Hipertensi

Hypertension Heart Disease

APEKS:SIC VMid claviculer

The World Health Organization (WHO)

estimates that 20% of the world’s

current adult population has

hypertension

Prevalence of hypertension

Awareness, Treatment and Control of High Blood Pressure in Canada

Patients unaware of their high blood pressurePatients unaware of their high blood pressure 43%43%Aware but not treated and not controlledAware but not treated and not controlled 22%22%Treated but not controlledTreated but not controlled 21%21%Treated and controlledTreated and controlled 13%13%

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

4433%%

2222%%2211%%

1133%%

Trends in the awareness, treatment and control of hypertension in the

U.S.

Awareness 51.0% 73.0% 68.4%

Treated 31.0% 55.0% 53.6%

Controlled 10.0% 29.0% 27.6%

NHANES II

1976-80

NHANES III

(Phase I)1988-91

NHANES III

(Phase II)1991-94

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

Failure to treat to target– MD Reluctance– Accurate blood pressure

measurements

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

(non-Rx)

Relctnce: enggan Rstant : mlawan

Diseases Attributable to Hypertension

Hypertension

Heart failureHeart failureStrokeStroke

Coronary heart diseaseCoronary heart disease

Myocardial infarctionMyocardial infarction

Left ventricular Left ventricular hypertrophyhypertrophy

Aortic aneurysmAortic aneurysmRetinopathyRetinopathy

Peripheral vascular diseasePeripheral vascular disease

Hypertensive Hypertensive encephalopathyencephalopathy

Chronic kidney failureChronic kidney failure

Cerebral hemorrhageCerebral hemorrhage

AllVascular

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

Hypertension Optimal Treatment (HOT) study

9.9 10.0 9.3

24.4

18.6

11.9

0

5

10

15

20

25

30

90 mmHg 85 mmHg 80 mmHgTarget DBP group

Major CV events per 1000 patient years

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

Lancet 1998;351:1755–1762

Intensive 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 control

Any diabetes-related endpoint

Diabetes-related deaths

Stroke Microvascular disease

–24% P<0.005

–32% P<0.05

–44% P<0.05

–37% P<0.01

Tight control (n=758)Less tight control (n=390)

Deterioration in visual acuity

–47% P<0.005

BMJ 1998;317:703–713

Tight BP control decreases morbidity and mortality in patients with diabetes

BP targets

BP targets in guidelines are becoming more stringent

Coexistent cardiovascular risk factor profile is important

The relationship between BP and mortality is not dictated by a J-shaped curve

Strngt : ktat,kras

Initial Assessment

Target organ damage

Overall cardiovascular risk

Rule out secondary and often curable causes

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

Components of Risk StratificationTarget Organ Damage/Clinical Cardiovascular Disease

BrainBrain

HeartHeartKidneysKidneys

EyesEyes

ArteriesArteries

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

Components of Risk StratificationMajor Cardiovascular Risk Factors

HypertensionAge

SmokingDyslipidemiaDiabetesFamily history

Obesity

> 45 years Male> 45 years Male> 55 years Female (Postmenopausal) > 55 years Female (Postmenopausal)

CAD <65 FemaleCAD <65 FemaleCAD <55 MaleCAD <55 Male

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

1414

Stratification of risk to quantity Stratification of risk to quantity prognosisprognosis

Other risk factor and Other risk factor and disease historydisease history

Normal Normal SBP 120-SBP 120-129129DBP 80-84DBP 80-84

High High normalnormalSBP 130-SBP 130-139139DBP 85-89DBP 85-89

Grade 1Grade 1SBP140-SBP140-159159DBP 90-DBP 90-9999

Grade 2Grade 2SBP 160-SBP 160-179179DBP 100-DBP 100-109109

Grade 3Grade 3SBP SBP >> 180180DBP DBP > > 110110

No other risk factorsNo other risk factors Average Average riskrisk

Average Average riskrisk

Low Low added added risk risk

Moderate Moderate added riskadded risk

High High added added riskrisk

1 – 2 risk factors1 – 2 risk factors Low added Low added riskrisk

Low added Low added riskrisk

Moderate Moderate added added riskrisk

Moderate Moderate added riskadded risk

Very Very high high added added riskrisk

3 or more risk factors 3 or more risk factors or TOD or DMor TOD or DM

Moderate Moderate added riskadded risk

High High added riskadded risk

High High added added riskrisk

High High added riskadded risk

Very Very high high added added riskrisk

ACCACC High High added riskadded risk

Very high Very high added risk added risk

Very high Very high added added riskrisk

Very high Very high added rsikadded rsik

Very Very added added riskrisk

Blood pressure (mm Hg)

2003 ESH-ESC

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

The ideal antihypertensive agent

• 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: percentage of patients requiring combination therapy to achieve target DBP

90 mmHg

37.1%

62.9%

85 mmHg

31.7%

68.3%

80 mmHg

26.1%

73.9%

Combination therapyMonotherapy

Target DBP group

The lower the target DBP, the greater the need for combination therapyHOT: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 ActivationSNS Activation-Vasoconstriction- Sodium retention

RAS = renin-angiotensin systemSNS = sympathetic nervous system

24

Thiazide

Lowers BloodPressure

NatriureticActivates

Renin AngiotensinSystem

Reduces antihypertensive effect

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Reduce Adverse Effects of Drug Therapy:

ACE inhibition or Angiotensin Receptor Blockers

• Retain potassium

Thiazide Diuretics

• Excrete Potassium

CombinationPrevents hypokalaemia of thiazide therapy

Limits hyperkalaemia of RAS(r angt sys) blockade

26

27

28

29

WHAT IS THE IDEAL WAY OF CONTROLLING BP?

The new therapeutic window in hypertension

100

80

60

40

20

0

100

80

60

40

20

0

Efficacy (%)

Freedom from side effects (%)

Dose

Man In’t Veld AJ. J Hypert, 1997

IDEAL treatment

Traditional

30

31

32 ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB, = calcium channel blocker.Chobanian AV et al. Chobanian AV et al. JAMA. JAMA. 2003;289:2560-2572.2003;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 ClassificationLifestyle Modification

Initial Drug TherapyWithout Compelling

IndicationWith Compelling

Indication

Normal<120/80 mm Hg

Prehypertension120-139/80-89 mm Hg

Stage 1 hypertension140-159/90-99 mm Hg

Stage 2 hypertension160/100 mm Hg

Encourage

Yes

Yes

Yes

No drug indicated Drug(s) for the compelling indications

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)

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• 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.

34

• 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 thiazide-type diuretic

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

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Easy as ABCDA = 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

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A or BInhibit the

Renin-AngiotensinSystem

C or DDo not inhibit the

Renin-AngiotensinSystem

More EffectiveIn Younger

More EffectiveIn Older

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

YoungerOr Diabetes

( 55yrs)

Older (55yrs)or Black

A or B C or D1.

A or (B) + C or D2.

A or (B) + C + D3.

A or (B) + C + D + other4.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 Diuretics2. ACE inhibitors / AIIRA Calcium antagonists3. ACE inhibitors / AIIRA Beta-blockers

(Special condition)4. Beta-Blockers Diuretics5. Beta-Blockers Calcium Antagonists

SUMMARY

COMBINATION THERAPY IN HTN MANAGEMENT IS LOGIC AND EVIDENCE BASED

MAXIMIZE EFFECT, MINIMIZE SIDE EFFECT

COMBINATION THERAPY IN HTN INCREASE COMPLIANCE

THE END