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Hypertension & Cardiovascular Risk Factors
Final Year Cardiology Teaching
2003-4
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Outline
• Global burden of cardiovascular disease
• Epidemiology of cardiovascular disease
• Hypertension– Epidemiology– Clinical features– Investigation
• Cardiovascular risk assessment
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The Global Burden of Disease
The scope of the problem
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Leading Causes of Death and Disability (DALY’s)
Rank Cause % Rank Cause %
1 Lower respiratory infections 8.2 1 Ischemic heart disease 5.9
2 Diarrhoeal diseases 7.2 2 Major depression 5.7
3 Perinatal conditions 6.7 3 Road traffic accidents 5.1
4 Major depression 3.7 4 Cerebrovascular disease 4.4
5 Ischemic heart disease 3.4 5 COPD 4.2
6 Cerebrovascular disease 2.8 6 Lower respiratory infections 3.1
7 Tuberculosis 2.8 7 Tuberculosis 3.0
8 Measles 2.7 8 War 3.0
9 Road traffic accidents 2.5 9 Diarrhoeal diseases 2.7
10 Congenital abnormalities 2.4 10 HIV 2.6
1990 2020
Global Burden of Disease Study, 1996
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*
**
*
World Health Report 2002
Mortality due to leading global risk factors
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Cardiovascular risk factors
Blood pressure
Lipids
Diabetes
Smoking
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BP and relative risk of stroke and CHD
Brit Med Bull 1994;50:272-98
Approximate mean usual BP Approximate mean usual BP
12376
12376
13684
13684
14891
14891
16298
16298
175105
175105
4.00
2.00
1.00
0.50
0.25
4.00
2.00
1.00
0.50
0.25
Stroke CHD
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Blood Pressure and Risk of Congestive Heart Failure:the Framingham Study
0
20
40
60
80
100
120
140
35-44 45-54 55-64 65-74
Ave
rag
e a
nnu
al r
ate
/ 10
,00
0
Age at examination
NormotensiveBP <140/90 mmHg
HypertensiveBP >160/95 mmHg
Kannel et al. 1972
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Systolic BP as a risk factor for renal failure
0
20
40
60
80
100
< 117 117-123 124-130 131-140 > 140
White men 300,645
African-American men 20,222
Systolic BP, mmHg
Inci
denc
e / 1
00,0
00 p
erso
n ye
ars
MRFIT ‘screenees’ Klag MJ, JAMA ‘97; 277: 1293
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Cholesterol and risk of CHD & cardiovascular death
Approximate mean usual cholesterol (mmol/l)
4.0 4.5 5.0 5.5 6.0
4.00
2.00
1.00
0.50
0.25
Re
lati
ve
Ris
k
(51652 participants, 310 events)
Approximate mean usual cholesterol (mmol/l)
4.0 4.5 5.0 5.5 6.0
4.00
2.00
1.00
0.50
0.25
Re
lati
ve
Ris
k
Coronary Heart Disease(51652 participants, 310 events)
Re
lati
ve
Ris
k
Cardiovascular Death(9 studies, 49296 participants, 938 events)
Approximate mean usual cholesterol (mmol /l)
4.0 4.5 5.0 5.5 6.0
4.00
2.00
1.00
0.50
0.25
Approximate mean usual cholesterol (mmol /l)
4.0 4.5 5.0 5.5 6.0
4.00
2.00
1.00
0.50
0.25
Eastern Stroke & Coronary Heart Disease Project
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Association between cholesterol and ischemic stroke
4.0 4.5 6.05.55.0
Rela
tive
risk
Approximate mean usual cholesterol concentration (mmol/L)
Asia Pacific Cohort Studies Collaboration
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0
20
40
60
80
100
120
140
160
Developed Developing World
mil
lio
ns
Worldwide Prevalence of Diabetes1997
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0
1
2
3
4
5
6
CH
D
CH
F
Str
oke
All
CV
D
Non
-CV
D
All
caus
e
Oth
er C
VD
Non-diabeticsDiabetics
Asia-Pacific Cohort Studies Collaboration
Risks of death in diabetics and non-diabetics
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Smoking
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0
50
100
150
200
250
300
350
1 2
Years
Cu
mu
lati
ve d
ea
ths
(in
mil
lio
ns)
Premature Deaths From Tobacco Use
Preventable if adults quit (halving global cigarette consumption by 2020)
Preventable if young adults do not start (halving global uptake by 2020)
Other premature deaths from tobacco-related causes
2000-2024 2025-2049
The World Health Report, 1999: Making a Difference
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Blood Pressureor
Hypertension?
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Hypertension and alcoholC. Lian, French army physician, 1915
0
5
10
15
20
25
30
Sobres Moyens Buveurs Grands Buveurs
% h
ype
rten
sive
Sobres <1 litre wine/ dayMoyens buveurs: 1-1.5 litres wine/ dayGrands buveurs: 2-2.5 litres wine/ dayTres grands buveurs: 3 litres wine/ day + 4-6 aperitifs
Tres GrandsBuveurs
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Blood Pressureor
Hypertension?
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The ‘normal’ distribution of diastolic BP within a population
0
5
10
15
20
50 60 70 80 90 100 110 120 130
Diastolic BP, mmHg
% o
f sc
reen
ed p
opul
atio
n
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Hypertension: a practical definition
That level of blood pressure at which investigation and treatment
do less harm than good
Rose
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Assessment of the Hypertensive Patient
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History+
Examination
Hypertension risk factorsWeight
Family historySalt, Alcohol,Stress
Target organ damageHeartBrainEyes
Kidneys
Clues to 2o HTSymptoms
DrugsSigns
Other CV risk factorsLipids
SmokingDiabetesExercise
Concurrent conditionsAsthma
GoutPregnancy
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Investigations• Urine• Blood• ECG
? Specialised investigations• Renal USS• 24-hour ABPM• Echocardiography• Angiography• Hormone assays• CT / MRI scanning
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Indications for further investigations
• Clinical features of an underlying cause• Early onset (< 30 y)• Rapid progression• Proteinuria, haematuria, glycosuria• Severe hypertension, difficult to control• Vascular disease: peripheral, coronary, carotid• Heart failure, ‘flash’ pulmonary oedema• Lack of nocturnal dip on ABPM
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Secondary causes of hypertension…
…. comprise a small proportion of overall cases, probably < 5%
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The Heinz guide to hypertension
Renal artery stenosis
Pyelonephritis
Obstruct nephropathy
Vesico-ureteric reflux
Ask-Upmark kidney
Renal dysplasia
Renin JGA tumor
Glomerulonephritis
Polycystic disease
Analgesic kidney
Systemic sclerosis
ITT purpura
Haemolytic uremic
1o Aldosteronism
Cushing’s syndrome
Phaeochromocytoma
DOC excess
Cong adrenal h’plasia
Gluc remediable
Diabetes
Amyloidosis
Carbenoxalone
Obstruct sleep apnoea
Alcohol
MAO-I inhibitors
Pre-eclampsia
Liquorice
Sympathomimetics
Chronic renal failure
Poliomyelitis
11- OH-St dehyd def
Porphyria
Acromegaly
Aortic coarctation
intracranial pressure
Oral contraceptive
Endothelinoma
Lead poisoning
Corticosteroids
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Renal artery stenosis
Secondary causes of hypertension
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Polycystic kidney
Secondary causes of hypertension
Phaeochromocytoma
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Phaeochromocytoma
MIBG scan
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Target Organ Damage&
Complications of Hypertension
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Target organ damage: left ventricular hypertrophy
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Target organ damage: hypertensive retinopathy
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Grade 4 hypertensive retinopathy
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Intra-cerebralhaemorrhage
Complications of hypertension
Myocardial infarction inhypertrophied left ventricle
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Management of Hypertension
Non-pharmacological/ lifestyle
Pharmacological
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Measures that lower blood pressure: weight salt intake alcohol consumption physical exercise fruit & vegetable consumption
Measures to reduce cardiovascular risk: Stop smoking saturated fat, poly- & mono-unsaturates oily fish consumption total fat intake
Non-pharmacological interventions
BHS Guidelines 1999
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The Mediterranean Diet
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BP lowering treatment and cardiovascular risk
Brit Med Bull 1994;50:272-98
Tot
al n
umbe
r of
indi
v idu
als
affe
cted
Stroke CHD All vasculardeaths
All otherdeaths
1200
1000
800
600
400
200
% reductionin odds
38%SD 4
16%SD 4
T C
T C
T CT C
Fatal events
Non-fatal events
T=treatmentC=control
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Drug treatment of hypertension
Diuretic
Beta-blocker
Calcium-channel blocker
ACE-inhibitor
(Alpha-blocker)
Angiotensin receptorblocker
Most hypertensives will need 2 drugs to control BP Drug combinations may be synergistic
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How to choose anti-hypertensive therapy
ACE inhibitor (AII antagonist) Aor-blocker B
Calcium antagonist C Diuretic D
One drug: Younger, non-black A or BOlder, black C or D
Two drugs: (A or B) + (C or D)
Three drugs: (A or B) + C + D
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Target blood pressure
< 140/90 mmHg
…. except in those with diabetes or chronic renal disease
< 130/80 mmHg
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Cholesterol & cardiovascular disease
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“Large randomised trials demonstrate lowering LDL- cholesterol by 1 mmol/l reduces non-fatal MI and fatal CHD by about 25% ( about half the the effect predicted from epidemiological studies for a similar reduction in long term cholesterol lowering in people without vascular disease ) “ Collins 2002With greater reductions in cholesterol there are correspondingly larger reductions in CHD endpoints.
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Landmark Statin Trials: LDL-C Levels vs Events at 5 Years
Follow-up
5.4 (210)2.3 (90) 2.8 (110) 3.4 (130) 3.9 (150) 4.4 (170) 4.9 (190)
0
5
10
15
20
25
AFCAPS-S
WOSCOPS-S
WOSCOPS-PCARE-S
LIPID-P
4S-P
LIPID-S
CARE-P
4S-S
AFCAPS-P
Modified from Kastelein JJP. Atherosclerosis. 1999;143(suppl 1):S17-S21.
Per
cen
tag
e w
ith
CH
D e
ven
t
LDL-C, mmol/L (mg/dL)
S=statin treated; P=placebo treated* Extrapolated to 5 Years
Secondary preventionPrimary preventionSimvastatin
Pravastatin
Lovastatin
ASCOT-S*
ASCOT-P*Atorvastatin
HPSl-S
HPSh-S
HPSl-P
HPSh-P
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