Hypertension and New Treatments With Dr Vogt

Dr Thomas Nero discusses treatments for hypertension with Dr Liffert Vogt focusing on lifestyle changes as well as new therapies

Transcript

Hypertension and New Treatments With Dr Vogt

Dr Nero: Welcome to Patient Pulse. I'm Dr. Thomas Nero. Today we have, , Professor, Liffert Vogt who's a professor of nephrology at the University of Amsterdam in the Netherlands. He just, published the LAUNCH HTN trial, and he's a, expert in, nephrology and in blood pressure reduction.

And today we're gonna talk a lot about blood pressure. Dr. Vogt, thank you for joining us

Dr Vogt: Yeah, thank you for the invitation. I'm happy to join

Dr Nero: I don't know whether, it gets, discussed quite enough is the importance of hypertension and controlling hypertension, not just on stroke reduction, and I know that stroke reduction is probably foremost in most people's minds, but also on the importance of, myocardial infarction risk, renal failure risk, and vascular disease risks.

Can you talk a little bit about how important blood pressure control is for the patient?

Dr Vogt: , Blood pressure is, the leading cause of death. So if you look at the number of people that die from cardiovascular disease, hypertension is the number one killer. And that really illustrates why it's so important to control blood pressure,

, So that's a very simple statement. And then, the question, , is why is blood pressure reduction leading to,, more protection? And that is a very more nuanced discussion, I would think. But if you see a patient in your office, controlled blood pressure is actually independent of being in the kidney, department or the cardiology department or in the general practice,

blood pressure control is the number one risk factor we all want to control.

Dr Nero: And, it's one of those things that simultaneously seems like it's easily controlled and also seems that it's not easily controlled, and we'll get into that in a little, in a second. As a cardiologist, I'm interested in not just the protection for the stroke protection, which we all talk about, but, blood pressure control decreases heart attack risk as much as getting cholesterols under control.

, So There is a question of what is adequate blood pressure control. And I think that, , there's, , some differences in the European approach and in the US approach, but what is your approach?

What do you think is adequate blood pressure control, and, , how do you think that this is best attained?

Dr Vogt: Yeah. Now you really, enter the danger zone because there are groups, they say you should measure twenty-four-hour ambulatory

blood pressure monitoring or you should do an unattended blood pressure measurement in your office while there is no physician or nurse present But in general, if we rely on home blood pressure measurements that I think is perhaps the most valuable, way to assess blood pressure because then the patient is involved in measuring the blood pressure him or herself.

That below hundred thirty, below eighty millimeters of mercury, that's a controlled blood pressure. And if it's higher than that and are good data, the longer you're above that limit, the risk for any outcome you, imagine is higher. So , the time that you're within control, uh, very similar to glucose measurements actually.

The, the time that you're in control leads to better outcomes. So below hundred thirty, below eighty

Dr Nero: , I agree with you that, home blood pressure monitoring is really where it's at because they are active in understanding their own blood pressures and their own health,

and sometimes it takes multiple medications to get there. But before we get to the pills, because, we all would like to avoid pills, what do you think of diet and exercise, in, trying to control our blood pressures?

Dr Vogt: Yeah, I think that's a great question because we tend to move easily to prescribing new medication. But the problem of hypertension is it's asymptomatic, so people are not aware of having a problem. So You teach them by measuring the blood pressure at home that they might have a problem because you tell them what's the target, below one hundred and thirty/eighty, and that might also motivate them, to pay attention to lifestyle.

And in, in that sense-- Well, I'm a kidney doctor, so I'm, I like electrolytes, so then always sodium pops up in my mind as first. But there are many other things, of course. I think it's very important to, have a healthy lifestyle to control blood pressure in a better way is that you have enough physical activity.

I'm living in the Netherlands, so I cycle to my hospital, which is fifteen kilometers every day, and then I need to go back home, so thirty in total. Uh, so that's a way to be healthy, but it also is good for control of blood pressure. But also, if you acknowledge that sodium is a very important factor here.

So nearly all hypertensive patients are salt sensitive. That means that if they eat too much salt, their blood pressure will be high. If you reduce salt intake, and we have very nice data, blood pressure goes down, with an effect size. It's very similar to one or two drugs.

, This is also a way to stimulate your patients to adhere to healthy lifestyle because you can tell them, "Oh, hey, you are now using five different pills, but perhaps we can cut it down with two or three." So s- And then the problem, of course, is be- because it's very easy to say in your office, "Cut salt intake."

The thing is, eighty percent of what the salt we consume comes from processed food, foods that, are made in factories and sold in the supermarkets. So if you want to prevent, the high salt intake, you should go to unprocessed food, food that means that you need to prepare your meal yourself with fresh, fresh products.

I think, the best way. But then again, it's important because these foods are also more expensive. -- But now we enter in a different d-discussion, of course. How can we implement healthy lifestyle in society in general? But for, as an advice from office, tell your patients, stick to healthy foods, fresh foods that you prepare yourself.

And ultimately, you will eat more vegetables and more fruits, and that's good because it also contains potassium, and high potassium intake is also blood pressure lowering. So cut salt and increase your potassium intake via the fruities and the veggies.

Dr Nero: So if there is a number, and because patients love to focus in on numbers, if there's a number for sodium intake, what do you recommend? Are you recommending for most patients to go under fifteen hundred milligrams of sodium a day, u- under a thousand milligrams of sodium a day? Hard to do, but, um, but achievable, easily achievable.

Dr Vogt: Yeah, that really depends on also the other diseases you have. So 1,500 milligrams, I think is, better to accomplish, I would think, than thousand. And that also has to do because if you go to the shops and you go to thousand, then you have the risk of getting, uh, deficiencies in your diet because you're buying stuff that does not only contain salt, but also not other things.

, In that sense, it's very difficult , to go to too strict, limits, I would think. So, 1,500 is more what I would ad-advise.

Dr Nero: And do you ever advise patients to use salt substitutes, that are potassium-based, , to help improve that?

Dr Vogt: It's really an excellent question. I think, - the salt substitutes we have now, , contain sixty to seventy-five percent of potassium instead of sodium, while they have the same taste as the normal table salt. , And we know that it reduce blood pressure, and it also-- we know from Chinese data, that it redu-reduce the risk of stroke and myocardial infarction.

The only problem, of course, is that, uh, because the most of the evidence comes from, China and also Taiwan, , we're not sure whether the effect sizes they saw observed there, the effect on blood pressure, the effect on heart disease is the same in other societies, but in generally said, I think, yes, salt substitutes are a good idea, but If you do this as a sole thing, it's not enough. Then again, you need to pay attention what you buy in the shop, of course.

Dr Nero: And the, the last one that I usually recommend is patients going over to a low-processed carbohydrate diet, there is some very strong data showing that that has almost an equivalent benefit as patients trying to go over to a low-sodium diet., If we can have people focus on fruits, vegetables, legumes, um, and trying to decrease processed foods in general, we're gonna go a long way into controlling blood pressure without the needs of these agents.

. So what are the medications that you usually start patients out with? And are you in the camp that says that we should be starting out patients on multiple pills at lower doses or, or even the polypill?

Dr Vogt: Yeah, it's a very good question. So we know that if you just start one antihypertensive drug, so one blood pressure-lowering drug, you won't get , the blood pressure target you're aiming at. So you always need to combine. The problem is, of course, I have a nephrology practice, so I see ki-kidney patients. Uh, they are advanced in the healthcare sy-system. So I'm not a, a general practitioner I think in the first-line medical care, you better start with two pills instead of one because then you immediately get your targets.

And we know the quicker you are on the target that directly translates in better heart and heart disease control, also-- We know that if you have lower dosages of multiple drugs, that is a very logical way to do that.

Dr Nero: , There's a lot of really interesting data on looking at the fact that low doses of multiple medications work better than just trying to increase one medication up to its highest dose. You really do get, , a lessening of the effect as you go up on those medications.

, So we all have patients who have difficulty controlling their blood pressures, and let's say we have a patient on two or three medications already coming into your clinic, and their blood pressures are still high.

How do you address that? Do you, , try to relook at the diet and exercise pieces first, or do you say, "Okay, let's really go into , some of the big guns, to try to get the blood pressures down"?

Dr Vogt: Yeah, actually I do both. I check twenty-four hour urine and measure sodium and potassium, also urea. So then I have an idea about the dietary patterns. I know that is not common practice for everyone, but that gives you a sense about sodium consumption.

The, the twenty-four hour potassium excretion give you a sense about the vegetable, uh, legumes, also the, the dairy intake and the urea is a very nice marker for, the protein intake in these patients. So I, I use these, but -- I don't want to waste time because as said, the longer you are uncontrolled, the worse your outcome.

So you-- yes, I also, tell them, "Okay, we'll, we'll start a new drug." Uh, and I normally then if you're already on three pills, depends a little bit on the combination. It's very logical to, for instance, , go to something that, , interferes with aldosterone, because we know that on top of that, you'll have very significant blood pressure lowering efficacy.

But again, I also tell always we can stop that if you adhere to a healthy diet., And, physical activity is for me a bit more difficult to measure. You can also ask, , are you watching TV all the time? If yes, then you know that's not a good sign.

Dr Nero: Yeah, I do think that the, , the carrot and the stick approach is, is important. And, uh, if you give them the carrot of, "Hey, you get your blood pressure that's under control, you don't have to come to the office quite as frequently, and perhaps we're gonna get you onto fewer pills," those things really, can work wonders.

Um, I agree with everything you said, and one of the things that, you know, I do reach for adding on are often, the, a-aldosterone antagonist spironolactone, , but tell me a little bit about your trial with Lorundrostat

This is a really interesting new drug, which is on the aldosterone a-axis. It actually is an aldosterone synthase inhibitor, so decreasing the production of aldosterone. Tell us what your trial showed

Dr Vogt: That is a very interesting trial. So, this, the trial was , the LAUNCH-HTN trial where we selected uncontrolled blood pressure people, uh, with all different backgrounds. So it was a very balanced, trial with good representation of various people with uncontrolled blood pressure.

Uh, and then we demonstrated that if you look at the blood pressure-lowering effects as compared to placebo, , we demonstrated ten millimeters of mercury blood pressure, decrease. Uh, which is actually on top of these medications, a very impressive blood pressure-lowering effect

Dr Nero: Yeah, I don't think that a lot of,, people who are outside of medicine, when they look at a five-millimeter or a ten-millimeter blood pressure effect, um, that doesn't seem that, that great. But a five-millimeter blood pressure effect is huge in blood pressure trials.

A ten-millimeter, , improvement is dramatic. And, with this drug at a relatively low dose, , that it is potentially going to be,, a drug that will be able to enable us to stop other medications as well and get on , fewer tablets overall.

So, , I'm very excited about, where this is going to, get to us in the future. But I think that the take-home points here though are the, that, , we really do need to get blood pressure under control. That blood pressure isn't just about stroke reduction, it's really about overall decrease in cardiovascular events, heart failure events, hospitalizations, heart attacks, strokes, kidney failure.

, It's a big deal, and we need to focus in on this a little bit more, to improve our patients' outcomes. And I think that the more patients realize that and the more all the people within our healthcare system understand that, we'll do even better.

So thank you very much for joining us today are there any last parting words of wisdom,, 

Dr Vogt: Pay attention to your lifestyle. So don't eat too much salt. Um, use your bike, cycle a lot. Uh, even come to the Netherlands, you can cycle a lot here. That's good for your cardiovascular health, and that's all for the purpose to control our blood pressure so - then we'll live a healthy life for a long time

Dr Nero: Well, , I thank you again

Dr Vogt: Thank you. Thank you