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Prevention, Treatment, Control and Sodium Reduction Policy

Prevention, Treatment, Control and Sodium Reduction Policy . Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead Division for Heart Disease and Stroke Prevention . U.S. Department of Health and Human Services Centers for Disease Control and Prevention.

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Prevention, Treatment, Control and Sodium Reduction Policy

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  1. Prevention, Treatment, Control and Sodium Reduction Policy Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead Division for Heart Disease and Stroke Prevention U.S. Department of Health and Human Services Centers for Disease Control and Prevention

  2. Overview of this Module • Hypertension and the impact on population health • Assessment of hypertension • Challenges in hypertension control • JNC-VII treatment guidelines • System-based initiatives to improve control • Hypertension and sodium connection • Community and population based changes to promote prevention

  3. Prevention 4% Medical Services 96% Health Behaviors 50% Environment 20% Genetics 20% Access to Care 10% Discrepancy Between Health Determinants and Spending of $1.7 Trillion, 2007 Factors Influencing Health National Health Expenditures Source: Prevention Institute. 2007. Reducing Healthcare Costs Through Prevention. Available at http://www.preventioninstitute.org/documents/HE_HealthCareReformPolicyDraft_091507.pdf

  4. Epidemiology

  5. Hypertension Mortality Rates http://apps.nccd.cdc.gov/DHDSPAtlas/reports.aspx

  6. The Magnitude of the Problem • Hypertension is the single largest risk factor for cardiovascular disease mortality, accounting for 45% of all CVD deaths1 • INTERSTROKE Study concluded that hypertension provides 34.6% of the population-attributable risk (PAR) for stroke2, while INTERHEART found it provides 17.9% of the PAR for myocardial infarction3 • The PAR is the reduction in incidence that would be observed if the population were entirely unexposed (did not have hypertension). 1. IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. 2. O’Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case–control study. The Lancet 2010; 376:112–23 3. Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, Alvaro Avezum, Fernando Lanas, Matthew McQueen, Andrzej Budaj, Prem Pais, John Varigos, Liu Lisheng, on behalf of the INTERHEART Study Investigators, Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study, The Lancet, 2004: 9438, 11–17.

  7. Comprehensive Approach to Hypertension Control • Focused clinical interventions for those at high risk • Lifestyle advice • Population-based strategies

  8. Stages of CVD Intervention • Primordial – Before risk factors develop • Primary – Treatment of risk factors • Secondary – After a CVD event occurs

  9. Primordial Prevention – Preventing Risk Factors from Developing • In 1978, Strasser introduced the concept of primordial prevention. Once a risk factor has developed, it can be difficult to reduce the risk it contributes to overall health • “Medications and lifestyle interventions cannot reduce CVD event rates to levels seen in those who maintain optimal risk factor profiles (ideal cardiovascular health) into middle and older ages.” Lloyd-Jones DM. Improving the cardiovascular health of the US population. JAMA. 12 ;1314 -1316 .

  10. Population Strategy WHO, Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk., 2007

  11. Major Shifts in Population Risks and Expanded Treatment, U.S. Change in numbers of deaths + • Risk Factors worse: +17% • Obesity (increase) +7% • Diabetes (increase) +10% • Risk Factors better: -65% • Population BP fall -20% • Smoking -12% • Cholesterol (diet) -24% • Physical activity -5% • Treatments: -47% • AMI treatments -10% • Secondary prevention -11% • Heart failure -9% • Angina: CABG & PTCA -5% • Hypertension therapies -7% • Statins (primary prevention) -5% 0 341,745 fewer deaths in 2000 - 1980 2000 Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. NEJM 2007; 356: 2388.

  12. What Can You Do to Make a Difference? • Approximately 68 million U.S. adults (1 in 3) have hypertension • Only 46% of adults with hypertension had adequately controlled blood pressure. The Million Hearts™ initiative has set a goal of 65% control by 2017 overall, and 70% in the clinical setting Valderrama A, et al. Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors. MMWR. 2011;60(36);1248-1251.

  13. Patient Level Strategy • A 10mmHg lower systolic blood pressure (SBP) – or 5mmHg lower diastolic blood pressure (DBP) – is associated with an approximately 20–25% lower risk of coronary heart disease (CHD) and an approximately 40% lower risk of stroke Stamler J, Stamler R, Neaton JD, Blood pressure, systolic and diastolic, and cardiovascular risks. US population data, Arch Intern Med, 1993;153:598–615. Asia Pacific Cohort Studies Collaboration, Blood pressure and cardiovascular disease in the Asia Pacific region, J Hypertens, 2003;21:707–16. MacMahon S, Peto R, Cutler J, et al., Blood pressure, stroke and coronary heart disease. Part I, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias, Lancet, 1990;335:765–74. http://www.touchbriefings.com/pdf/2988/giampaoli.pdf

  14. JNC VII Treatment Guidelines

  15. Assessment • Assess for major cardiovascular risk factors • Assess for identifiable causes of hypertension • Sleep apnea • Drug induced/related • Chronic kidney disease • Primary aldosteronism • Renovascular disease • Cushing’s syndrome or steroid therapy • Pheochromocytoma • Coarctation of aorta • Thyroid/parathyroid disease Greenland P. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: Executive Summary. JACC. Vol. 56, No. 25, 2010.

  16. Lifestyle interventions • JNC VII recommends therapeutic lifestyle change only for most people with pre-hypertension • Weight reduction • DASH diet • Dietary sodium reduction • Physical Activity • Moderate alcohol consumption http://www.nhlbi.nih.gov/guidelines/hypertension/

  17. JNC VII Medication Recommendations* • Pre-hypertension • Lifestyle interventions • Stage 1 Hypertension • (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination • Stage 2 Hypertension • (SBP ≥160 or DBP ≥100 mmHg) 2-drug combination for most (usually thiazide-type diuretic* and ACEI, or ARB, or BB, or CCB) ACEI = ace inhibitors ARB = angiotensin receptor blockers BB = beta blockers CCB = calcium channel blockers *JNC-VII includes chlorthalidone among thiazide-type diuretics.

  18. Medication Adherence • Clinician empathy increases patient trust and motivation • Physicians should consider their patients’ cultural beliefs and individual attitudes in formulating therapy • Team-based care (pharmacy medication therapy management, physician assistants, nurse practitioners, etc.) • Consider the Morisky Medication Adherence questionnaire for your hypertensive patients

  19. Challenges in Hypertension Control

  20. Special Populations • Minorities • Blacks have an increased rate of conversion from pre-hypertension to hypertension • Median age-adjusted conversion time when 50% of patients converted from pre-hypertension to hypertension was ≈2.7 years in whites and ≈1.7 years in blacks • Over age 80 • Significant benefits from treatment • May be more sensitive to medication side effects or drug interactions due to an increased number of medications taken Selassie A, et al. Progression is accelerated from prehypertension to hypertension in blacks. Hypertension. 2011; 58:579-587.

  21. Resistant Hypertension • Hypertension not controlled using a combination of 3 antihypertensive drug classes, including a diuretic • Non-compliance/adherence with medication • Fluid imbalance – renal failure • Hormonal imbalance

  22. Incidence of Resistant Hypertension • Study from Colorado Kaiser Permanente, found that 1.9% of patients (1 in every 50 patients) with incident hypertension who were begun on treatment developed resistant hypertension within a median of 1.5 years from initial treatment • They found 16% of patients on 3 or more drugs continued to have resistant hypertension Daugherty SL, et al. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation. February 29, 2012. Epub ahead of print]

  23. What Happens if Hypertension isn’t Controlled? • Left ventricular hypertrophy (LVH) • Heart failure • Chronic kidney failure • Stroke (cerebral hemorrhage) • Vascular dementia • Retinopathy

  24. Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor Intervention Trial* White Men (n = 300,645) Black Men (n = 20,222) 83.1 Incidence of ESRD per 100,000 Person-Years 37.2 32.4 27.3 26.2 15.8 14.2 9.1 5.4 5.4 <117 117-123 124-130 131-140 >140 Systolic Blood Pressure (mm Hg) *The original cohort of 332,544 men included 11,677 men in other ethnic groups whose data are excluded from this comparison. ESRD = end-stage renal disease Klag MJ, et al. End-stage renal disease in African-American and white men. 16-year MRFIT findings. JAMA. 1997;277:1293-1298.

  25. Effects of Systolic and Diastolic BloodPressures on CHD Mortality: MRFIT* 48.3 CHD Death Rate Per 10,000 Person-Years 80.6 37.4 34.7 43.8 31.0 38.1 25.5 23.8 24.6 25.3 16.9 25.2 20.6 13.9 24.9 12.8 10.3 160+ 11.8 12.6 8.8 11.8 100+ 140-159 8.5 90-99 9.2 Diastolic Blood Pressure(mm Hg) 80-89 120-139 75-79 Systolic Blood Pressure(mm Hg) 70-74 <120 <70 *Data shown only for 316,099 white men 35 to 57 years of age who were followed for a mean of 12 years. CHD = coronary heart disease MRFIT = Multiple Risk Factor Intervention Trial Neaton JD, et al. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152:56-64.

  26. Risk of Stroke Death According to Blood Pressure (mm Hg): MRFIT † Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) Relative Risk of Stroke Death † † † † * * * * * 10 1 2 3 4 5 6 7 8 9 Decile (Highest 10%) (Lowest 10%) ≥151≥98 14292 <112<71 11271 11876 12179 12581 12984 13286 13789 SBP DBP MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001. Stamler J, et al. Arch Intern Med. 1993;153:598-615; He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.

  27. System-based Initiatives to Improve Control

  28. Meaningful Use and Pay-for-Performance • PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure • Percentage of patients aged 18 and older who are screened for high blood pressure. • PQRS Measure #236 (NQF 0018): Hypertension: Controlling High Blood Pressure • Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/<90) during the measurement year.

  29. Team-based care – the Role of the Pharmacist • The Asheville Project is a community-based, pharmacist-directed, medication therapy management (MTM) program provided for several employers in the Asheville, NC area • Patients with hypertension receiving education and long-term medication therapy management services achieved significant clinical improvements that were sustained for as long as 6 years • ↓cardiovascular events • ↑ adherence to medications Bunting BA, et al. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:23–31.

  30. Quality Improvement and Clinical Decision Support • A proven concept that improves care! • Alerts • Reminders • Reports • Templates for management • Built-in access to guidelines • Enhances implementation of quality improvement initiatives

  31. Clinical-Community Reporting Efforts • RWJF Aligning Forces for Quality • Public reporting – Wisconsin Collaborative for Healthcare Quality http://www.wchq.org/reporting/results.php?category_id=0&topic_id=17&source_id=0&providerType=0&region=0&measure_id=78

  32. The Connection Hypertension and Sodium

  33. The Effect of Sodium Intake on Blood Pressure • Sodium intake is one of several dietary factors that increases blood pressure • Sodium is the principal cation of the extracellular fluid and functions as the osmotic determinant in regulating extracellular fluid volume and plasma volume • Sodium is stored in the blood and in the fluid surrounding the cells; kidneys control the body sodium concentration by clearing excess sodium through urine

  34. The Effect of Sodium Intake on Blood Pressure • Sodium affects blood pressure by changing blood volume • Absorbed sodium remains in the extracellular compartments, including • plasma (at [140 mmol/L]; interstitial fluid [145 mmol/L]; plasma water [150 mmol/L]; muscle tissue [3 mmol/L]) • These levels maintain blood pressure in the normal range • Increased sodium intake =increased blood volume = higher blood pressure • Sodium reduction = decreased blood volume = lower blood pressure Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: National Academies Press; 2004.

  35. Excess Sodium Intake Leads to Hypertension • Sodium, through hypertension, is a major contributor to death, disability, disparities, and costs attributable to cardiovascular diseases (CVD) • Economic burden • Treatment for heart disease, stroke, and other CVD accounts for 1 in 6 U.S. health dollars spent($273 billion in 2008) • Globally, 8.5 million deaths could be averted over 10 years from 2006 to 2015 through a 15% reduction in sodium intake Vital Signs: MMWR 2011; 60(4):1-3–8 Heidenreich PA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123;933–944. Asaria P, et al. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044–53.

  36. Sodium Reduction Benefits All Ranges of Blood Pressure • Evidence supports a strong, direct relationship between blood pressure and vascular mortality • No evidence of a blood pressure threshold—vascular mortality increases throughout the range of blood pressures in both nonhypertensive and hypertensive individuals • Average blood pressure was reduced by 22.7/9.1 mm Hg in patients with resistant hypertension when switched from a high to low sodium diet • In most individuals blood pressure is reduced within days to weeks of reducing sodium intake Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: National Academies Press; 2004. Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia J, Calhoun DA. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension. 2009; 54: 475 - 481

  37. DASH and DASH Sodium Trials • Dietary Approaches to Stop Hypertension (DASH) Trial • Compared the effects of three diets – typical American diet, fruits and vegetable diet, and a diet rich in fruits and vegetables and low fat dairy, and reduced in saturated fat, total fat, and cholesterol • All diets provided ~ 3,000 mg sodium per day • Combination diet (DASH) produced the largest blood pressure reduction after 8 weeks – average ↓ of 5.5 / 3.0 mm Hg • Participants with hypertension experienced an average blood pressure ↓ of 11.4 / 5.5 mm Hg • DASH Sodium Trial • DASH diet and three levels of sodium intake – 1,150 mg, 2,300 mg, and 3,450 mg • DASH diet and a low level of sodium ↓ SBP by 7.1 mg Hg • Participants with HTN experienced a BP ↓ of 11.5 mm Hg Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-1124; Sacks et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. N Engl J Med 2001; 344:3-10

  38. Sodium Intake Levels: Recommended and Actual • Recommended levels of sodium intake • 2010 Dietary Guidelines for Americans • Reduce sodium to < 2300 mg/day • For specific populations: 1,500 mg/day • ≥51 years old • African Americans • Have high blood pressure, diabetes, or chronic kidney disease • About half the U.S. population and the majority of adults • Actual sodium intake • Average daily sodium intake for U.S. adults is >3,300 mg/day USDA and HHS. Dietary Guidelines for Americans, 2010. 7th edition. Washington, DC: Government Printing Office; 2010. Vital Signs: MMWR 2012; 61(Early Release);1-7

  39. Individual Sodium Reduction Has Population Benefits • Reducing the sodium content by 25% of the top 10 food category contributors to sodium intake could result in a 360 mg reduction in average sodium consumption in the United States • Reducing average population sodium consumption by 400 mg has been projected to avert up to 28,000 deaths from any cause and save $7 billion in health-care expenditures annually CDC, MMWR;2012;61:1-7. Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590–9.

  40. Reducing Sodium Intake Reduces Blood Pressure • Reducing average population sodium intake to 1,500 mg/day may • Reduce cases of hypertension by 16 million • Save $26 billion health care dollars • Gain 459,000 Quality Adjusted Life Years (QALYs) • Even reducing sodium intake to 2,300 mg/day could • Reduce cases of hypertension by 11 million • Save $18 billion health care dollars • Gain 312,000 QALYs Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Eng J Med 2001;344:3–10. Palar K, et al. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot 2009;24(1):49–57.

  41. Percent of US persons exceeding their 2010 Dietary Guidelines for Americans sodium intake recommendations* % Age Group *All people age 51 and older should reduce sodium intake to 1,500 mg/day. MMWR 2011;60:1413-1417

  42. Most of the sodium we eat comes from processed and restaurant foods Mattes RD, et al. Relative contributions of dietary sodium sources. J AM Coll Nutr 1991;10:383–393.

  43. 44% of US sodium intake comes from ten types of foods CDC, MMWR;2012;61:1-7.

  44. Other Guidelines and Recommendations • Institute of Medicine • Reduce the sodium content of the U.S. food supply • Health practitioners: commitment to incorporate guidelines on sodium intake into prevention messages and standards of care • Million Hearts™ • Reduce population sodium intake by 20% by January 1, 2017 • Healthy People 2020 • Reduce mean U.S. population sodium intake to 2,300 mg per day by 2020 • American Heart Association • Reduce population sodium intake to 1500 mg per day

  45. Other Guidelines and Recommendations • American Medical Association • Stepwise, minimum 50% reduction insodium in processed foods, fast-food products, and restaurantmeals over the next decade • Physiciansand other clinicians should educate patients about the benefitsof long-term, moderate reductions in sodium intake • Substantial public health benefits accrue from small reductionsin population blood pressure distribution, achievable withlong-term modest reduction in sodium intake • AMA supports the National Salt Reduction Initiative • Aim is to lower U.S. population sodium intake by 20% over five years through sodium reduction in packaged, processed and restaurant foods by 25% over that time period Dickinson B, Havas S. Reducing the Population Burden of Cardiovascular Disease by Reducing Sodium Intake A Report of the Council on Science and Public Health. Arch Intern Med. 2007;167(14):1460-1468.

  46. Adults with Self-Reported Hypertension Who Received and Acted on Low-Salt Advice Age, years 50% Advice and behavioral change Behavioral Risk Factor Surveillance System, 19 states, 1 territory, and Washington, DC, 2007

  47. Role of the Provider AMA recommends that health care providers educate patients on how to reduce sodium intake However, nearly 70% of primary health care providers report advising their patients to remove the salt shaker from the table, and the majority reported advising patients to add less salt during cooking, even though these behaviors are unlikely to result in major sodium reduction Havas S, Dickinson BD, Wilson M. The urgent need to reduce sodium consumption. JAMA. 2007;298:1439-41. Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1):76-78. doi:10.1001/archinternmed.2011.620. Image adapted from CDC Vital Signs Fact Sheet, Where’s the Sodium

  48. Health Care Providers Who Agree with Importance of Sodium Reduction for their Patients Statement: “Most of my patients should reduce their sodium intake” Health care provider Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1):76-78. doi:10.1001/ archinternmed.2011.620.

  49. Role of the Provider • Patients may be able to lower the required dose of blood pressure medicines through reduced sodium intake • Patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction • Referral to a Registered Dietitian for Counseling • Education during BP screenings • Downloadable CDC resource: Reducing Sodium in Your Diet to Help Control Your Blood Pressure • Advise consumption of fresh fruits and vegetables, frozen fruits and vegetables without sauce, and no salt added canned vegetables • Advise limiting processed foods high in sodium

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