1 Hypertension Hypertension - Complications Complications and Social Impact and Social Impact Dr. Ho Hung Kwong, Duncan 何鴻光 何鴻光 何鴻光 何鴻光 MBBS(HK), MRCP(UK), FHKAM(Med), FHKCP, FRCP(Edin) FAHA, FSCAI Specialist in Cardiology Definition and classification of Definition and classification of hypertension: JNC VII hypertension: JNC VII Hypertension is defined as blood pressure ≥140/90 mmHg or ≥100 ≥160 Stage 2 hypertension or 90-99 140-159 Stage 1 hypertension or 80-89 120-139 Prehypertension and <80 <120 Normal Diastolic (mmHg) Systolic (mmHg) Category JNC VII. JAMA 2003;289:2560-2572
30
Embed
Hypertension -Complications and Social Impact Hypertension -Complications and Social Impact Dr. Ho Hung Kwong, Duncan 何鴻光 MBBS(HK), MRCP(UK), FHKAM(Med), FHKCP, FRCP(Edin) FAHA,
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Hypertension Hypertension -- Complications Complications and Social Impactand Social Impact
Dr. Ho Hung Kwong, Duncan 何鴻光何鴻光何鴻光何鴻光MBBS(HK), MRCP(UK),
FHKAM(Med), FHKCP, FRCP(Edin)FAHA, FSCAI
Specialist in Cardiology
Definition and classification of Definition and classification of hypertension: JNC VIIhypertension: JNC VII
Hypertension is defined as blood pressure ≥140/90 mmHg
or ≥100≥160Stage 2 hypertension
or 90-99140-159Stage 1 hypertension
or 80-89120-139Prehypertension
and <80<120Normal
Diastolic
(mmHg)
Systolic
(mmHg)
Category
JNC VII. JAMA 2003;289:2560-2572
2
Prevalence of HypertensionPrevalence of Hypertension
Prevalence of hypertension*: Prevalence of hypertension*: North America and EuropeNorth America and Europe
0
10
20
30
40
50
60
70
80
United
Sta
tes
Canad
a
Europ
eIta
ly
Sweden
Englan
dSpa
in
Finlan
d
Germ
any
Pre
vale
nce
(%)
MenWomenTotal
Wolf-Maier K, et al. JAMA 2003;289:2363-2369* BP ≥140/90 mmHg or treatment with antihypertensive medication
3
Prevalence of hypertension: AsiaPrevalence of hypertension: Asia
01020304050607080
China
(200
0/20
01)
Taiwan
(199
4)
Hong K
ong
(199
7)
Singap
ore
(199
8)
Mala
ysia
(199
6)
Thaila
nd (1
991)
Philipp
ines
(199
9)
Indo
nesia
(199
4)
India
(Mum
bai, 1
999)
Japa
n (19
92-9
5)
Pre
vale
nce
(%)
Men
Women
Total
Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol1997;24:987-988; National Health Survey 1998, Singap ore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134; Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
Hypertension control rates around the worldHypertension control rates around the world
JNC VI. Arch Intern Med 1997;157:2413-2446; Joffres MR, et al. Am J Hypertens 1997;10:1097-1102; Colhoun HM, et al. J Hypertens 1998;16:747-752; Chamotin B, et al. Am J Hypertens 1998;11:759-762;
Marques-Vidal P, et al. J Hum Hypertens 1997;11:213-220
4
National Health and Nutrition National Health and Nutrition Examination Survey (NHANES) Examination Survey (NHANES)
34%27%29%10%Control†
59%54%55%31%Treatment
70%68%73%51%Awareness
1999-2000
III
(Phase 2 1991-94)
III
(Phase 1 1988-91)
II
(1976-80)
Trends in awareness, treatment and control of high blood pressure in adults aged 18-74*
* High blood pressure * High blood pressure defined asdefined as SBP ≥140 mmHg or SBP ≥140 mmHg or DBP ≥90 mmHg or takingDBP ≥90 mmHg or taking antihypertensiveantihypertensive medicationmedication† SBP <140 mmHg and DBP <90 mmHg† SBP <140 mmHg and DBP <90 mmHg
Unpublished data for 1999Unpublished data for 1999 ––2000 compiled by M. 2000 compiled by M. WolzWolz , , National Heart, Lung and Blood Institute: JNC VINational Heart, Lung and Blood Institute: JNC VI
At-a-Glance Summary TablesMales and Cardiovascular Diseases
Heart Disease and Stroke Statistics – 2006 Update, American Heart Association
5
Impact of HypertensionImpact of Hypertension
Millimetres matter …Millimetres matter …
“A 2“A 2 --mmHg reduction in DBP would mmHg reduction in DBP would
result in … a 6% reduction in the risk of result in … a 6% reduction in the risk of
CHD and a 15% reduction in the risk of CHD and a 15% reduction in the risk of
ESRD (also called end-stage kidney disease) is a condition closely related to high blood pressure, and occurs when the kidneys can no longer function normally on their own.
• The incidence of reported ESRD has almost doubled in the past 10 years. (NHLBI, from usrds.org Web site)
• 82,588 patients died from ESRD in 2003.• Diabetes continues to be the most common
reported cause of ESRD.
AtherosclerosisAtherosclerosis
8
Other Related DiseaseOther Related Disease
Relative importance of SBP and DBP as Relative importance of SBP and DBP as predictors of CHD risk as a function of agepredictors of CHD risk as a function of age
* The difference between SBP and DBP proportional hazard regression coefficients, ie, β(SBP) - β(DBP), was estimated for each age group
Choice of Choice of antihypertensiveantihypertensive therapy:therapy:ESH/ESC 2003ESH/ESC 2003
• Main benefits are due to BP lowering• Specific drug classes may differ in their effects• Drugs are not equal in adverse-event profiles• Major drug classes are suitable for initiation and
maintenance of therapy• Choice of drug will be influenced by patient
experience and preference, and cost and risk profile
• Long-acting drugs that provide once-daily, 24-hour efficacy are preferable
1. This Trial had to be stopped earlier than expected due to significant reductions in cardiovascular death and all cause mortality in patients taking CCB – based regimen (amlodipine besylate) versus a standard Beta blocker based regimen.
2. In addition, they were less likely to develop diabetes compared to patients taking the Beta blocker-based regimen.
SecondaryNon-fatal MI (exc. Silent) +fatal CHDTotal coronary end pointTotal CV event and proceduresAll-cause mortalityCardiovascular mortalityFatal and non-fatal strokeFatal and non-fatal heart failure
ConclusionsConclusions• Amlodipine ± perindopril based therapy confers an advantage
over atenolol ± thiazide based therapy on all major CV end points, all-cause mortality and new-onset diabetes
• Irrespective of the reasons for benefit, the amlodipine ±perindopril regimen should be preferred to the standard regimen of atenolol ± thiazide for most patients with hypertension
• Compared with standard antihypertensive therapy without statintherapy, the amlodipine ± perindopril regimen plus atorvastatinreduced coronary and stroke events by almost 50%
ASCOT-BPLA, LANCET, vol 366 September 10, 2005
23
ASCOTASCOT--BPLABPLA
Implications on Hypertension Implications on Hypertension GuidelinesGuidelines
NICE Guideline 2006NICE Guideline 2006
24
Pharmacological interventionsPharmacological interventions• Drug therapy reduces the risk of cardiovascular disease
and death. Offer drug therapy to: – patients with persistent high blood pressure of 160/100
mmHg or more– patients at raised cardiovascular risk (10-year risk of
CVD of 20% or more or existing CVD or target organ damage) with persistent blood pressure of more than 140/90 mmHg.
• In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic . For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese.
• In hypertensive patients younger than 55 , the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II recept or antagonist if an ACE inhibitor is not tolerated).
General issues when prescribing
• Offer patients with isolated systolic hypertension (systolic blood pressure more than 160 mmHg) the same treatment as patients with both raised systolic and diastolic blood pressure.
• Offer patients older than 80 years the same treatment as other patients aged 55 or older – take account of any co-morbidity and other drugs they are taking.
26
General issues when prescribing
• Prescribe drugs taken only once a day if possible.
• Prescribe non-proprietary drugs if these are appropriate and minimise cost.
• Give information about the benefits and side effects of drugs so that patients can make informed choices.
Drug treatmentDrug treatment
Key issues in updating the recommendations
• Beta-blockers : In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, particularly stroke. Beta-blockers were also less effective than an ACE inhibitor or a calcium channel blocker at reducing the risk of diabetes, particularly in patients taking a beta-blocker and a thiazide-type diuretic.
• Calcium-channel blockers or thiazide-type diuretics : These are the most likely drugs to confer benefit as first-line treatment for most patients aged 55 or older.
27
Drug treatmentDrug treatmentKey issues in updating the recommendations
• People younger than 55 years : The evidence suggests that initial therapy with an ACE inhibitor may be better than initial therapy with a calcium-channel blocker or a thiazide-type diuretic.
• Using more than one drug : Adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa) is a logical combination, and has been commonly done in trials. There is little evidence on using three drugs so the recommendation is based on the most straightforward option.
28
BetaBeta --blockerblocker• Beta-blockers are no longer preferred as a routine initial therapy for
hypertension
• But consider them for younger people, particularly:– women of childbearing potential– patients with evidence of increased sympathetic drive– patients with intolerance of or contraindications to ACE
inhibitors and angiotensin-II receptor antagonists
• If a patient taking a beta-blocker needs a second drug, add a calcium-channel blocker rather than a thiazide-type diuretic, to reduce the patient’s risk of developing diabetes.
BetaBeta --blockerblocker• If a patient’s blood pressure is not controlled by a regimen that includes
a beta-blocker (that is, it is still above 140/90 mmHg), change their treatment by following the flow chart above.
• If a patient’s blood pressure is well controlled (that is,140/90 mmHg or less) by a regimen that includes a beta-blocker, consider long-term management at their routine review. There is no absolute need toreplace the beta-blocker in this case.
• When withdrawing a beta-blocker, step down the dose gradually.
• Beta-blockers should not usually be withdrawn if a patient has a compelling indication for being treated with one, such as symptomatic angina or a previous myocardial infarction.
For 1st line treatment of essential hypertension (people at low risk of heart failure)
• Calcium Channel Blockers are the most cost effective option because they are associated with a low risk of diabetes and they also have a good effectiveness profile across the range of other cardiovascular disease risks.
The cost of cardiovascular diseases The cost of cardiovascular diseases and strokeand stroke
Heart Disease and Stroke Statistics – 2006 Update, American Heart Association
30
Heart Disease and Stroke Statistics – 2006 Update, American Heart Association