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

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

Discrepancy Between Health

Determinants and Spending of $1.7
Trillion, 2007
Prevention 4%
Health Behaviors
50%

Environment 20%

Medical Services
96%

Genetics 20%
Access to Care 10%

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

EPIDEMIOLOGY

Hypertension Mortality Rates

http://apps.nccd.cdc.gov/DHDSPAtlas/reports.aspx

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 populationattributable 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. ODonnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE
study): a casecontrol study. The Lancet 2010; 376:11223
3. Salim Yusuf, Steven Hawken, Stephanie unpuu, 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, 1117.

Comprehensive Approach to
Hypertension Control

Focused clinical interventions for those at

high risk

Lifestyle advice

Population-based strategies

Stages of CVD Intervention

Primordial Before risk factors develop

Primary Treatment of risk factors

Secondary After a CVD event occurs

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 .

Population Strategy

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

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%

341,745
fewer deaths
in 2000

1980

2000

AMI treatments
Secondary prevention
Heart failure
Angina: CABG & PTCA
Hypertension therapies
Statins (primary prevention)

Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000.
NEJM 2007; 356: 2388.

-10%
-11%
-9%
-5%
-7%
-5%

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.

Patient Level Strategy

A 10mmHg lower systolic blood pressure

(SBP) or 5mmHg lower diastolic blood
pressure (DBP) is associated with an
approximately 2025% lower risk of
coronary heart disease (CHD) and an
approximately 40% lower risk of stroke

1. Stamler J, Stamler R, Neaton JD, Blood pressure, systolic and diastolic, and cardiovascular risks. US population data, Arch Intern Med, 1993;153:598615.
2. Asia Pacific Cohort Studies Collaboration, Blood pressure and cardiovascular disease in the Asia Pacific region, J Hypertens, 2003;21:70716.
3. 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;335:76574.
4. http://www.touchbriefings.com/pdf/2988/giampaoli.pdf

JNC VII TREATMENT

GUIDELINES

Assessment

Greenland P. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in

Asymptomatic Adults:
Executive Summary. JACC. Vol. 56, No. 25, 2010.

Lifestyle interventions

JNC VII recommends therapeutic lifestyle

change only for most people with prehypertension

Weight reduction
DASH diet
Dietary sodium reduction
Physical Activity
Moderate alcohol consumption

http://www.nhlbi.nih.gov/guidelines/hypertension/

JNC VII Medication Recommendations*

Pre-hypertension
Lifestyle interventions

Stage 1 Hypertension
(SBP 140159 or DBP 9099 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,
ACEIor =
ace
BB,
or inhibitors
CCB)
ARB
BB
CCB

= angiotensin receptor blockers

= beta blockers
= calcium channel blockers

*JNC-VII includes chlorthalidone among thiazide-type diuretics.

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

CHALLENGES IN
HYPERTENSION CONTROL

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.

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

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]

What Happens if Hypertension isnt

Controlled?
Left ventricular hypertrophy (LVH)
Heart failure
Chronic kidney failure
Stroke (cerebral hemorrhage)
Vascular dementia
Retinopathy

Incidence of ESRD by Systolic Blood Pressure:

Incidence of ESRD per

100,000 Person-Years

Multiple Risk Factor Intervention Trial*

White Men (n = 300,645)

83.1

Black Men (n = 20,222)

37.2
27.3
15.8
5.4

<117

5.4

117-123

26.2
9.1

124-130

32.4

14.2

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.

Slide Source
Hypertension Online
www.hypertensiononline.
org

Effects of Systolic and Diastolic Blood

Pressures on CHD Mortality: MRFIT*
48.3

CHD Death Rate

Per 10,000
Person-Years

80.6

37.4
34.7

31.0

43.8
38.1

25.5
23.8

24.6
16.9

20.6

25.3
25.2

13.9
10.3

24.9
12.8

11.8

12.6

160+

8.8
11.8
100+
140-159
8.5
90-99
9.2
Diastolic
80-89
120-139
Blood Pressure
75-79
Systolic
(mm Hg)
70-74
<120
<70
Blood Pressure
(mm Hg)
*
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.

Risk of Stroke Death According to

Blood Pressure (mm Hg): MRFIT

Relative Risk of
Stroke Death

Systolic Blood Pressure (SBP)

Diastolic Blood Pressure (DBP)

*
1

<112
DBP <71

112
71

*
*

*
7

Decile

(Lowest 10%)
SBP

118
76

121
79

125
81

129
84

10

(Highest 10%)
132
86

137
89

142
92

151
98

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.

Slide Source
Hypertension Online
www.hypertensiononline.
org

SYSTEM-BASED INITIATIVES
TO IMPROVE CONTROL

Meaningful Use and Pay-forPerformance

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.

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;48:2331.

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

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

The Connection

HYPERTENSION AND SODIUM

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

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.

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):1-38

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;933944.
Asaria P, et al. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control
tobacco use. Lancet 2007;370:204453.

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

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

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. 7 th edition. Washington, DC: Government Printing Office;
2010.
Vital Signs: MMWR 2012; 61(Early Release);1-7

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;362:5909.

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;344:310.
Palar K, et al. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health
Promot 2009;24(1):4957.

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

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;10:383393.

44% of US sodium intake

comes from ten types of foods
Rank

Food Types

Bread and rolls

7.4

Cold cuts and cured meats

5.1

Pizza

4.9

Poultry

4.5

Soups

4.3

Sandwiches

4.0

Cheese

3.8

Pasta mixed dishes

3.3

Meat mixed dishes

3.2

10

Savory snacks

3.1

CDC, MMWR;2012;61:1-7.

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

Other Guidelines and

Recommendations

American Medical Association

Stepwise, minimum 50% reduction in sodium in processed foods,
fast-food products, and restaurant meals over the next decade
Physicians and other clinicians should educate patients about the
benefits of long-term, moderate reductions in sodium intake
Substantial public health benefits accrue from small reductions in
population blood pressure distribution, achievable with long-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.

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

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, Wheres the Sodium

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.

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

Role of the Provider

Current food environment makes it difficult

for consumers who want or need to
consumes less sodium to do so
Reduction of sodium in the food supply,
coupled with consumer education and
knowledgeable use of food labels, may
provide greater choice and control over
sodium intake, a modifiable risk factor for
high blood pressure, heart disease, and
stroke

Patient Education Its

Not the Salt Shaker, Its
the Food Choices!

www.cdc.gov/sal
t

COMMUNITY AND POPULATIONBASED CHANGES TO PROMOTE

PREVENTION

Community Partners

Community health workers and Promotores

de Salud
A liaison between health and social services and the
community facilitating access to care
Provides a trusted liaison through a shared culture with
the people they serve

Barbershop- and beauty shop-based

interventions to improve hypertension
control
Faith-based support programs

Ferdinand KC, et al. Community-based approaches to prevention and management of hypertension and
cardiovascular disease.
Journal of Clinical Hypertension. 2012. Online ahead of print. DOI:10.1111/j.1751-7176.2012.00622.x

Population-Based Strategy
SBP Distributions
After
Interventio
n

Before
Interventio
n
Reductio
n in BP

Reductions
in SBP

Stambler
.Hypertension.
1991; 117-120.

% Reduction in Mortality
Stroke

CHD

Total

-6

-4

-3

-8

-5

-4

-14

-9

-7

CDC Efforts Related to Hypertension

Control

Community Transformation Grants

Sodium Reduction in Communities

WISEWOMAN program

State Health Departments

Million Hearts Initiative

Public Health

Public health approaches such as

increasing physical activity and reducing
trans-fats and salt in processed foods
can achieve a downward shift in the
distribution of a populations blood
pressure.

In addition to CDC activities on the

previous slide, CDC funds many other
programs to promote healthy lifestyles.

http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

Quick Facts about

Hypertension and Sodium
9 in 10
people eat
too much
sodium

Every 39
seconds an
adult
dies of heart
attack,
stroke, or
other
cardiovascul
ar disease

44% of the
sodium we
eat comes
from 10
types of
foods
Reducing
sodium by
1,200
mg/day
can save
$20 B

Image adapted from CDC Vital Signs

Fact Sheet, Wheres the Sodium

Nearly 1 in 2
people with
hypertension
doesn't have
it under
control

Image adapted from CDC Vital Signs Fact

Sheet, High Blood Pressure and

Hypertension Control and Sodium Reduction

EDUCATOR TOOLKIT

Resources
CDC Vital Signs: Hypertension and Cholesterol
http://
www.cdc.gov/vitalsigns/CardiovascularDisease/inde
x.html

CDC Vital Signs: Wheres the Sodium?

http://www.cdc.gov/vitalsigns/Sodium/index.html

CDC Vital Signs: Prevalence, Treatment, and

Control of Hypertension
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm
6004a4.htm?s_cid=mm6004a4_w

Resources
CDC Grand Rounds: Sodium Reduction:
Time for Choice
http://www.cdc.gov/about/grandrounds/archives/2011/April2011.htm

CDC Blood Pressure Information

http://www.cdc.gov/bloodpressure/

DASH Diet
http://www.nhlbi.nih.gov/health/public/heart/hb
p/dash/new_dash.pdf

Resources
JNC VII
http://www.nhlbi.nih.gov/guidelines/hypertension/

The Asheville Project

http://www.innovations.ahrq.gov/content.aspx?
id=3380

Morisky Medication Adherence Questionnaire

http://www.ncbi.nlm.nih.gov/pubmed?term=Morisky
%20DE%2C%20Ang%20A%2C%20Krousel-Wood
%20M%2C%20Ward%20H.%20Predictive%20Validity
%20of%20a%20Medication%20Adherence

Important Hypertension
Trials

SHEP (Systolic Hypertension in the Elderly Program)

ALLHAT (Antihypertensive and Lipid-Lowering Treatment to

Prevent Heart Attack Trial)

The mean systolic blood pressure was 4mm Hg higher in blacks and 2 mm Hg higher in nonblacks in the lisinopril group than in the chlorthalidone group. Blood pressure control was 813% better in the chlorthalidone group than in the lisinopril group for blacks. Although in the
trial overall the chlorthalidone group was better controlled than the lisinopril group, this
difference between the two groups among blacks is quite striking.

MRFIT (Multiple Risk Factor Intervention Trial)

In persons aged 60 years and over with isolated systolic hypertension, antihypertensive
stepped-care drug treatment with low-dose chlorthalidone as step 1 medication reduced the
incidence of total stroke by 36%

Changed protocol in clinics using primarily HCTZ to chlorthalidone due in part to an a higher
trend in mortality in clinics using predominantly hydrochlorothiazide. Changing to
chlorthalidone was associated with a trend toward better outcomes.

TROPHY (Trial of Preventing Hypertension)

Found that it is possible to prevent or delay the onset of clinical hypertension in people with
blood pressure that falls within the "prehypertension" category

Important Hypertension
Trials
TOHP (Trials of Hypertension Prevention)
Sodium reduction, previously shown to lower blood pressure, may also
reduce long term risk of cardiovascular events.

TONE (Trial of Nonpharmacologic Interventions in the Elderly)

Reduced sodium intake and weight loss constitute a feasible, effective,
and safe nonpharmacologic therapy of hypertension in older persons.

HYVET (Hypertension in the Very Elderly Trial)

According to Timothy Gardner, M.D., President of the American Heart
Association: The results of HYVET demonstrate that effective
antihypertensive treatment with indapamide (Natrilix SR) in persons
aged 80 years old or older, is beneficial in reducing the risk of
cardiovascular events, and thus extends the patient group in whom
prevention must be pursued.

Case Studies
From Medscape Education
Timing is Everything: 24-Hour Control of Blood
Pressure
William C. Cushman, MD
http://theheart.medscape.org/viewarticle/759171

How well prepared are your residents for

managing hypertension?

Study from Johns Hopkins of baseline knowledge of PGY3

internal medicine residents
Hypertension

62-66%

Lipid Management

31-36%

Diabetes 35-40%
Smoking 53-54%
Obesity 44-47%
Total of 15 Chronic Diseases 48-50%

Baseline knowledge of PGY3 did not differ from PGY1 and

PGY2
Sisson SD, Dalal D. Internal Medicine residency training on topics in ambulatory care: A status report. Am Jour of
Medicine. 2011;124(1):86-90.

Discussion Questions
(could be used before delivering the module or
after)

You have a busy Family Medicine Practice

1. At what point would you consider referring a patient for
hypertension control?
2. How does team-based care delivery for hypertension control
work in your clinic?
3. Can you think of ways to improve your health information
technology to improve hypertension control?
4. How do you guide your patients to reduce sodium in their diet?