Hypertension - Langsa

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



Established CV or renal disease


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 +


≥ 3 risk factors, MS, or OD

Lifestyle changesLifestyle

changes and consider drug

treatment Lifestyle changes +

Drug treatment

Lifestyle changes +

Drug treatment

Lifestyle changes +


Diabetes Lifestyle changesLifestyle

changes + Drug treatment

Established CV or renal disease

Lifestyle changes +


Lifestyle changes

+ immediate

drug treatment

Lifestyle changes and immediate drug treatment

Lifestyle changes +


Lifestyle changes +


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

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Hypertension - Langsa