Hypertension Heart Disease

APEKS:SIC VMid claviculer

The World Health Organization (WHO) estimates that 20% of the worlds current adult population has hypertension Prevalence of hypertension

Awareness, Treatment and Control of High Blood Pressure in CanadaPatients unaware of their high blood pressure43%Aware but not treated and not controlled22%Treated but not controlled21%Treated and controlled13%Joffres et al. Am J Hypertens 2001; 14(11):1099-1105

Trends in the awareness, treatment and control of hypertension in the U.S.Awareness 51.0%73.0%68.4%Treated31.0%55.0%53.6%Controlled10.0%29.0%27.6%NHANES II

1976-80NHANES III(Phase I)1988-91NHANES III(Phase II)1991-94Controlled BP = SBP

Causes of Resistant Hypertension Efficacy of medications Patient compliance:Side effectsConvenienceLack of symptomsPatient educationCost Failure to treat to targetMD ReluctanceAccurate blood pressure measurementsSecondary CausesSleep apneaRenal vascular HTNEndocrine causesChronic renal failureRx Drugs (NSAIDS, steroids)White-coat HTNPseudo-hypertensionVasoactive substances (non-Rx)Relctnce: enggan Rstant : mlawan

Diseases Attributable to HypertensionHypertensionHeart failureStrokeCoronary heart diseaseMyocardial infarctionLeft ventricular hypertrophyAortic aneurysmRetinopathyPeripheral vascular diseaseHypertensive encephalopathyChronic kidney failure

Cerebral hemorrhage

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

Hypertension Optimal Treatment (HOT) study9.910.09.324.418.611.905101520253090 mmHg85 mmHg80 mmHgTarget DBP groupMajor CV events per 1000 patient years All patients (n=18 790)Diabetics (n=1501)*Lancet 1998;351:17551762Intensive BP-lowering decreases cardiovascular risk in patients with hypertension, especially among those with diabetes

UKPDS: relative risk reduction with tight versus less tight blood pressure controlAny diabetes-related endpointDiabetes-related deathsStrokeMicrovascular disease24% P

BP targetsBP targets in guidelines are becoming more stringentCoexistent cardiovascular risk factor profile is importantThe relationship between BP and mortality is not dictated by a J-shaped curveStrngt : ktat,kras

Initial AssessmentTarget organ damageOverall cardiovascular riskRule out secondary and often curable causes

Components of Risk StratificationTarget Organ Damage/Clinical Cardiovascular DiseaseTarget end-organs should be assessed by history and physical examinationAdapted from: JNC VI. Arch Intern Med 1997;157: 2413-46

Components of Risk StratificationMajor Cardiovascular Risk FactorsHypertensionAgeSmokingDyslipidemiaDiabetesFamily historyObesity> 45 years Male> 55 years Female (Postmenopausal) CAD

Stratification of risk to quantity prognosis Blood pressure (mm Hg) 2003 ESH-ESC

The ideal antihypertensive agentEffectively reduces BPMaintains BP control over 24 h withonce-a-day dosingEffective in all hypertensive patientsNo adverse effectsNo negative metabolic side effectsAffordable

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

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

HOT: percentage of patients requiring combination therapy to achieve target DBP90 mmHg37.1%62.9%85 mmHg31.7%68.3%80 mmHg26.1%73.9%Combination therapyMonotherapyTarget DBP groupThe lower the target DBP, the greater the need for combination therapyHOT:Hypertesion Optimal Treatment

Advantages of combination therapyAdditive antihypertensive efficacy (due to complementary mechanisms of action)Higher patient response ratesSimple titration and dosing schedulesMaintained or improved tolerabilityImproved patient complianceCost effective

RAS = renin-angiotensin systemSNS = sympathetic nervous system

Thiazide ActivatesRenin AngiotensinSystem

Reduce Adverse Effects of Drug Therapy:CombinationPrevents hypokalaemia of thiazide therapyLimits hyperkalaemia of RAS(r angt sys) blockade

WHAT IS THE IDEAL WAY OF CONTROLLING BP?

The new therapeutic window in hypertension100806040200100806040200Efficacy (%)Freedom from side effects (%)DoseMan Int Veld AJ. J Hypert, 1997IDEAL treatmentTraditional

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

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

BP target of

Most patients with hypertension will require 2 or more antihypertensive drugs to achieve BP goalsAccording 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 agentsWhen 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 thiazide-type diuretic

Chobanian AV et al. JAMA. 2003;289:2560-2572.Guidelines Committee. J Hypertens. 2003;21:1011-1053.

Easy as ABCDA = ACE-Inhibitor or Angiotensin Receptor BlockerB = - BlockerC = Calcium Channel BlockerD = Diuretic (thiazide)

More EffectiveIn YoungerMore EffectiveIn Older

YoungerOr Diabetes ( 55yrs)Older (55yrs)or BlackA or BC or D1.A or (B) + C or D2.A or (B) + C + D3.A or (B) + C + D + other4.

Recommended Combinations1. ACE inhibitors / AIIRADiuretics2. ACE inhibitors / AIIRACalcium antagonists3. ACE inhibitors / AIIRABeta-blockers(Special condition)4. Beta-BlockersDiuretics5. Beta-BlockersCalcium Antagonists

SUMMARYCOMBINATION THERAPY IN HTN MANAGEMENT IS LOGIC AND EVIDENCE BASEDMAXIMIZE EFFECT, MINIMIZE SIDE EFFECTCOMBINATION THERAPY IN HTN INCREASE COMPLIANCE THE END

Slide 1. Trends in the awareness, treatment and control of hypertension in the U.S.The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) highlights the results of the National High Blood Pressure Education Program in increasing awareness, prevention, treatment, and control of hypertension.1 Although surveys showed an increasing awareness among Americans of their high blood pressure (BP) and an increase in the number of patients treated, and successfully controlled from NHANES II to the first phase of NHANES III, no further progress has been recorded in the subsequent survey (NHANES III, Phase 2).2Declines in age-adjusted mortality rates for coronary heart disease and stroke in the period from 1972 to 1994 have been dramatic, although the decline in stroke levelled out from 1992 onwards. The prevention and treatment of hypertension remains an important public health challenge.

Slide 2. BP targetsWith each sequential edition of management guidelines on hypertension, the recommended BP targets become more stringent. The most recent issues by the World Health Organization and the International Society for Hypertension,3 and the JNC VI guidelines recommend BP targets of