Editor's Note: Henry R. Black, MD, interviews John D. Bisognano, MD, PhD, professor of medicine at the University of Rochester Medical Center in New York, about resistant hypertension.
Dr Black: Hi. I'm Dr Henry Black. I'm an adjunct professor of medicine at New York University Langone Medical Center, and I'm here today with my friend and colleague, John Bisognano from Rochester, New York. John, welcome.
Dr Bisognano: Thank you, Henry. I'm Dr John Bisognano, and I'm professor of medicine at University of Rochester Medical Center and the president-elect of the American Society of Hypertension.
Dr Black: You're a bona fide cardiologist, something I'm not, and have a strong interest in hypertension. What in particular about hypertension makes you so interested? Is it resistant hypertension?
Dr Bisognano: I have a real interest in resistant hypertension, but hypertension really drives so much of cardiovascular disease, whether it is heart attack, stroke, or heart failure. And we're seeing more and more patients with resistant hypertension and more patients with hypertension in general. So, treating and evaluating hypertension has become more and more of what general cardiologists do.
Early Blood Pressure Control in Patients With Heart Failure With Preserved Ejection Fraction
Dr Black: What does a general cardiologist do when you first see a hypertensive patient? What tests do you order? What things on a physical examination do you focus on?
Dr Bisognano: From a general cardiology standpoint, we're always first looking for signs of target organ damage (eg, left ventricular hypertrophy and renal insufficiency, including an elevated creatinine, lower glomerular filtration rate, or signs of proteinuria). We have a good amount of patients with diastolic heart failure, which, from our perspective, is a disease that could largely be prevented or at least delayed by treating hypertension years before the patient actually runs into trouble. So many patients are admitted to the hospital with diastolic heart failure exacerbations or, as we call it now, heart failure with preserved ejection fraction. In these patients, I often see a history of high blood pressure or blood pressure that was not treated aggressively 10 or 15 years beforehand.
Dr Black: It sounds like the key to dealing with heart failure with preserved ejection fraction is to prevent it, not to figure out a way to treat it because treatment has been pretty disappointing. Isn't that so?
Dr Bisognano: It has been disappointing. All of the good therapies that have been proposed for the treatment of heart failure with preserved ejection fraction have not been all that effective. What we really are left with is just symptomatic treatment, which is naturally important to the patient. However, the mortality of patients with hospital admissions for diastolic heart failure, as opposed to systolic heart failure, is actually pretty similar. Keeping these patients out of the hospital is a difficult thing. Again, I always look back at the history, and they are often the patients whose systolic blood pressure was 150 mm Hg, 160 mm Hg, 170 mm Hg, who were, to some degree, inappropriately reassured about their blood pressure. Many people wrote it off as being just white coat hypertension, but these are patients who could have really benefited years in advance from pushing their systolic blood pressure down to 140 mm Hg or even lower.
Dr Black: Do you use echocardiography at first or order a CT or MRI? What is your approach to evaluating the heart in a hypertensive patient?
Dr Bisognano: For the general patient who we see, we don't see a need to add an echocardiogram or an MRI or any advanced imaging because it's not going to affect our treatment goals. It will have a minimal effect, if any, on which medications we initially prescribe for these patients. Once we start having a patient with resistant hypertension who is taking two, three, or four medications, and we're still above goal, we often find that they're also experiencing some symptoms of shortness of breath, chest pain, or other symptoms of a coronary disease.
This is a group of patients in whom we may consider additional diagnostic testing. It would be warranted for reasons that go beyond just the hypertension itself. I find an echocardiogram useful in many of these patients because they often describe some shortness of breath. Additionally, many of these patients also have sleep apnea, which is something we evaluate in almost every patient with truly resistant hypertension.
Sleep Apnea and Secondary Hypertension
Dr Black: Do you have to be a snorer to have sleep apnea, or are there other clues?
Dr Bisognano: The classic patient is the heavier patient who snores and has clear apnea episodes during the night, which probably encompasses the majority of patients with sleep apnea. However, I see a good number of patients who have a fairly normal body habitus who do snore a little bit, have symptoms of daytime sleepiness, or are waking up many times during the night. It's interesting to note that these patients often say that they're waking up during the night to go to the bathroom. In fact, they're waking up, and during the time that they're awake, they decide to go to the bathroom. These are patients for whom I have a high suspicion of sleep apnea, and I've detected it in a good number of patients without the typical large body habitus and heavy snoring.
Dr Black: Do you do ambulatory blood pressure monitoring in these patients?
Dr Bisognano: In these patients, we do ambulatory blood pressure monitoring, but we often find that it is difficult to get insurers and Medicare to provide reasonable reimbursement. In my patient population, many do home blood pressure monitoring, which in the motivated patient, the patient I can rely on, provides a similarly good piece of information as ambulatory blood pressure monitoring. Most home blood pressure devices cost $49 to $59 at drugstores. We also have the advantage that our local supermarket chain has good blood pressure kiosks that they calibrate every 2 or 3 weeks to give good blood pressure readings. I think that's key as well.
Dr Black: How do you approach secondary hypertension?
Dr Bisognano: The first approach is mainly by symptoms and by their history. If they have symptoms suggestive of hyper- or hypothyroidism, we go after that. Patients who have laboratory findings of low potassium or potassium that's inappropriately low for being on low-dose diuretics, we think of hyperaldosteronism.
Naturally, we're always thinking of pheochromocytoma in our patients, but that's exceedingly rare, and in my 10 years of practice here, I have only detected that in a couple of patients. Many of the patients with a history consistent with pheochromocytoma are just having some anxiety disorders, which is a valid cause of hypertension and a valid treatment target. I use our psychology and psychiatry consult services for those patients, along with their primary care physician. It's very easy to toss off patients with labile hypertension as having panic attacks or other anxiety disorders, but this may be, in many of our patients, the target of therapy. It's just as important as finding other secondary causes of hypertension.
Dr Black: Do you work with advanced practice nurses as well?
Dr Bisognano: In our hypertension program, we have three advanced practice providers, all nurse practitioners. I often say that they've worked with me for 10 years, and they know what I'm going to do even before I do; they're sitting there very patiently waiting for the drug choice I make or the diagnostic test that I might order. We have a very clear approach to most of our patients as to what medications we may use in the first, second, or third line.
When it comes to resistant hypertension, most patients are on the ABCDs of hypertension (ie, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, beta blocker, calcium channel blocker, and diuretic). The question often comes up with these patients: Do we adjust the doses? Do we change the medications? At what point should we consider adding an aldosterone antagonist, such as spironolactone or eplerenone, to get their blood pressure down? Naturally, we use all of the medications available to us if we have to, like minoxidil, clonidine, hydralazine, and alpha blockers. However, by and large, most of our patients are already on three or four medications and have lifestyle and diet modifications that we can suggest to them as well.
Taking Blood Pressure Medications at Night and Medication Adherence
Dr Black: There's some interest in giving blood pressure medications at night, something I'm not in favor of. What's your position on that?
Dr Bisognano: So much of treating blood pressure is patient adherence. When we diagnose a patient with high blood pressure, we're usually not giving them news that they want. It's an additional burden. Very few patients actually feel better when their blood pressure is treated. Some do, and there have been some studies[1] showing that quality of life improves in patients whose blood pressure is treated. Unlike hypertension, with other diseases they're willing to accept a little bit of complexity. Taking a blood pressure medication at night may be complex for them, but there are some data[2] that it may be the equivalent of adding up to another medication, and it may be effective in some patients. Certainly, you don't want to give them diuretics right before they go to bed. But sometimes, patients take their blood pressure at home, and they're concerned about elevations in the evenings, so I may suggest that they take something around dinnertime. I try not to make the treatment any more complex than it has to be.
Dr Black: My concern with giving blood pressure medication at night is that almost all of the drugs, with one exception that I'm aware of, have been studied using administration in the morning or 6:00 in the evening, not at night. I think we have to be very careful to extrapolate from what happens during the morning or the day to what might happen at night. We did the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial, which was a verapamil preparation that was designed to be used at night.[3] But other than that, I don't know of any of the agents that we currently use that were studied for nighttime use.
What do you do about intima-media thickness MRI and some of the more sophisticated imaging tests? Do you use those very often?
Dr Bisognano: We use them very rarely, and I think part of this is that so many patients have hypertension that boils down to just adjusting their lifestyle to some degree and coming up with a cocktail of medications that they can tolerate. For most of our older patients with hypertension, lifestyle modification is useful, but it's usually not going to solve their problem. In our clinic, it's more about focusing on medication tolerance, medication affordability, and also looking for barriers as to why patients don't want to take their medications as prescribed. Some of our data looking at our local payers suggest that patients refill their medications as little as 60% to 80% of the time, based on dispensing over a 1-year period. A lot of our patients with resistant hypertension aren't really patients who require an additional medication. It's that we have to address why they're not taking the medications that they're prescribed and looking for the barriers that the patient has, whether they be financial, a perception of being on too many medications, or drug side effects. We really work quite closely with them to identify the barriers to taking their medications.
Dietary Sodium Reduction: Yea or Nay?
Dr Black: Do you have a position on how much sodium we should eat every day? Do you think that 1500 mg might be a bit aggressive, and maybe 2300 mg would be okay?
Dr Bisognano: I think there are certainly patients, such as older patients or patients with renal insufficiency, in whom strict sodium restriction may give them 10 mm Hg or perhaps more reduction in their blood pressure. However, I think in treating hypertension, we have to look at the reality of a lot of our patients. Now I certainly see patients who eat excessive salt. I had one patient who I recall was frying Italian sausage one day and said that he always liked to put salt on it because that really was "cooking it," not just adding salt to it for flavor.
Some patients have a perception that adding large amounts of salt to salty food is the way that life has to be lived. I think with those patients, we should say, "You know, you really shouldn't eat that much salt." But most of our patients who lead a reasonable life, who have a reasonable salt intake, and don't always eat canned food, I'm not sure that focusing on sodium during their clinic visit or during a dietary visit is going to get us the most bang for the buck.
Dr Black: John, thank you very much. I really admire your approach to hypertension. It is nice to see a cardiologist who's so savvy in this area, and I really appreciate it. I would like to encourage people to attend the American Society of Hypertension meeting in May in New York City. We'll certainly see you there.
Disclosure: John D. Bisognano, MD, PhD, has disclosed the following relevant financial relationships:
Received research grant from: CVRx
Received income in an amount equal to or greater than $250 from: CVRx
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Cite this: Henry R. Black. A General Cardiologist's Approach to Managing Hypertension - Medscape - Nov 23, 2015.
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