CARDIOVASCULAR RISK ASSESSMENT

AS A CORNERSTONE OF
HYPERTENSION MANAGEMENT

Siska S. Danny, MD

Department of Cardiology and Vascular Medicine FMUI

National Cardiovascular Center Harapan Kita Jakarta
August 2016
Hypertension,
Dyslipidemia, Diabetes,
Smoking, Obesity
 Definition of Hypertension

1940s 1970s 1980s

BP > 180/110 mmHg BP > 160/95 BP > 140/90

HYPERTENSION: BP values which correlates closely

to significant increase in cardiovascular death

Category Systolic Diastolic

Normal < 120 and < 80

Prehypertension 120-139 or 80-89

Hypertension Level 1 140-159 or 90-99

Hypertension Level 2 ≥ 160 or ≥ 100

Isolated systolic Hypertension ≥ 140 or <90

Indonesian Society of Hypertension/
InaSH
 Multiple Risk GLOBAL
ASSESS for Cardiovascular Diseases
CARDIOVASCULAR
RISK IN ALL HYPERTENSIVE PATIENTS!
91% Hypertension patients 61% of cardiovascular
have at least 1 additional disease is related to high
Risk Factors BP or high cholesterol

91%

1. Rantala A, et al. J Intern Med 1999

2. Wannamethee S, et al. J Hum Hypertens 1998
3. WHO Global Program on Evidence of Health Policy
Real life scenarios in clinical practice
Case #1 Case #2

• 45 yo male, asymptomatic, • 45 yo male, asymptomatic,

recently diagnosed HT during recently diagnosed HT during
regular MCU. regular MCU
• BP 150/90. • BP 150/90
• BMI 23.5 • BMI 28.5
• History of HT in both parents. • Father had MI at the age of
• Active smoker 40yo. Mother had diabetes.
• Slightly elevated total • Not smoking, no regular
cholesterol. Normal LDL. exercise
FBG 98 mg/dL. • LDL 160 mg/dL. FBG 131
mg/dL

SAME INITIAL DIFFERENT DIFFERENT

BP RISK PROFILE STRATEGY
How to predict cardiovascular risk?
How to calculate cardiovascular risk?
• Framingham Risk
Score
• Systematic Coronary
Risk Evaluation
(SCORE)
• Reynolds Risk Score
• WHO/ISH Risk
Prediction Chart for
epidemiological
subregion
 WHO ARE IN THE HIGH RISK
GROUPS?

Ton VK, et al. Clin. Cardiol 2013:e1-e6

Variables calculated in the scoring system

Male sex, Age (men > 55, women > 65),

RISK FACTORS smoking, dyslipidemia, abnormal glucose
tolerance test, obesity, family history of
premature CVD

ASYMPTOMATIC
ORGAN DAMAGE LVH, Wide pulse pressure in the elderly,
Carotid wall thickening/plaque, Carotid-
femoral PWV prolonged, Low ABI, CKD
mild-moderate, Microalbuminuria
DIABETES MELITUS
Cerebrovascular disease, Coronary
heart disease, Heart failure,
ESTABLISHED CV Symptomatic PAD, Moderate-severe
CKD, advanced retinopathy
OR RENAL DISEASE

Mancia et al. Eur Heart J 2013;34(28):2159-219

 Combination
therapy earlier

More Drug of
aggressive choice
approach, according to
start therapy compelling
earlier indications
Management strategy is directed
toward lowering the total CV Risk
instead of lowering BP only

Do not miss
Treatment for
comorbidities
associated
 look for
risk factors
them!
HYPERTENSION MANAGEMENT ALGORITHM
ESH-ESC 2013

Mancia et al. Eur Heart J 2013;34(28):2159-219

 Multiple Antihypertensive Agents
Are Needed to Achieve Target BP
Number of antihypertensive agents
Trial Target BP (mm Hg) 1 2 3 4

ALLHAT SBP <140/DBP <90

UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
AASK MAP <92
IDNT SBP <135/DBP <85

DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood
pressure.
Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
Lewis EJ et al. N Engl J Med. 2001;345:851-860.
Cushman WC et al. J Clin Hypertens. 2002;4:393-405.
Which drugs to use?

Mancia et al. Eur Heart J 2013;34(28):2159-219

 Treatments for
Efforts to reduce
associated risk
total CV Risk
factors

• Lipid Lowering agents

• Treatment of hyperglycemia
• Antiplatelet therapy
Lipid lowering agents

Mancia et al. Eur Heart J 2013;34(28):2159-219

HT AND DM

HT 20-60% DM
overlap

• Over 1.5 billion people • 177 mil: Prevalence of

worldwide DM worldwide 2000
• 1 in 3 adults • 366 mil: Prevalence of
• 7 million deaths/year DM worldwide 2030

A significant increase in microvascular AND macrovascular

complications. The presence of HT causes up to 4 fold
increase of CV risk in diabetic ptsMancia G. Eur Heart J 2013;34:2159-2219
Ryden L. Eur Heart J 2013;34:3035-3087
2003 WHO/ISH statement on management of hypertension
Treatment of hyperglycemia
• In hypertensive patients with diabetes, a HbA1c
target of <7.0% is recommended with anti
diabetic treatment

• In more fragile elderly patients with a longer

diabetes duration, more comorbidities and at high
risk, treatment to a HbA1c target of <7.5–8.0%
should be considered

Mancia et al. Eur Heart J 2013;34(28):2159-219

Antiplatelet therapy
Low dose Aspirin for Low to moderate risk patients not
Primary Prevention recommended (absolute benefit
and harm are equivalent)
Should also be considered in
hypertensive patients with
reduced renal function or a high
CV risk
Should be given only when BP is
well controlled.
Low dose Aspirin for Strongly recommended. Absolute
Secondary prevention risk reduction larger than risk of
bleeding
Mancia et al. Eur Heart J 2013;34(28):2159-219
THANK YOU