hypertension - langsa
TRANSCRIPT
HYPERTENSION MANAGEMENT : WHAT IS THE CURRENT
STANDARD CARE ?
Nurkhalis Muchlis, MD , FIHADEPARTMENT OF CARDIOLOGY & VASCULAR MEDICINE
FACULTY OF MEDICINE UNIVERSITY OF SYIAH KUALA BANDA ACEH
Hypertension is a Risk Factor for Cardiovascular Disease
9.5
2.4 2.0 2.1
21.3
6.2 7.3 6.3
Adapted from Kannel WB. JAMA. 1996;275:1571-1576.
Bien
nial
age
-adj
uste
d ra
te
per 1
000
patie
nts a
t risk
Risk ratio
Normotensive Hypertensive
22.7
3.3 5.0 3.5
45.4
12.49.9
13.9
0
10
20
30
40
50
2.0 3.8 2.0 4.0CAD Stroke PAD CHF
Men
0
10
20
30
40
50
2.2 2.6 3.7 3.0CAD Stroke PAD CHF
Women
HYPERTENSION IS THE NUMBER ONE RISK FACTOR FOR GLOBAL MORTALITY
Attributable mortality in millions (total: 55,861,000)0 87654321
High BP
Tobacco
High cholesterol
Unsafe sex
High BMI
Physical inactivity
Alcohol
Underweight
Ezzati et al. Lancet 2002;360:1347–60
Lewington et al. Lancet 2002;360:1903–13
CARDIOVASCULAR MORTALITY RISK DOUBLES WITH EACH 20/10 MMHG INCREMENT*CV mortality risk
0
2
4
8
115/75 135/85 155/95 175/105
6
2x
4x
8x
SBP/DBP (mmHg)
*Individuals aged 40–69 years
1x
HIGH–NORMAL BP INCREASES THE RISK OF CARDIOVASCULAR DISEASE
130–139
121–129
<120
mmHgHigh–normal
Normal
Optimal
Vasan et al. N Engl J Med 2001;345:1291–7
Cumulative incidence of CV events (%)
14121086420
0 2 4 6 8 10 12 14Time (years)
BP Reductions as Small as 2 mmHg Reduce the Risk of CV Events by up
to 10%
Meta-analysis of 61 prospective, observational studies 1 million adults 12.7 million person-years
Prospective Studies Collaboration. Lancet 2002;360:1903-1913.
2 mmHg decrease in mean SBP 10%
reduction in risk of stroke mortality
7% reduction in risk of IHD mortality
Epidemiologic impact on mortality of blood pressure reduction in the population
Reduction in SBP
(mmHg)
% Reduction in Mortality
Stroke CHD Total
2 -6 -4 -33 -8 -5 -45 -14 -9 -7
Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888
AfterIntervention
BeforeIntervention
Reduction in BP
Prev
alen
ce %
Hypertension is an asymptomatic disease
95%
5%
ESSENTIAL
15 % of Adult Population Age 40 - 75 years = 46.7 millions people Cost of OAH drugs US$ 43 millions per annum
7 million pts
Hypertension in practice 2nd, Beevers & MacGregor
Hypertension Treatments
Rules of Halves
7 million pts
Hypertension
50 % Diagnosis50 % not diagnosed
50 % Treated50 % not treated
50 % well treated(12.5 % of all
hypertensives)
50 %poorly controlled
AWARENESS, TREATMENT AND CONTROL OF
HIGH BLOOD PRESSURE
Patients unaware of their high blood pressureAware but not treated and not controlledTreated but not controlledTreated and controlled
Joffres et al. Am J Hypertens 2001; 14(11):1099-1105
43%
22%21%
13%
Percentages of Patients whose Hypertension is Controlled
Adapted from G. Mancia / L. Ruilope
USA: JNC VI. Arch Intern Med 1997Canada: Joffres et al. Am J Hypertens 1997 England: Colhoun et al. J Hypertens 1998France: Chamontin et al. Am J Hypertens 1998
< 140/90 mmHg < 160/95 mmHgUSA
27
England6
Canada16
France
24
Finland
20.5
Germany
22.5
Spain
20
Scotland17.5
Australia
19
India9
> 65 years
Marques-Vidal P et al. J Hum Hypertens 1997
Blessing in disguise ?DO WE REACH THE TARGET ?
Optimal : <120 and < 80Normal : 120-129 and/or 80 - 84High Normal : 130-139 and/or 85-89
Pre-hypertension
Isolated Sys.Hpt (ISH) : > 140 and <90
Normal
Grade 1 : 140-159 and/or 90-99Grade 2 : 160-179 and/or 100-109Grade 3 : > 180 and/or > 110
Stage 1
Stage 2
ESC-ESH 2007 JNC-VII
DENIFITION AND CLASSIFICATION OF BLOOD PRESSURE LEVEL
JNC VII committee, JAMA 2003: 289;2560-2572
JNC VII AND ESHESC SUMMARY : TARGET BLOOD PRESSURE GOALS
Type of hypertension BP goal (mmHg)
Uncomplicated <140/90
Complicated
Diabetes mellitus <130/80
Kidney disease <130/80*
Other high risk (stroke, myocardial infarction)
<130/80
*Lower if proteinuria is >1 g/day• The JNC VII. JAMA 2003;289:2560-72
• ADA Position Statement. Diabetes Care 2002;25:S33-S49• 2007 ESH/ESC J Hypertens 2007;25:1105-1187
• 2007 National Kidney Foundation. KDOQI. Am J Kidney Dis 2007;49 (Suppl 2):S1-S180
PATHOGENESIS OF HYPERTENSION
Blood Pressure = Cardiac Output (CO) X Peripheral Resistance (PR)Hypertension Increased CO and/or Increased PR
Excess sodium intake
Reduced Nephron number
Stress Genetic Alteration
Endothelium derived factors
Obesity
Autoregulation
Functional ConstrictionStructural Hypertrophy
HyperinsulinemiaCell membrane alteration
Renin Angiotensin Excess
Preload Contractility
Sympathetic nervous overactivity
Fluid Volume Venous
Constriction
Decreased Filtration surface
RenalSodium retention
Kaplan NM, Clinical Hypertension 7th ed. 2002; 63
03/05/2023
ANTIHYPERTENSIVE PROVIDES PROTECTION ACROSS THE CARDIO-RENAL-METABOLIC CONTINUUMSupported by:-• >90 studies• >70’000 patients• >40 countries• >45 endpoints• >70 mn patient-years exp.
End-stage heart
diseaseA combined version of the CVD and renal pathophysiological continuum. Adapted from Dzau et al. Circulation 2006;114:2850-2870
Athero-sclerosis
LVH
Myocardial infarction
Stroke
Remodeling
CHF
Risk factorsHypertension Dyslipidemia
Diabetes ObesitySmoking
Endothelial dysfunction
Microalbumiuria
Proteinuria
End stage renal
disease (ESRD)
Pre-diabetes
New Onset
Diabetes
Diabetes
DiabeticComplication(NephropathyNeuropathyRetinopathy)
Reduces CV mortality10
Reduces LV mass index1
Reduces CHF hospitalization9
Reduces endothelial cell
activation2
Reduces microalbuminuria5
Reduces triglycerides7
Reduces stroke6
Reduces risk of new onset diabetes3
Risk factors Risk factorsHypertension Dyslipidemia
Diabetes ObesitySmoking
Hypertension Dyslipidemia
ObesityEndothelialdysfunction
1.Thurmann Circulation 1998; 2.Nomura Throm Res 2006; 3.Julius Lancet 2004; 4.Maggioni AHJ 2005; 5.Viberti Circulation 2002; 6.Mochizuki Lancet 2007; 7.Saiki Diab Resear 2006; 8.Hollenberg J Hyper 2007; 9.Weber Lancet 2004; 10.Julius Hypertension 2006
Coronary thrombosis
CV Continuum
Renal Continuum
Diabetes Continuum
Reduces atrial fibrillation4
Reduces proteinuria8
• Lifestyle
• Pharmacological
TREATMENT APPROACHES:
Very high added risk
High added risk
High added
risk
High added risk
Moderate added risk
≥ 3 risk factors, mets, organ damage, or diabetes
Very high added risk
Very high added risk
Very high added
risk
Very high added risk
Very high added risk
Established CV or renal disease
Very high added risk
Moderate added risk
Moderate added
risk
Low added risk
Low added risk
1-2 risk factors
High added risk
Moderate added risk
Low added
riskAverage
riskAverage
riskNo other risk factors
Grade 3 HT
Grade 2 HT
Grade 1 HT
High normalNormal
Other risk factor, organ damage, or disease
Blood pressure (mm Hg)
HT: hypertension; mets: metabolic syndrome; CV: cardiovascularMancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
Cardiovascular Risk Stratification
Other risk factor, OD, or disease
Normal High normal Grade I HT Grade II HT Grade III HT
No other risk factors
No BP intervention
No BP intervention
Lifestyle changes for several months than drug treatment if BP
uncontrolled
Lifestyle changes for several weeks than
drug treatment if BP uncontrolled
Lifestyle changes +
immediate drug treatment
1-2 risk factors Lifestyle changes Lifestyle
changes
Lifestyle changes for several weeks than
drug treatment if BP uncontrolled
Lifestyle changes for several weeks than
drug treatment if BP uncontrolled
Lifestyle changes +
immediate drug treatment
≥ 3 risk factors, MS, or OD
Lifestyle changesLifestyle
changes and consider drug
treatment Lifestyle changes +
Drug treatment
Lifestyle changes +
Drug treatment
Lifestyle changes +
immediate drug treatment
Diabetes Lifestyle changesLifestyle
changes + Drug treatment
Established CV or renal disease
Lifestyle changes +
immediate drug treatment
Lifestyle changes
+ immediate
drug treatment
Lifestyle changes and immediate drug treatment
Lifestyle changes +
immediate drug treatment
Lifestyle changes +
immediate drug treatment
HT: hypertension; MS: metabolic syndrome; CV: cardiovascular; OD: organ damage
Initiation of Antihypertensive Treatment
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
INDICATIONS FOR PHARMACOTHERA
PY
USUAL BLOOD PRESSURE THRESHOLD VALUES FOR INITIATION OF PHARMACOLOGICAL TREATMENT OF HYPERTENSION
Condition Initiation
SBP or DBP mmHg
• Systolic or Diastolic hypertension 140/90• Diabetes• Chronic Kidney Disease 130/80
I. Indications for Pharmacotherapy
BLOOD PRESSURE TARGET VALUES FOR TREATMENT OF HYPERTENSION
Condition Target SBP and DBP
mmHgIsolated systolic hypertension <140 Systolic/Diastolic Hypertension• Systolic BP • Diastolic BP
<140<90
Diabetes or Chronic Kidney Disease• Systolic • Diastolic
<130<80
II. Goals of Therapy
Lifestyle Modifications
Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, Beta-Blockers, CCB) as needed.
With Compelling Indications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI/ARB/ Beta-Blockers/ CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider Beta-Blockers, CCB,
ACEI, ARB, or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
JNC VII, 2003
CHOICE OF PHARMACOLOGICAL TREATMENT FOR HYPERTENSIONIndividualized treatment• Compelling indications:
• Ischemic Heart Disease• Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI• Left Ventricular Systolic Dysfunction• Cerebrovascular Disease• Left Ventricular Hypertrophy• Non Diabetic Chronic Kidney Disease• Renovascular Disease• Smoking
• Diabetes Mellitus• With Nephropathy• Without Nephropathy
• Global Vascular Protection for Hypertensive Patients• Statins if 3 or more additional cardiovascular risks• Aspirin once blood pressure is controlled
Compelling Indication*
Recommended DrugsClinical Trial Basis†Diureti
cBB ACEI ARB CCB Aldo ANT
Heart Failure ACC/AHA Heart Failure Guideline,132 MERIT-HF,133 COPERNICUS,134 CIBIS,135 SOLVD,136 AIRE,137 TRACE,138 ValHEFT,139 RALES,140 CHARM,141
Post-myocardial infarction
ACC/AHA Post-MI Guideline,142
BHAT,143 SAVE,144 Capricorn,145 EPHESUS,146
High coronary disease risk
ALLHAT,109 HOPE,110 ANBP2,112 LIFE,102 CONVINCE,101 EUROPA,114 INVEST,147
Diabetes NKF-ADA Guideline,88,89 UKPDS,148 ALLHAT,109
Chronic kidney disease NKF Guideline,89 Captopril Trial,149 RENAAL,150 IDNT, 151 REIN, 152 AASK,153
Recurrent stroke prevention
PROGRESS,111
BB indicates -blocker; ACEI, angiotensin-converting enzyme inhibitor;ARB, angiotensin receptor blocker; CCB, calcium channel blocker; Aldo ANT, aldosterone antagonist.* Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the BP.† Conditions for which clinical trials demonstrate benefit of specific classes of antihypertensive drugs used as part of an antihypertensive regimen to achieve BP goal to test outcomes.
CLINICAL TRIAL AND GUIDELINES BASIS FOR COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSESS
SUMMARY Hypertension is major risk factor for
Cardiovascular event and kidney disease premature death
Lifestyle modification & Dash diet Non-farmachologic treatment for control blood preasure
The Guidelines recomendation for patients with hypertension will require two or more antihypertensive medications to achieve BP goal
I. INDICATIONS FOR PHARMACOTHERAPYAFTER DIAGNOSIS OF HYPERTENSION (1)
• Patients at low risk with stage 1 hypertension (140-159/90-99 mmHg)• lifestyle modification can be the sole therapy.
• Patients with target organ damage (e.g. left ventricular hypertrophy) (140-159/90-99 mmHg)• Treat with pharmacotherapy
• Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg