Hypertension Heart Disease

APEKS:SIC V Mid claviculer

Prevalence of hypertension

The World Health Organization (WHO)

estimates that 20% of the worlds

current adult population has

hypertension

Awareness, Treatment and Control of High Blood Pressure in Canada

13% 43% 21% 22%

Patients unaware of their high blood pressure Aware but not treated and not controlled Treated but not controlled Treated and controlled

43% 22% 21% 13%

Joffres et al. Am J Hypertens 2001; 14(11):1099-1105

Trends in the awareness, treatment and control of hypertension in the U.S.

NHANES II 1976-80 NHANES III (Phase I) 1988-91 NHANES III (Phase II) 1991-94

Awareness Treated

51.0% 31.0%

73.0% 55.0%

68.4% 53.6%

Controlled

10.0%

29.0%

27.6%

Controlled BP = SBP <140 mmHg and DBP <90 mmHg

Adapted from Burt et al. 1995

Causes of Resistant Hypertension

Efficacy of medications Patient compliance:
Side effects (-) Convenience Lack of symptoms Patient education Cost

Secondary Causes
Sleep apnea Renal vascular HTN Endocrine causes Chronic renal failure Rx Drugs (NSAIDS, steroids) White-coat HTN

Failure to treat to target

MD Reluctance Accurate blood pressure measurements
Relctnce: enggan Rstant : mlawan complcekrelaanghdy

Diseases Attributable to Hypertension

Stroke

Coronary heart disease

Heart failure
Cerebral hemorrhage

Myocardial infarction

Left ventricular hypertrophy

Hypertension

Chronic kidney failure

Aortic aneurysm Retinopathy Peripheral vascular disease

Hypertensive encephalopathy

All Vascular

Adapted from: Dustan et al. Arch Intern Med 1996; 156:1926-1935

Hypertension Optimal Treatment (HOT) study

Intensive BP-lowering decreases cardiovascular risk in patients with hypertension, especially among those with diabetes
Major CV events per 1000 patient years 30 25 20 15
11.9 24.4

All patients (n=18 790) Diabetics (n=1501)

18.6

10 5 0

9.9

10.0

9.3

90 mmHg

85 mmHg Target DBP group

80 mmHg

Lancet 1998;351:17551762

UKPDS: relative risk reduction with tight versus less tight blood pressure control
Tight BP control decreases morbidity and mortality in patients with diabetes
Any diabetes- Diabetes-related deaths related endpoint

Stroke

Microvascular disease

Deterioration in visual acuity

24% P<0.005 32% P<0.05

37% P<0.01
Tight control (n=758) Less tight control (n=390) 44% P<0.05 47% P<0.005 BMJ 1998;317:703713

BP targets

BP targets in guidelines are becoming more stringent Coexistent cardiovascular risk factor profile is important

Strngt : ktat,kras

Initial Assessment
Target organ damage Overall cardiovascular risk Rule out secondary and often curable causes

Components of Risk Stratification

Target Organ Damage/Clinical Cardiovascular Disease

Target end-organs should be assessed by history and physical examination Eyes

Brain Heart

Kidneys

Arteries

Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46

Components of Risk Stratification

Major Cardiovascular Risk Factors

Hypertension

Age

> 45 years Male > 55 years Female (Postmenopausal)

Smoking Dyslipidemia Diabetes

Family history
Obesity

CAD <65 Female CAD <55 Male

Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46

Stratification of risk to quantity prognosis

Blood pressure (mm Hg)
Other risk factor and disease history Normal SBP 120129 DBP 80-84
Average risk Low added risk Moderate added risk High added risk

High normal SBP 130139 DBP 85-89

Average risk Low added risk High added risk Very high added risk

Grade 1 SBP140159 DBP 90-99

Low added risk Moderate added risk High added risk Very high added risk

Grade 2 SBP 160179 DBP 100109

Moderate added risk Moderate added risk High added risk Very high added rsik

Grade 3 SBP > 180 DBP > 110

High added risk Very high added risk Very high added risk Very added risk

No other risk factors

1 2 risk factors

3 or more risk factors or TOD or DM ACC

2003 ESH-ESC

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The ideal antihypertensive agent

Effectively reduces BP
Maintains BP control over 24 h with once-a-day dosing

Effective in all hypertensive patients

No adverse effects No negative metabolic side effects Affordable

 Persistent use of monotherapy Obsession with first line therapy Poor recognition of the importance and efficacy of combination therapy Lack of advice on most appropriate drugs to use in combination

BP monotherapy:BP fall <10% Statin therapy: Cholesterol fall 30-40%

Clinical Practice: Most people with hypertension are treated with monotherapy

Clinical Evidence: Most people in clinical trials are treated with combination therapy

HOT(Hyp.Optimal.Treatment): percentage of patients requiring combination therapy to achieve target DBP

Target DBP group
90 mmHg

85 mmHg

80 mmHg

37.1%

31.7% 68.3%

26.1% 73.9%

62.9%

Combination therapy Monotherapy

The lower the target DBP, the greater the need for combination therapy HOT:Hypertesion Optimal Treatment

Advantages of combination therapy

Additive antihypertensive efficacy (due to complementary mechanisms of action) Higher patient response rates Simple titration and dosing schedules Maintained or improved tolerability Improved patient compliance Cost effective

Drug Action - vasodilatation

RAS Activation SNS Activation -Vasoconstriction - Sodium retention

RAS = renin-angiotensin system SNS = sympathetic nervous system

Thiazide
Natriuretic Lowers Blood Pressure

Activates Renin Angiotensin System

Reduces antihypertensive effect

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Reduce Adverse Effects of Drug Therapy:

ACE inhibition or Angiotensin Receptor Blockers Thiazide Diuretics

Retain potassium(K)

Excrete Potassium

Combination
Prevents hypokalaemia of thiazide therapy Limits hyperkalaemia of RAS(renin angt sys) blockade

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WHAT IS THE IDEAL WAY OF CONTROLLING BP? The new therapeutic window in hypertension
IDEAL treatment 100 80 60 Traditional 40 20 0 Dose Efficacy (%) Freedom from side effects (%)
29 Man Int Veld AJ. J Hypert, 1997

100 80 60 40 20 0

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Initial Drug Therapy

BP Classification
Normal <120/80 mm Hg Prehypertension 120-139/80-89 mm Hg Stage 1 hypertension 140-159/90-99 mm Hg

Lifestyle Modification
Encourage

Without Compelling Indication

With Compelling Indication

Yes

No drug indicated

Drug(s) for the compelling indications Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

Yes

Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination 2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB)

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; 32 BB = beta blocker; CCB, = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.

Stage 2 hypertension 160/100 mm Hg

Yes

 BP target of <140/90 mm Hg for patients with uncomplicated hypertension without compelling indications BP target of <130/80 mm Hg for patients with diabetes

Combinations of 2 or more drugs are usually needed to achieve target BP goal

BP target of <130/80 mm Hg for patients with chronic renal disease*

Combinations of 3 or more drugs are often needed to reach target BP goal

*Chronic kidney disease = GFR <60 mL/min per 1.73 m2 or presence of albuminuria (>300 mg/d or 200 mg/g creatinine). Chobanian AV et al. JAMA. 2003;289:2560-2572. American Diabetes Association. Diabetes Care. 2003;26(Suppl 1):S33-S50. Guidelines Committee. J Hypertens. 2003;21:1011-1053.

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 Most patients with hypertension will require 2 or more antihypertensive drugs to achieve BP goals According to baseline BP and presence or absence of complications, therapy can be initiated either with a low dose of a single agent or with a low-dose combination of 2 agents When BP is >20/10 mm Hg above goal, consideration should be given to initiating 2 drugs, either as separate prescriptions or in fixed-dose combinations, one of which should be a thiazidetype diuretic
Chobanian AV et al. JAMA. 2003;289:2560-2572. Guidelines Committee. J Hypertens. 2003;21:1011-1053.

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Easy as ABC D
A = ACE-Inhibitor or Angiotensin Receptor Blocker B = - Blocker C = Calcium Channel Blocker D = Diuretic (thiazide)
Adapted from : Better blood pressure control: how to combine drugs Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org 35

A or B
Inhibit the Renin-Angiotensin System More Effective In Younger

C or D
Do not inhibit the Renin-Angiotensin System More Effective In Older

Adapted from : Better blood pressure control: how to combine drugs Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org

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Younger Or Diabetes ( 55yrs)

1.
2. 3. 4.

Older (55yrs) or Black C or D

A or B

A or (B) + C or D A or (B) + C + D A or (B) + C + D + other

Adapted from : Better blood pressure control: how to combine drugs Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org

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Recommended Combinations
1. ACE inhibitors / AIIRA 2. ACE inhibitors / AIIRA 3. ACE inhibitors / AIIRA
4. Beta-Blockers 5. Beta-Blockers

Diuretics Calcium antagonists Beta-blockers (Special condition) Diuretics Calcium Antagonists

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SUMMARY
COMBINATION THERAPY IN HTN MANAGEMENT IS LOGIC AND EVIDENCE BASED MAXIMIZE EFFECT, MINIMIZE SIDE EFFECT COMBINATION THERAPY IN HTN INCREASE COMPLIANCE

THE END