americans*,Whites*,Mexican
18、 Americans,*Non-Hispanic.,Mortality From High Blood Pressure Higher in African Americans,Overall Mortality Rates From Causes Related to Hypertension, 2003*,*High blood pressure listed as a primary or contributing cause of death. High blood pressure=systolic 140 mmHg or diastolic 90 mmHg, taking anti
19、hypertensive medicine, being told 2 times by a physician that you have high blood pressure.,Mortality Rate, %,African American,Female,Male,Female,20,10,30,40,50,49.7,14.9,40.8,14.5,0,60,Male,White,In hypertensive African Americans, 30% and 20% of all deaths in men and women, respectively, may be due
20、 to high blood pressure.,Adapted from Thom T et al. Circulation. 2006;113:e85e151.,*Includes those 17 years of age with diagnosed and undiagnosed hypertension. National Center for Health Statistics. NHANES 1999-2000 (CD-ROM); NHANES III.,% Not at Goal BP Systolic Diastolic Patient Type (mm Hg) BP BP
21、,Total hypertensives 140/90 57% 26% African American 140/90 60% 32% Mexican American/ Hispanic 140/90 63% 30% Older patients (60 years) 140/90 71% 9% Symptomatic CHD 140/90 47% 4% Patients with diabetes 130/85 81% 24%,NHANES (1999-2000),Patients Not at JNC VI BP Goals,Risk-Factor Clustering by Race
22、and Sex,Stone et al JAMA. 1996;275:1104-1112.,Percentage,Obesity (BMI 30 kg/m2),Population (%),30,25,2000,2001,2002,2003,*JanJune,20,15,0,2004*,8,6,4,2,0,2000,2001,2002,2003,2004*,Diagnosed diabetes,CDC. 2004 NHIS; www.cdc.gov/nchs/nhis.htm.,21.8,23.0,23.9,23.7,24.3,5.9,6.4,6.5,6.6,6.6,Obesity and D
23、iabetes Among US Adults: Growing prevalence,+11.9%,+11.5%,American Indians/ Alaska Natives,Age-Adjusted Prevalence of Diabetes* by Race/Ethnicity in the US,Percent,Hispanic/Latino Americans,Non-Hispanic Blacks,Non-Hispanic Whites,*In people 20+ years old,CDC. National Diabetes Fact Sheet. 2002.,Sour
24、ces: 1997-1999 National Health Interview Survey and 1988-1994 National Health and Nutrition Examination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the Indian Health Service,19%,15%,14%,7%,Estimated Percentage of Americans Age 18 and Older Who Report No Leisure-Time
25、 Physical Activity by Race and Sex,Source: Physical Activity and Health: A Report of the Surgeon General, United States Department of HHS,The Rising Tide of ESRD,USRDS. Annual data report. 2000.,1984,1986,1988,1990,1992,1994,1996,1998,2000,2002,2004,2006,2008,2010,0,100,200,300,400,500,600,700,R2 =
26、99.8%,326,217,372,407,661,330,No. of ESRD Patients (x 1000),Year,Years of Potential Life Lost to Total Heart Disease Before Age 75 by Race and Gender,Clark et al Heart Dis. 2001;3:97-108; National Vital Statistics System, Health, United States, 199697.,1980,1985,1990,1995,0,1000,2000,3000,4000,1980,
27、1985,1990,1995,Years,White women,African-American women,White men,African-American men,Failure to Reach Treatment Goals Carries Costly Burden,Paramore LC et al. Am J Manag Care. 2001;7:389-398.,N = 1000 managed-care patients with treated hypertension,Greater medication costs,More physician visits,9.
28、7,4.1,0,4,8,12,120 mm Hg,180 mm Hg,Mean visits per year,Severity of hypertension (mm Hg),0,200,400,600,130/85,140/90 159/99,160/100,130/85 139/89,Mean drug cost per patient per year* ($ US),Controlled,Uncontrolled,*Based on 1999 average wholesale price,Maximum SBP,Kenneth A. Jamerson, M.D. Professor
29、 of Cardiovascular Medicine University of Michigan Medical Director, Program for Multi-cultural Health Ann Arbor, Michigan,Are We in Control?The Importance of Early Risk Identification and Treatment,Getting To Goal and Staying There in Ethnic Minority Populations,Challenges and Solutions in Minority
30、 Populations,The Tecumseh Blood Pressure Study,A prospective epidemiological study of the antecedents of hypertension and cardiovascular disease in 1,100 young men and women,Ann Arbor,Tecumseh,Cholesterol,Triglycerides,N=124 (aged 18-28 years) Adapted from Julius et al. JAMA 1990;264:354-358,P0.001
31、P0.01 P0.05,Tecumseh BP Study: Association of DBP and Other CHD Risk Factors,S. Julius, et al: JAMA 264:354-358, 1990,Blood Pressure Trends in Tecumseh, Michigan,Hypertensive Normotensive,*,*,*,*,*,*,P .01,*,P.001,*,Is There a Unique Etiology for Hypertension in African Americans?,Causes and Causes
32、for Concern,The Association of Skin Color with Blood pressure in US blacks with Low Socioeconomic Status Klag, M J. Whelton, P K. Coresh, J. Grim, C E. Kuller, L H.JAMA. 1991 Feb 6;265(5):639-40; AbstractTo determine the association of skin color, measured by a reflectometer, with blood pressure in
33、US blacks, we studied a community sample of 457 blacks from three US cities. Persons taking antihypertensive medications were excluded. Both systolic and diastolic blood pressure were higher in darker persons and increased by 2 mm Hg for every 1-SD increase in skin darkness. However, the association
34、 was dependent on socioeconomic status, whether measured by education or an index consisting of education, occupation, and ethnicity, being present only in person with lower levels of either indicator. Using multiple linear regression, both systolic and diastolic blood pressure remained significantl
35、y associated with darker skin color in the lower levels of socioeconomic status, independent of age, body mass index, and concentrations of blood glucose, serum urea nitrogen, serum uric acid, and urinary sodium and potassium. The association of skin color with blood pressure only in low socioeconom
36、ic strata may be due to the lesser ability of such groups to deal with the psychosocial stress associated with darker skin color. However, these findings also are consistent with an interaction between an environmental factor associated with low socioeconomic status and a susceptible gene that has a
37、 higher prevalence in persons with darker skin color.,Deciphering The Etiology and Associations,Do African Americans respond to antihypertensive therapy differently than other races or ethnic groups?,Response to Therapy A Critical Issue for Drug Selection and Care,African American, %,White, %,Blood
38、Pressure Response to Quinapril: The ATIME Study,Mokwe E et al. Hypertension. 2004;43(6):12027.,SBP (average change),20.0,Mean 10.5 SD 13.4 Lower Quartile 2.2 Upper Quartile 20.0 Interquartile Range 17.8,39,27,15,3,9,21,33,45,57,15.0,10.0,5.0,0,Mean 15.3 SD 12.2 Lower Quartile 7.3 Upper Quartile 23.5
39、 Interquartile Range 16.2,20.0,15.0,10.0,5.0,0,SD = standard deviation.,Is It Important To Block The RAS In African Americans?,HOPE PROGRESS SOLVD ValHeft V-Heft LIFE OCTAVE ALLHAT,Landmark Trials That Give Us Data, Guidance, and Perspective,African American Study of Kidney Disease and Hypertension,
40、Landmark and Longitudinal Studies,Achieved Blood Pressure in AASK,Cumulative Incidence of Confirmed Declining GFR Event, Dialysis or Death by Drug Group (Data as of 10/19/01),p-value A vs B C vs B* A vs C* adjusted .042 .19 .005,Cumulative Incidence,.,Implications Of The AASK Study,Aggressive contro
41、l of blood pressure can eliminate ethnic differences in ESRDInadequate treatment of hypertension may cause excess risk of target organ diseaseCultural, rather than genetic differences, may underlay the excess risk of hypertensive ESRD,International Society of Hypertension in Blacks,IMPACT Campaign,S
42、cience Guidelines Behavioral Change,Vascular Matrix Summit,Dr. Gary Gibbons Dr. Abraham Aviv Rick Kittles, MD Charles Rotimi, MD David Harrison, MD Willa Hsueh, MD Helmy Siragy, MD Douglas Vaughan, MD Dr. Brent Egan Ken Jamerson, MD,The Problem,Does Being African American Modify the Problem?,Models
43、to Explain Health Disparities,Racial Genetic ModelCause of HD: Population differences in the distribution of genetic variants Health-behavior ModelCause of HD: Differences between R/E groups in the distribution of individual behaviors related to health such as diet, exercise, and tobacco use SES Mod
44、elCause of HD: Over-representation of some R/E groups within lower SES Psychosocial Stress ModelCause of HD: Stresses associated with minority group status, especially the experience of racism and discrimination,Race (Social),Ancestry (Genetic),Disease,Critical Relationships,Although much genetic va
45、riation (85-90%) is shared among all human populations, about 5% of SNPs have high levels of allele frequency differential (d50%). We call these markers Ancestry Informative Markers (AIMs).,Ancestry Informative Markers (AIMs),Ancestry Can Be Estimated Across Chromosomal Regions,Seldin et al. Genome
46、Res. 14:1076 -1084, 2004,Smith et al. AJHG 74:1001-1013, 2004,European Genetic Contribution in African-American Populations Living in Different Areas of the U.S.,Parra et al. AJHG 1998; Parra et al. AJPA 2002; Kittles et al. unpublished,Group definition and membership.Can we accurately assess genomi
47、c ancestry?How does genomic ancestry relate to skin color and possibly SES?How useful is genomic ancestry for informing us about disease risk? Health Disparities: are they due to biological differences?How do we prevent repeating the negative past abuses of “race”.,Era of Genomic Ancestry and Challe
48、nges Related to Health,RESULTS BP Control at 18 Months,Accomplishing Something,ACCOMPLISH: Hypothesis,ACCOMPLISH will test a new strategy for the treatment of hypertension: Dual therapy provided in a single tablet. The combination of benazepril and amlodipine will reduce cardiovascular morbidity and mortality in patients with high-risk hypertension by 15% when compared to the combination of benazepril and HCTZ.,Jamerson KA et al. Am J Hypertens. 2004;17:793801.,ACCOMPLISH: Primary Endpoint,
