Dr Ileana Piña (Montefiore Medical Center, New York, NY, US) discusses whether gender and race disparities exist for essential hypertension. With references to the SPRINT trial, she discusses a number of issues around this important topic, to look at the SPRINT trial outcomes, the affect of gender, race and social determinants on hypertension and the importance of patient adherence to medical treatment.
1. What options are available to manage essential hypertension and what outcomes are we seeing?
2. Does race and gender affect outcomes?
3. Can we hypothesise why these disparities occur?
4. What can be done to harmonise treatment?
Filmed on location at CRT 2020.
Interviewer: William Cadden
Videographer: Charlie McClanahan
Tags: denervation, hypertension, SPRINT trial, african american, caucasian, blood pressure
Transcript Below :
Question 1 : What options are available to manage essential hypertension and what outcomes are we seeing?
[Pina] We have a lot of options to manage essential hypertension. Certainly, we have so many medications, they work sometimes alone or sometimes in combination. And then for those that are really resistant, even though it's a tiny amount of patients, we have denervation. Denervation has been somewhat controversial because the SYMPLICITY HTN-3 trial showed no difference with a sham control, but I think it's being revisited with doing it a little bit better, et cetera. But I've been taking care of hypertensive patients for over 30 years, and I can tell you that the drugs work. If the patient has something else going on that's making them hypertensive, like high aldosterone, hyperaldosteronism, then you need to go search for that. But you do a work up when the patients come in. So we have a lot of options, and what outcomes do we want? Well, we want to reduce death. We want to reduce heart failure. We want to reduce stroke, and that's in fact what the SPRINT trial did. The SPRINT trial, which was a very large NIH sponsored trial, separated patients into two groups. One that was a standard treatment, didn't tell them what drugs to use, gave them a list of drugs and let the clinicians do it. And then the other group was intensive treatment, so you wanted to get the blood pressure down, you're talking about hypertensives, 120/80, and it worked. They were able to not only get the blood pressure down, but keep it down. And lo and behold, the primary outcome was so positive that they stopped the trial. And more importantly for me as a heart failure doc, is that heart failure was reduced by 50%. The biggest problem that we have is that the patients don't take their meds. They're not adherent. Very often they'll skip because hypertension unless you already have heart failure or you already had a stroke, can be symptomless 'cause we call it the silent killer because the patients may have it and don't even know it. And so we talk about check and control. Check the blood pressure, but control the blood pressure. And I wish I could get it into their heads to take their medicines because I know what's coming at the end.
Question 2 : Does race and gender affect outcomes?
[Pina]Well, it's very interesting because in the SPRINT trial, they didn't enroll enough women to my liking, 35% of the patients were women. They enrolled a fair number of African Americans. Now the trial was only done in the United States, so they enrolled a fair number of African Americans. And whether it was an African American, a non-white, a Caucasian or Hispanic, they got the blood pressure down. Now, the African Americans had higher blood pressures, maybe not treated as well, and they certainly had higher levels of blood pressure. And they were a group that was hard to treat, but it was in there. But you can get the blood pressure down even in them. Now the difference in the outcomes between men and women was different. The men experienced a really nice wide outcome between standard dose and intensive dose. The women, it was much narrower. But you wonder if it's related to the small number of women. You know, the larger the trial, the better the chances you have of finding a difference.
Question 3 : Can we hypothesise why these disparities occur?
[Pina] We talk a lot about the social economic aspects of healthcare, and a study was published in the New England Journal maybe now a couple of years ago about barber shops. This study included the barber shops which may be where the African American men go, when they have friendships and relationships. And the caseworkers went in there to talk to them about taking their blood pressure medicines, and guess what, it worked. So it may have a lot to do with socio-economic differences, not necessarily differences in the medications. The medications should work. Now we know that African American blood pressure is tough to treat and that it's more prevalent maybe than the Caucasians. However, they can be treated as long as they take their medicines. So we're always looking at the social determinants of health, access to care, access to clinic, access to providers that look like them. Certainly, the number of African American providers and Hispanic providers, for that matter, we need to do better. We're getting into the schools to get kids interested in medicine.
Question 4 : What can be done to harmonise treatment?
[Pina} Again, harmonising treatment has to do with a patient's adherence. We're writing a paper right now for the American Heart Association on adherence because we think it's such a big issue. And, for example, if your patient, if you can convince them to take one pill a day, one, maybe you can combine the medications. So there are combination medications. ACE inhibitor or with a diuretic. So if they could get one medicine down that would be an interesting option for those people who are really tough. The other one is if they can remember breakfast and bedtime, those are times that most people will have a cup of coffee or a cup of tea or juice or something. So if you can convince them to link events of their day with their medicines, going to bed, you know, having it next to your bed, having the medications. Anything that will help them. Tricks to get them to be adherent. When the day goes on they're going to forget. That's why three-times a day medicines don't work.