Good afternoon, thanks for inviting me here today. I'm going to get this started talking about the state of hypertension and current guidelines. These are my disclosures. So, as we all know, hypertension is a huge public health issue, both economically and in terms of disease burden, and approximately 1.3 billion people have hypertension worldwide, and that's about a third of all adults. So, when we look in the US specifically, there's about 116 million people who have hypertension. This is based on NHANES data from, this was till 2018, so this is even out of date, so it's probably even a little higher. And when you look, I don't see this as a pointer, but anyway, when you look at the green box, so under the people who actually qualify for, as being hypertensive and qualify for not only lifestyle modification, but medication, you can see that only about 26% of people actually have controlled blood pressure. So, a huge amount of people, almost 70 million people do not have controlled blood pressure. And then when you look at that pink colour with the uncontrolled people, you can see that about 50% actually get treatment and about 50% remain untreated. So, huge efforts need to be done, you know, from a public health point of view to try and improve blood pressure control. So now, when you look, so that was all, that data was done when the blood pressure goal was 140 over 90 or lower. So, when you look at the prevalence of hypertension after the reclassification to a blood pressure goal of less than 130 over 80, all these prevalence has increased tremendously. So, you can see overall you had a prevalence of about 32% in patients, I mean, generally in the population where this increased to 46% once you lower the blood pressure goal. And you can see overall it's increasing in all age groups and in both genders. And particularly, you know, we have a massive amount of hypertension in all the ethnicities, but the worst actually in non-Hispanic Blacks. So, almost 60% of people have hypertension overall in that ethnicity. So then, this is another study looking at NHANES data, actually looking up to the latest data of 2017 to 2020. And you can see here that they looked at blood pressure control and you can see it's really interesting this because you can see from 2009 to 2020, the rate of blood pressure control decreased significantly in the United States. So, I think this is two reasons. I mean, one is obviously changing the blood pressure goal in 2017. But the other thing is that in 2014, there were guidelines published that was called JMC-8 or the 2014 guidelines. And what they suggested, they actually increased the blood pressure targets to 150 over 90 for all adults, for most adults, let's put it that way. So, what happened is I think people started treating blood pressure less aggressively and there was more physician apathy towards this. So, we've really seen this trend of worsening blood pressure control. So, hopefully now with the new guidelines, more hopefully education and awareness, we should see an improvement in these levels with the next NHANES report. So, just talking a little bit about resistant hypertension. So, just briefly, the definition of resistant hypertension is anyone whose blood pressure is above goal and is using three concurrent antihypertensive agents with one being a diuretic at the maximally tolerated doses or anyone who has the blood pressure above their target goal with using four or more medications. So, what is really the true prevalence of resistant hypertension? So, if you look at the circles, I thought this is a nice diagram, you can see outside you have, it describes patients, you know, in general, the uncontrolled hypertension. And then we look more deeply into it, you can see that a lot of the patients actually have apparent treatment resistant hypertension, which I'm going to go into a few more minutes. And of that, a lot of that is made up of pseudo-resistant hypertension. So, we have really a small amount of people who actually have true resistant hypertension. If you look at the other diagram where the yellow triangle, 21% of patients in this paper were reported to have resistant hypertension. But if you can, if you look, actually about 32% of those patients had uncontrolled resistant hypertension, but truly refractory hypertension was only 3%. So, I think most of the resistant hypertension that we talk about is really due to other issues. So, when we talk about apparent treatment resistant hypertension, we should always exclude white coat hypertension because this, you know, leads to mislabeling resistant hypertension or even hypertension in general. And when I say pseudo-resistant, this also includes just proper blood pressure measurements. And then we obviously have to also exclude non-adherence, which is really the biggest issue in resistant hypertension, at least in the United States. So, then we're really left with a much smaller amount of patients who have true resistant hypertension. So, you know, white coat hypertension is really important to exclude because we don't want to over-treat patients. And even in all the studies that I've been part of, a lot of patients actually get excluded from the studies because when you do ambulatory blood pressure monitoring, a lot of their blood pressures actually fall within the normal range. But I do want to point out that this labeling here. So, if you're already on anti-hypertensive medication, we actually call it white coat effect, not white coat hypertension. And I also want to just say a word about masked hypertension because masked hypertension is actually found in the kidney studies. I'm a nephrologist. But what they saw is that patients came to the office and their blood pressures were good, but on ambulatory monitoring, they saw that their blood pressures at home were high and particularly at night, where they don't have, mostly in chronic kidney disease patients, but they actually either don't get dipping at night or they actually get what we call reverse dipping. So, they go up at night. But most of the people, most people get diagnosed by office blood pressure. So, it's really important to focus on training your staff to measure blood pressure correctly. And really the AOBP, which is the automated office blood pressure method, is really preferred. And that is what we did in Sprint, which I was also part of. And it really gives the patient time to rest for five minutes and then it's automated. You get three readings with a minute apart and then you get the mean of the three. So, this is really helpful to, you know, really define our patients. And this lessens the amount of patients with resistant hypertension. And, you know, these people are usually pseudo-resistant. So, when we're talking about the guidelines. So, in 2017, the HAACC presented guidelines where they changed the definition of hypertension. So, anybody, if you look there with stage one hypertension, anyone with a blood pressure over 130 over 80 is now defined as hypertension. So, I'm really lowering the bar a lot. And then when they talked about treatment targets, really every single population is now targeted in a blood pressure of less than 130 over 80. And, you know, this is a big change from prior definitions and guidelines. And then more recently, we now have the CADEGO guidelines, which are the International Kidney Guidelines, and they actually suggest a blood pressure of less than 120 over 80 for all our patients. So, this is an evolving situation, but I think at least 130 over 80 is what we should be going for in most of our patients who are ambulatory, you know, not the elderly, you know, nursing home patients, but ambulatory patients, this is what we should be going for. So, why is hypertension so uncontrolled? And there's so many different reasons, as you can see nicely depicted on the slide, but poor medication adherence is definitely the number one factor. And I'll show you a little bit of data on that in a minute. But also, you know, just physician inertia, not following, you know, really guidelines in terms of therapy, you know, not using appropriate diuretics, for example. And then, you know, just a huge load on the patient, polypharmacy. So, you know, these patients always usually have other comorbidities as well. So, they're taking many other medications too. So, these are just a number of barriers that prevent good blood pressure control. So, once you add extra medications, adherence really drops off. So, here is a study, and what they showed is when you add your third medication, the lack of adherence doubles. So, you know, the more meds we add, the less likely patients are going to be taking them. So, combination pills can really help reduce this burden. And then, this is a meta-analysis where they looked at from a number of studies where they actually did testing. So, they looked at the urine and blood metabolites of the drugs, and patients knew they were getting testing. And what they showed here that across these trials, 44% of patients were partially adherent to the medications, with 17% of patients totally non-adherent. And we know that the adherence rate is going to be higher when you're in a trial. So, in the real world, this is probably a lot worse. And then, I'm just not going to say too much, because I think Michael is going to address this, but just to say, obviously, we know even minor reductions in blood pressure, even 5 to 10 millimeters, really reduces important cardiovascular outcomes, such as heart failure and stroke. So, you know, optimizing medication therapy is really important. These are actually the European guidelines, but this just depicts the slide well. But they actually start patients above goal with dual therapy from the outset. So, usually a diuretic, plus a calcium channel blocker, or an ACE and ARB. And we're really going the same way, except you usually start with one and add up to three in any particular order. There's no real good data showing one blood pressure medication is better than another overall. And the biggest, the most important goal is to just to achieve blood pressure control. And then, you know, after your third med, most people, based on the data, you know, would add a mineralocorticoid as a fourth line drug, or a beta blocker if you have a specific indication, you know, particularly in a cardiovascular indication. And, you know, what do we do then? You know, the suggestion is to refer to a hypertension specialist, and this is an RDN section. So, obviously, you know, this is the time to start thinking about, you know, what's next when you've maximized your medical therapy. So, just to summarize, you know, hypertension prevalence is increasing globally with very poor control in all ethnicities, but much worse in the non-Hispanic Blacks. And, you know, we really need to measure blood pressure correctly, exclude white coat hypertension, and treat masked hypertension, as well as optimize medication therapy. And I think medication adherence is such a big, big issue. You know, I don't think there's one answer to address this, but this is really a public health issue that needs to be addressed, particularly in the U.S. And resistant hypertension, although it's a big challenge to treat, true resistant hypertension prevalence is probably very, very low. So, I'll end there, and I think we're going to take questions later in the panel. Thank you.

hypertension

blood pressure control

public health issue

prevalence

resistant hypertension