An Evidence Based Approach To Hypertension
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Transcript of An Evidence Based Approach To Hypertension
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An evidence-based approach to Hypertension
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Agenda
• Hypertension: The global epidemic
• Classification and Management
• Which is more important SBP or DBP?
• Diuretics in the Guidelines
• Support of recent trials for diuretics
• Conclusion
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Hypertension: The global epidemic
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Hypertension: Leading cause of death
Attributable Mortality (In millions)Attributable Mortality (In millions)
High mortality, developing regionHigh mortality, developing region
Lower mortality, developing regionLower mortality, developing region
Developed regionDeveloped region
00 8877665544332211
High blood pressureHigh blood pressure
TobaccoTobacco
High cholesterolHigh cholesterol
Unsafe sexUnsafe sex
High BMIHigh BMI
Physical inactivityPhysical inactivity
AlcoholAlcohol
Indoor smoke from solid fuelsIndoor smoke from solid fuels
Iron deficiencyIron deficiency
UnderweightUnderweight
Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360.
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%
Reuters Business Insight – Healthcare – 2004 (USA, JAP, FRA, GER, ITALY, SPAIN, UK)
Hypertension prevalence world-wide
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Hypertension prevalence world-wide
Billions
+ 60%
2000 2025
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Hypertension prevalence world-wide
WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004.
Italy38%Spain
47%
England42%
Germany55%Canada
27%
U.S.A.28%
Sweden38%
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Finland21%
Italy9-23%
Spain5-16%
France27%
England6-10%
Scotland18%
Germany8-23%Canada
16-17%
U.S.A.29-31%
Sweden6%
BP<140/9035-64 years
WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004.
Hypertension control world-wide
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Hypertension Awareness, Treatment and Control:US 1976 - 2000
JNC-VII. Hypertension. 2003;42:1206–1252
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Blood Pressure and risk of CV events
Lawes CM et al. J Hypertens. 2006;24:423-430
2/3 of strokes and 1/2 of cases of ischemic
heart disease
are attributable to suboptimal blood pressure
control
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Blood Pressure and risk of Stroke Mortality
MRFIT trial. Arch Intern Med 1992; 152:56-64
0
2
4
6
8
10
<85 85-89 90-99 100+ <130 130-139 140-159 160+
Blood pressure (mm Hg)
Ris
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10
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0 p
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ars Diastolic Systolic
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Blood Pressure and risk of CAD Mortality
0
5
10
15
20
25
30
35
40
75-79 80-89 90-99 100+ <120 120-139 140-159 160+
Blood pressure (mm Hg)
Ris
k o
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AD
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10
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0 p
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on
-ye
ars
Diastolic Systolic
MRFIT trial. Arch Intern Med 1992; 152:56-64
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Classification and Management
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BP Classification
JNC-VII. Hypertension. 2003;42:1206–1252
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BP Classification
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
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BP threshold with different types of measurement
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
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Risk Stratification
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
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When to initiate antihypertensive treatment?
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
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Factors influencing prognosis
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
Risk Factors:Systolic and diastolic BP levels
Levels of pulse pressure (in the elderly)Age > 55 for men, > 65 for women
SmokingDyslipidemia
Abnormal glucose tolerance testAbdominal obesity Physical inactivity
Family history of premature CVD
Subclinical organ damage:LVH
Carotid wall thickening or plaqueCarotid-femoral PWV >12m/s
Slight increase in plasma creatinineLow GFR or creatinine clearance (<60ml/mn)
Microalbuminuria
Established CV or renal disease:Cerebrovascular disease
Heart diseaseRenal disease
Peripheral artery diseaseAdvanced retinipathy
Diabetes mellitus:Fasting plasma glucose >7mmol/L
Postload plasma glucose >11mmol/L
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SBP or DBP?
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SBP increases with age
Franklin SS et al. Circulation. 1997;96:308-315.
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Are people with elevated SBP always elderly?
NHANNES III
>50 years
79.7%
45.1%
40-50 years
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SBP is most predictive of cardiovascular events
MRFIT trial. Arch Intern Med 1992; 152:56-64
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SBP is most predictive of stroke
Borghi c et al. J Hypertens. 2002;20:1737-1742.
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SBP control, difficult to achieve
J Hypertens 2002;20:1461-1464.
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Hypertension control in European countries
Erdine S. J Hypertens. 2000;18:1348-1349.
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Guidelines Recommendation
• Greater emphasis must clearly be placed on managing systolic hypertension.
• Otherwise, the toll of uncontrolled SBP will cause increased rates of:
– Cardiovascular diseases.
– Renal diseases.
JNC 7 report, Hypertension. 2003; 42: 1206-1252.
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Guidelines Recommendation
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J Hypertens 2003;21:1983-1992
Goals of treatment
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
To achieve maximum reduction in the long-term risk of cardiovascular disease
• BP should be reduced to at least < 140/90 mmHg, and to lower values if tolerated, in all hypertensive patients
or• Target BP should be at least < 130/80 mmHg in
diabetics and in high risk patients (Stroke, MI, Renal dysfunction…)
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J Hypertens 2003;21:1983-1992
Goals of treatment
• Despite use of combination treatment, reducing SBP to <140 mmHg may be difficult
• Additional difficulties should be expected in elderly and diabetic patients, and in patients with CV damage
• SBP control is particularly rare…this explains why high BP remains a leading cause of death and cardiovascular morbidity worldwide
2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
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J Hypertens 2003;21:1983-19922007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
Benefits of treating SBP
“Whenever SBP is reduced by 10 mmHg, both
stroke and coronary events are markedly reduced”.
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Diuretics in the Guidelines
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JNC VII algorithm for HT treatment
JNC-VII. Hypertension. 2003;42:1206–1252
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JNC VII algorithm for HT treatment
« Thiazide-type diuretics should be in drug treatment for most patients, either alone or in
combination »
« Thiazide-type diuretics are unsurpassed in lowering blood pressure, reducing clinical
events, and tolerability»
JNC-VII. Hypertension. 2003;42:1206–1252
Thiazide-type Diuretics first-line
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2006 NICE / BHS algorithm for HT treatment
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• After reviewing all the reliable literature, including the most recent one (ASCOT-BPLA), the guideline committee decided to reject the BBs to the 4th line treatment (unless other indications such as CAD, arrythmias, … are present), and to keep the gold standard position of the diuretics as a cornerstone 1st line treatment for hypertension
NICE / BHS
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• CCBs are not recommended for use in elderly hypertensive patients because of side effects.
JNC 7 report, Hypertension. 2003; 42: 1206-1252.
Diuretics versus CCBs
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Diuretic antihypertensives:Support of recent trials
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SHEPThe Systolic Hypertension in the Elderly Program
• Double blind, randomized, placebo controlled study.
• Thiazide diuretic (chlorthalidone) Vs Placebo• 4,736 elderly HT Patients with ISH.
– 583 of them with T2 diabetics.
• Average follow up for 4.5 Ys.• Main outcome is fatal and nonfatal Stroke.
Curb Dj, et al. JAMA.1996;276(23):1886-1892
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SHEP morbidity and mortality for non diabetics
Curb Dj, et al. JAMA.1996;276(23):1886-1892
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SHEP morbidity and mortality for diabetics
Curb Dj, et al. JAMA.1996;276(23):1886-1892
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• Prospective, randomised trial in 6614 patients aged 70-84 years with hypertension
• ACEI ,Ca blockers versus diuretics and ß-blockers
• “ Prescribers who had decided that thiazide diuretics should be first-line treatment for elderly hypertensive people will be further encouraged by the results of STOP 2”
Kendall,co mentary, Lancet,1999
STOP 2Swedish Trial in Old Patients,2
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• Diuretic based treatment reduced:- CHD
- MI
- Stroke
To the same degree as therapy based on ACE I, and CCB.
ALLHAT(Thiazide-type diuretic vs ACEi and CCB-33,357 hypertensives patients)
2. ALLHAT JAMA 2002;288:2981-29971. Appel LJ. JAMA. 2002;288:3039-3042.
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ALLHAT(Thiazide-type diuretic vs ACEi and CCB-33,357 hypertensives patients)
ALLHAT JAMA 2002;288:2981-2997
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ALLHAT(Thiazide-type diuretic vs ACEi and CCB-33,357 hypertensives patients)
2. ALLHAT JAMA 2002;288:2981-29971. Appel LJ. JAMA. 2002;288:3039-3042.
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High-dose diuretic and low-dose diuretic, both reduced the
incidence of stroke (-51%, -34%).
Psaty BM et al. JAMA. 1997;277:739-745.
Diuretics clearly reduce strokes
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Low-dose diuretic reduced the incidence of CHD (-28%).
Psaty BM et al. JAMA. 1997;277:739-745.
Diuretics clearly reduce CHD
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High-dose and low-dose diuretic therapy both significantly reduced cardiovascular mortality(-22% ,-
24%).
Psaty BM et al. JAMA. 1997;277:739-745.
Diuretics clearly reduce CV death
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Diuretics versus β-blockers
Trials in
elderly: Diuretics
or -Blockers
Diuretics
-Blockers
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-Blockers are reported to compare poorly with diuretics in reducing CV
events and strokes
Diuretics versus β-blockers
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Conclusion
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Diuretics: The cornerstone of hypertension treatment
They enhance the antihypertensive efficacy of all other antihypertensive drugs
1.Chobanian AV, Bakris GL, Black HR, et al. (JNC-7). Hypertension. 2003;42:1206-1252.2. WHO, ISH writing group statement on management of hypertension. J Hypertens. 2003;21:1983-1992
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1. The ALLHAT study JAMA. 2002; 288: 2981-2997 2. JNC - VII Report, JAMA , 2003;289:2560-2572
Conclusion
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THANK YOU