 Hi, good morning. I'm Dr. Stephanie Coulter of the Texas Heart Institute. I'm part of the Center for Women's Heart and Vascular Health, and I'm here today to speak to the Perfusion Conference 2021 about hypertension as a disease and as a risk factor. And we're going to go over some interesting data and blood pressure guideline changes. So as you know, heart disease is still the number one cause of death in the US and in the world. And stroke, which is really a similar etiology in its pathophysiology to artery disease in the heart, is the number five cause of death in the US. So if you add all of these things together, cardiovascular disease claims more alive than all forms of cancer combined. And there are currently about 86 million Americans living with some form of cardiovascular disease or the after effects of a stroke. Here's actually the breakdown of deaths attributable to cardiovascular disease in America. With coronary heart disease or obstructive artery disease, about half of it, stroke being about 16 percent, heart failure, which includes genetic cardiomyopathy, valvular cardiomyopathy, but most commonly coronary artery disease as a cause of ischemic heart failure. And then there's high blood pressure and diseases of the aorta and the periphery and then other causes. But still the major cause of death in the US for both men and women is column A, which is about 400,000 deaths per year for coronary artery disease in both women and in men. And in fact, you can see that in women, you know, we've overtaken the death rate by men for cardiac disease, which is interesting in that it's likely because women live longer. So they live longer to have the manifestations of coronary disease. Column B is actually all forms of cancer. And then there's diabetes accidents. And you can see that the lion's share of death in America is due to cardiac disease and secondary and second would be cancer. So breaking down cardiovascular disease, if we look at the rates of heart attacks per year, and we break it down by age, gender and ethnicity, as you grow older, your risk of cardiovascular disease really goes up, particularly in men after age 45. And in women, really, after menopause really around age 50, you can see that African Americans compared to whites have a much greater toll of death due to myocardial infarction and fatal coronary disease. With African American males greater than white males, but African American females have a greater risk than white males, which is really a staggering statistic. The prevalence of stroke by age and gender is shown in the following graph, which shows that really strokes are really increased in the elderly and are more common actually in men than in women. But you can see that the burden really grows as we age. And here is stroke death rate by age, sex and race. And you can see that the rate of death due to stroke in black Americans is double the risk of white Americans, Hispanics, and Native Americans as well. The causes of death in women really parallel what we find in the common group, but since we're a Center for Women's Health, we try to show the summary statistics that support the cause of death in women. And you can see, again, that cardiovascular disease is about 53% of the death rate. And women, cancer is about 25%. So it's really kind of small. But most importantly, breast cancer, which has gotten a lot of publicity in the last 15 to 20 years, because of great campaigns to improve women's outcome, have really highlighted the preventable effects of breast cancer. And that breast cancer deaths in American women is really only about 4% of all American women's deaths. So of note, hospital costs are increasing. You can see I love this slide that medications really are reasonably kind of flat ish, physician reimbursement, nursing home costs, home health are all flat, but the curve for the hospital continues to rise. So there's going to be increasing pressure on hospitals and on the budgets of hospitals to moderate the rise in the cost of care. Heart disease death rates, however, this is super optimistic slide to show how well we have done in the last 20 years to reduce the risk of dying from heart cardiovascular disease. So you can see that in blue men and in red women, starting from when the statistics were originally initiated, that male deaths were, you know, above almost 500,000 deaths per year. And women were getting up there as well. And they started to fall, men's rates of death started to fall in the mid 80s with the advent of some campaigns targeting males, including some major studies at this time, which showed that aspirin therapy and beta blocker therapy actually moderated the risk of dying. And big trials for acute treatment of acute MI including angioplasty, the invention of the statins and better blood pressure medications really went into effect during the late half of the 20th, the late quarter of the 20th century. And you can see that since 2000 rates of death in both males and females have actually just fallen dramatically. Overall, there's been about a 50% reduction in the risk of dying of a cardiovascular disease in both males and females. And those rates had continued to decline until the most recent summary statistics, which showed that there had been an uptick in the risk of dying in both men and in women, which is kind of concerning. The reason for these reductions is twofold. One is that we're much better at prevention. So half the benefit here is accredited to prevention, which is what we do in the office. We treat people with aspirin, blood pressure control, cholesterol, drugs. We're good with diabetes medications these days, as well as aspirin and plavix for people that have been determined to have established vascular disease. There's been a lot of emphasis on advertising campaigns, particularly for women. The Go Red campaign of Laura Bush has been shown to have benefited the benefits in women. So where is heart disease and stroke? I mean, where in the country is it? Now, this is important to me because A, I'm from Louisiana and B, I live in Texas. And if you can see these graphs for cardiovascular disease on top, those that are shaded in dark are ground zero for death rates due to vascular disease. If you look at coronary disease deaths, it's a little bit north of Louisiana. And if you look at stroke rate deaths, you know, we're looking at the deep south. So we're looking at some genetic risk, behavioral risks, and possibly even access to quality medical plans, given the impoverished nature of some of these states. If you look at the age-adjusted risk for stroke and heart disease here, blue is bad and orange or red is good. And deep blue is deep south. Texas is purple on the left, which is kind of an intermediate risk group. But certainly we want to be red in this, in this map. Unfortunately, we're green in stroke risk. So we're at a great risk. Remember that hypertension is a disease and it's a risk factor for artery disease. It's also a risk factor for kidney artery disease. It's also a risk factor for stroke. So hypertension causes coronary disease. It leads to cardiomyopathy, especially hypertensive cardiomyopathy, which is much more common in the black population. It can lead to heart failure. It can cause heart rhythm disturbances. In fact, the main cause for AFib is hypertension. It can lead to stroke, peripheral artery disease, et cetera. So remember that hypertension is a vascular disease and it is thought to be due to the tension in the blood vessel. But this tension in the blood vessel allows for plaque to develop and that plaque causes strokes, heart attacks, peripheral artery disease, and aneurysms. A landmark trial called the Sprint Study, we're going to go over a little bit because it's super important and it's changed our guidelines for how we take care of and how we manage hypertension in the outpatient setting. This was a landmark study and we had Dr. Welton as a visiting professor for a symposium that we host every year and a very important study. It was basically developed as the first strategy trial for blood pressure control. So in the past we had really no threshold for when blood pressure control should be targeted. We had a lot of trials looking at beta blockers or ACE inhibitors or calcium channel blockers were better, but really what we never had was a strategy trial which would be who needs treatment and to what goal. And that was the purpose of the Sprint trial. So we know that in observational studies that there's a strong association between blood pressure and death due to cardiovascular disease and that high blood pressure is extremely common and that it's the number one risk factor for mortality and disability and age-adjusted life years. Worldwide there's about a billion people that are adults that have hypertension and clinical trials have demonstrated antihypertensive therapy reduces the risk of heart disease. The optimal target for blood pressure and lowing had never been established. So the research question really was should we target a better blood pressure goal, a lower goal, where the systolic average blood pressure target in this trial was 120 versus standard treatment, which was a blood pressure of 140. The major inclusion criteria for the Sprint study included age over 50, a systolic blood pressure treated or untreated of 130 to 180, and you had to have at least one additional cardiovascular risk modifiers. Either you had to have clinical or subclinical coronary disease, but not stroke. You could have chronic kidney disease, but you had to have a GFR greater than 20 or a Framingham risk score over 15%, which is really quite high and or age over 75. The exclusion criteria were stroke, diabetes, polycystic kidney disease, heart failure, symptoms or an EF less than 35, over a gram of protein area, chronic kidney disease with a GFR less than 20, or in a patient that you didn't think could comply with the trial. So the enrollment and follow-up experiences as follows where there are about 14,600 patients who were screened, there are about 9,361 randomized, half and half to intensive treatment or standard treatment, and in the end with this continuation lost a follow-up and so there were 4,678 and 4,683 analyzed with an intention to treat. Here the baseline characteristics, the mean age was about 68, about 28% of patients were over 75, about a third were female, about 29, 30% were African American, about 10% were Hispanic, 20% had prior vascular disease. The 10-year mean Framingham cardiac risk score was 20, which is a really, really risky population. So the study inclusion criteria got what the study designers was looking for. They got people that were at grave risk of heart disease. About 90% of the people were already on medications. The average number of meds was 1.8. Blood pressure on average was actually really pretty well controlled in this trial. In fact by many standards for doctors the average blood pressure of 140 over 80 was like pretty good. Prespecified groups were looked at for special interests, age of course, gender, race, renal dysfunction, vascular disease and blood pressure levels. So the primary outcome was a composite of a first occurrence of myocardial infarction, acute coronary syndrome, stroke, heart failure, cardiac death. The primary hypothesis was that cardiovascular composite event rates would be lower in the intensive compared to the standard treatment and the estimated power to detect was thought to be well within the means of the power for this trial design and with four to six years of follow-up. So what did we do for the blood pressure? We monitored the blood pressure monthly for three months and every three months thereafter medicines were titrated and decisions based on the mean blood pressure. They get blood pressure readings at each visit using a structured step care approach and any drug from the classes were available and free of charge to the investigators to give to the patients and periodic assessments of orthostatic hypotension and related symptoms were checked at follow-up. Here's the algorithm for your review but basically they achieved what their goals were at one year that well actually by several months the standard treatment group was 140 you know 130 to 140 but the intensively treated group had intensively managed blood pressure with average systolic blood pressure of 120 okay so they achieved their results and you can see the curve separated quite early and stayed stable through over four years. On August the 20th of 2015 the DSMB stopped the study because there was too much benefit in the group that was treated with the intensive treatment at a median follow-up of three point two years and the secondary non-cardiovascular outcomes so this trial ran a design where there were three separate studies there was sprint hypertension sprint mine looking at cognitive impairment and sprint renal where they were looking at renal inter renal outcomes and these studies were reported separately so the sprint primary outcome was cardiac and you can see that there were 319 events in the standard treatment versus 243 in the intensively treated group with a number needed to treat to prevent to prevent a primary outcome of 61. So you can see the primary events and the p-values at the far right that the composite outcome was largely driven by heart failure and cardiovascular death so really a big impact on the rate of heart failure and death and almost the statistical getting toward MI as well all-cause mortality you can see is reduced and serious adverse events is seen here in this trial in this slide that showed there was more renal injury 4.1 percent versus 2.5 percent in the intensively treated group compared to the standard which was obviously statistically significant there was abnormalities of the electrolytes more commonly in the intensively treated group as well as syncope and hypotension the sodium you can see orthostatic hypotension was actually quite uncommon to be associated with dizziness but was found to be about 16 percent of the population when they checked it in the office so and finally participants in the US with hypertension and additional cardiovascular risk when treated aggressively for blood pressure had reduction in cardiovascular events which is super important the treatment effects were similar and all six pre-specified groups of interest and the number needed to treat to prevent the primary outcome event with 61 and to prevent a death was 90 which is certainly part of what we should be doing and we've incorporated how we should incorporate this into our our normal routine for taking care of patients participants without kidney disease um had an incidence of a gfr reduction of about 30 percent more common in the intensively treated group but there were no significant serious adverse events between the two and no real differences in renal outcomes with in those that had ckd at baseline the sprint mine trial looked at cognitive um changes before and after treatment in the intensive versus the standard treatment group and this was super important showed that the risk of mild cognitive impairment and the risk of cognitive impairment and dementia was reduced by intensive blood pressure control which is super important so in fact um sprint mine um really helps us because it shows us there are only a few things that you can do to reduce the risk for dementia long term one is exercise two is um blood pressure control i mean really none of the medicines for Alzheimer's have really shown much benefit for cognitive decline so the jnci or the joint commission for um the treatment prevention and evaluation of high blood pressure jnc seven published in 2003 was updated in 2017 and these guidelines have been updated to say that health care providers should follow the following standards for accurate blood pressure measurement we should check the blood pressure on more than two readings on at least more than two occasions to estimate the individual blood pressure the out of office and self-monitoring of blood pressure are recommended to confirm the diagnosis of hypertension and for titration of blood pressure lowering and we've changed the categories so that normal blood pressure is less than systolic of 120 and diastolic less than 80 blood pressure over 120 or over 80 is abnormal now high blood pressure is considered when the blood pressure is over 130 or over 80 and that's stage one 130 to 139 or bottom number 80 to 90 and high blood pressure stage two is when it's over 140 or greater than 90 and hypertensive crisis is when the blood pressure is systolic greater than 180 or diastolic greater than 120 with associated symptoms and here it is in another way that you can assess it but it's important to remember that hypertension is super common in america so in fact that risk of a 40 year old developing hypertension in america is 93 percent in african americans it's 92 percent for hispanics it's 86 percent for whites it's 84 percent for asian chinese and it is the leading cause of death and disability adjusted life years worldwide and as a major contributor to events and women and blacks compared with whites in persons over 30 higher systolic and diastolic blood pressure are associated with adverse cardiac risk heart attack heart failure stroke artery disease and aneurysm so prevention and early intervention is the key there are things that you can and things that you cannot control you can control your blood pressure now medicines have improved dramatically blood pressure can be controlled with no real significant side effects we can move blood pressure meds around you need to check your blood pressure and monitor your blood pressure at home you need to use a good cuff and and you need a good relationship with your physician so that you can moderate your risk it's been shown actually recently in a trial of blood pressure control that in fact barbershops were better than doctors at controlling the blood pressure if given an algorithm to treat the blood pressure and i love this study because it shows that frequent monitoring and simple algorithmic algorithmic changes to blood pressure medications can be achieved out of the hospital out of the doctor's office by like not even medical professionals so as a medical profession we we we don't have a good excuses why we're not being able to get people's blood pressure under control we're not we're not educating the public better i think there's a lot we could do to improve it i spend a lot of time in my office and in health screenings explaining how to measure blood pressure and how to moderate it with exercise and salt restriction but certainly blood pressure is the top of the list of things that need to be controlled in order to prevent artery disease kidney failure stroke and death cholesterol levels can be controlled obesity levels there are new targets for obesity and new medicines that are coming out there's been a recent study looking at ozympic which is a specialized inhibitor of a protein in the kidney that makes you lose glucose into your urine but it also has a major effect on death due to heart failure a reduction in kidney disease and also improves your diabetes diet has worsened over the last 20 years in America with the average american eaten over six to 800 calories more than they did 20 years ago the obesity problem isn't just genetics because it changed within the last 20 years americans are putting on fat at record levels in the hospital you know if you didn't write down the bsa when you are um measuring on your intake you could just assume that the bsa is over two in most hospitalized patients and that includes women um certainly diet needs a major major modification in america but certainly we can control if we smoke we can control our physical activity we should be able to control our alcohol and drug use and we may or may not be able to control our stress our anxiety and depression particularly in this last year where so many things were out of our control all the things that are good for the body they tend to be good for all the systems in the body so exercise diet changes lack of smoking they benefit the entire body they reduce stress and anxiety they reduce your blood pressure they reduce your diabetes risk they reduce your cholesterol all in all all of this lifestyle choices accounts for about 60 of our life expectancy medications account for maybe 20 of our life expectancy and our genetic risk accounts for the other 20 the things that we cannot control include our genetics our family history our age it's sad and our race but certainly it's important that as healthcare um participants that we help our patients understand their risk we need to know what our risks are what the risks are to the patients there is a risk score tool that's been developed by some research groups in the country and it's been adopted by the american college of cardiology which is a risk estimate for 10-year risk for the development of hard events in cardiac disease it also gives a lifetime risk for cardiac disease but this risk score is calculated based on your age your sex your race your diastolic and systolic blood pressure your total your ldl and your non-hdl cholesterol whether or not you're diabetic whether or not you smoke and whether or not you're on hypertensive treatment a statin or aspirin and based on this risk calculated score it helps us to estimate who would benefit from treatment for the prevention of cardiac disease and you can see from this slide that pharmacologic treatment for blood pressure reduction is related to the ASCVD risk score and we recommend patients that have a high ASCVD risk score um those individuals who also have a diastolic blood pressure over 80 or a systolic blood pressure average over 130 either with or without clinical events should be treated for high blood pressure with the goal of a blood pressure of 120 over 80 it's important to remember that the prevalence of hypertension increases as every decade as we age so at a 80 80 percent of people have hypertension at 90 90 percent but men tend to have higher blood pressures than women and women start to catch up after the fifth decade after the onset of the menopause so in fact um most people in america will make threshold for the treatment of blood pressure blood pressure should be moderated by your lifestyle so in fact there's always a strong strong emphasis on exercise salt restriction healthy foods and vegetables because all of these things have a dramatic impact on the risk for cancer as well as cardiovascular events and also they improve your blood pressure control but outside of lifestyle if the blood pressure remains elevated certainly treatment of high blood pressure is has been successfully shown to reduce cardiovascular mortality heart failure deaths cognitive impairment as well as kidney disease in patients who have systolic blood pressure above 130 systolic or diastolic above 80 we've made tremendous gains in the last 20 years unfortunately for hospital administrators we're reducing the rates of bypass and coronary stenting but for all of our patients and for society in general we're making a dent in the deadliest disease in our in our existence at this time and every one of us is contributing to these beneficial effects i hope this lecture is well received and if there any comments or questions please reach out to me we're eager to respond here at texas heart institute and we're eager to make all of our colleagues as healthy as we can thank you