An Evidence Based Approach To Hypertension

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  • An Evidence Based Approach To Hypertension

    1. 1. An evidence-based approach to Hypertension
    2. 2. Agenda <ul><li>Hypertension: The global epidemic </li></ul><ul><li>Classification and Management </li></ul><ul><li>Which is more important SBP or DBP? </li></ul><ul><li>Diuretics in the Guidelines </li></ul><ul><li>Support of recent trials for diuretics </li></ul><ul><li>Conclusion </li></ul>
    3. 3. Hypertension: The global epidemic
    4. 4. Hypertension: Leading cause of death Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360. Attributable Mortality (In millions) High mortality, developing region Lower mortality, developing region Developed region 0 8 7 6 5 4 3 2 1 High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight
    5. 5. Hypertension prevalence world-wide % Reuters Business Insight – Healthcare – 2004 (USA, JAP, FRA, GER, ITALY, SPAIN, UK)
    6. 6. Hypertension prevalence world-wide Billions + 60% 2000 2025
    7. 7. Hypertension prevalence world-wide WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004. Italy 38% Spain 47% England 42% Germany 55% Canada 27% U.S.A. 28% Sweden 38%
    8. 8. Hypertension control world-wide Finland 21% Italy 9-23% Spain 5-16% France 27% England 6-10% Scotland 18% Germany 8-23% Canada 16-17% U.S.A. 29-31% Sweden 6% BP<140/90 35-64 years WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004.
    9. 9. Hypertension Awareness, Treatment and Control: US 1976 - 2000 JNC-VII. Hypertension. 2003;42:1206–1252
    10. 10. Awareness, treatment and control JNC-VII. Hypertension. 2003;42:1206–1252
    11. 11. Blood Pressure and risk of CV events <ul><li>2/3 of strokes and 1/2 of cases of ischemic heart disease </li></ul><ul><li>are attributable to suboptimal blood pressure control </li></ul>Lawes CM et al. J Hypertens. 2006;24:423-430
    12. 12. Blood Pressure and risk of Stroke Mortality MRFIT trial. Arch Intern Med 1992; 152:56-64
    13. 13. Blood Pressure and risk of CAD Mortality MRFIT trial . Arch Intern Med 1992; 152:56-64
    14. 14. Estimated Cumulative Incidence of Morbid Events in Untreated and Treated Hypertensive Patients *Including events such as hemorrhages, uncontrolled heart failure, diastolic blood pressure above specified limits, and cardiac, central nervous system, and renal events Veterans Administration Cooperative Study Group JAMA 1970;213(7):1143-1152
    15. 15. Classification and Management
    16. 16. BP Classification JNC-VII. Hypertension. 2003;42:1206–1252
    17. 17. BP Classification 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    18. 18. BP threshold with different types of measurement 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    19. 19. Risk Stratification 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    20. 20. When to initiate antihypertensive treatment? 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    21. 21. Factors influencing prognosis 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187. <ul><li>Risk Factors: </li></ul><ul><li>Systolic and diastolic BP levels </li></ul><ul><li>Levels of pulse pressure (in the elderly) </li></ul><ul><li>Age > 55 for men, > 65 for women </li></ul><ul><li>Smoking </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Abnormal glucose tolerance test </li></ul><ul><li>Abdominal obesity </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Family history of premature CVD </li></ul><ul><li>Subclinical organ damage: </li></ul><ul><li>LVH </li></ul><ul><li>Carotid wall thickening or plaque </li></ul><ul><li>Carotid-femoral PWV >12m/s </li></ul><ul><li>Slight increase in plasma creatinine </li></ul><ul><li>Low GFR or creatinine clearance (<60ml/mn) </li></ul><ul><li>Microalbuminuria </li></ul><ul><li>Established CV or renal disease: </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Heart disease </li></ul><ul><li>Renal disease </li></ul><ul><li>Peripheral artery disease </li></ul><ul><li>Advanced retinipathy </li></ul><ul><li>Diabetes mellitus: </li></ul><ul><li>Fasting plasma glucose >7mmol/L </li></ul><ul><li>Postload plasma glucose >11mmol/L </li></ul>
    22. 22. SBP or DBP?
    23. 23. SBP or DBP ?
    24. 24. SBP increases with age Franklin SS et al. Circulation. 1997;96:308-315.
    25. 25. Are people with elevated SBP always elderly? NHANNES III >50 years 79.7% 45.1% 40-50 years
    26. 26. SBP is most predictive of cardiovascular events MRFIT trial. Arch Intern Med 1992; 152:56-64
    27. 27. SBP is most predictive of stroke Borghi c et al. J Hypertens. 2002;20:1737-1742.
    28. 28. SBP control, difficult to achieve J Hypertens 2002;20:1461-1464.
    29. 29. Hypertension control in European countries Erdine S. J Hypertens. 2000;18:1348-1349.
    30. 30. Guidelines Recommendation <ul><li>Greater emphasis must clearly be placed on managing systolic hypertension. </li></ul><ul><li>Otherwise, the toll of uncontrolled SBP will cause increased rates of: </li></ul><ul><ul><li>Cardiovascular diseases. </li></ul></ul><ul><ul><li>Renal diseases. </li></ul></ul>JNC 7 report, Hypertension. 2003; 42: 1206-1252.
    31. 31. Guidelines Recommendation
    32. 32. Goals of treatment J Hypertens 2003;21:1983-1992 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187. <ul><li>To achieve maximum reduction in the long-term risk of cardiovascular disease </li></ul><ul><ul><li>BP should be reduced to at least < 140/90 mmHg, and to lower values if tolerated , in all hypertensive patients </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>Target BP should be at least < 130/80 mmHg in diabetics and in high risk patients (Stroke, MI, Renal dysfunction…) </li></ul></ul>
    33. 33. Goals of treatment <ul><li>Despite use of combination treatment, reducing SBP to <140 mmHg may be difficult </li></ul><ul><li>Additional difficulties should be expected in elderly and diabetic patients, and in patients with CV damage </li></ul><ul><li>SBP control is particularly rare…this explains why high BP remains a leading cause of death and cardiovascular morbidity worldwide </li></ul>J Hypertens 2003;21:1983-1992 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    34. 34. Benefits of treating SBP J Hypertens 2003;21:1983-1992 SBP Distributions Before Intervention After Intervention Reduction in BP JNC 7 report, Hypertension. 2003; 42: 1206-1252. Reduction in SBP mmHg 2 3 5 % Reduction in Mortality Stroke CHD Total – 6 –4 –3 – 8 –5 –4 – 14 –9 –7
    35. 35. Benefits of treating SBP <ul><li>“ Whenever SBP is reduced by 10 mmHg, both stroke and coronary events are markedly reduced”. </li></ul>J Hypertens 2003;21:1983-1992 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.
    36. 36. Diuretics in the Guidelines
    37. 37. JNC VII algorithm for HT treatment JNC-VII. Hypertension. 2003;42:1206–1252
    38. 38. JNC VII algorithm for HT treatment <ul><li>« Thiazide-type diuretics should be in drug treatment for most patients, either alone or in combination » </li></ul><ul><li>« Thiazide-type d iuretics are unsurpassed in lowering blood pressure, reducing clinical events, and tolerability » </li></ul>JNC-VII. Hypertension. 2003;42:1206–1252 Thiazide-type Diuretics first-line
    39. 39. 2006 NICE / BHS algorithm for HT treatment
    40. 40. <ul><li>After reviewing all the reliable literature, including the most recent one (ASCOT-BPLA), the guideline committee decided to reject the BBs to the 4 th line treatment (unless other indications such as CAD, arrythmias, … are present), and to keep the gold standard position of the diuretics as a cornerstone 1 st line treatment for hypertension </li></ul>NICE / BHS
    41. 41. <ul><li>CCBs are not recommended for use in elderly hypertensive patients because of side effects. </li></ul>Diuretics versus CCBs JNC 7 report, Hypertension. 2003; 42: 1206-1252.
    42. 42. Diuretic antihypertensives: Support of recent trials
    43. 43. SHEP The S ystolic H ypertension in the E lderly P rogram <ul><li>Double blind, randomized, placebo controlled study. </li></ul><ul><li>Thiazide diuretic (chlorthalidone) Vs Placebo </li></ul><ul><li>4,736 elderly HT Patients with ISH. </li></ul><ul><ul><li>583 of them with T2 diabetics. </li></ul></ul><ul><li>Average follow up for 4.5 Ys. </li></ul><ul><li>Main outcome is fatal and nonfatal Stroke. </li></ul>Curb Dj, et al. JAMA.1996;276(23):1886-1892
    44. 44. SHEP morbidity and mortality for non diabetics Curb Dj, et al. JAMA.1996;276(23):1886-1892
    45. 45. SHEP morbidity and mortality for diabetics Curb Dj, et al. JAMA.1996;276(23):1886-1892
    46. 46. <ul><li>Prospective, randomised trial in 6614 patients aged 70-84 years with hypertension </li></ul><ul><li>ACEI ,Ca blockers versus diuretics and ß-blockers </li></ul><ul><li>“ 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” </li></ul>STOP 2 S wedish T rial in O ld P atients,2 Kendall,co mentary, Lancet,1999
    47. 47. <ul><li>Diuretic based treatment reduced: </li></ul><ul><ul><ul><li>- CHD </li></ul></ul></ul><ul><ul><ul><li>- MI </li></ul></ul></ul><ul><ul><ul><li>- Stroke </li></ul></ul></ul><ul><ul><li>To the same degree as therapy based on ACE I, and CCB. </li></ul></ul>(Thiazide-type diuretic vs ACEi and CCB - 33,357 hypertensives patients) 2. ALLHAT JAMA 2002;288:2981-2997 1. Appel LJ. JAMA. 2002;288:3039-3042. ALLHAT
    48. 48. (Thiazide-type diuretic vs ACEi and CCB - 33,357 hypertensives patients) ALLHAT JAMA 2002;288:2981-2997 ALLHAT
    49. 49. (Thiazide-type diuretic vs ACEi and CCB - 33,357 hypertensives patients) 2. ALLHAT JAMA 2002;288:2981-2997 1. Appel LJ. JAMA. 2002;288:3039-3042. ALLHAT
    50. 50. Diuretics clearly reduce strokes High-dose diuretic and low-dose diuretic, both reduced the incidence of stroke ( -51%, -34% ). Psaty BM et al. JAMA. 1997;277:739-745.
    51. 51. Diuretics clearly reduce CHD Low-dose diuretic reduced the incidence of CHD ( -28% ). Psaty BM et al. JAMA. 1997;277:739-745.
    52. 52. Diuretics clearly reduce mortality Low-dose diuretic reduced the incidence of Total mortality ( -10% ). Psaty BM et al. JAMA. 1997;277:739-745.
    53. 53. Diuretics clearly reduce CV death High-dose and low-dose diuretic therapy both significantly reduced cardiovascular mortality( -22% ,-24% ). Psaty BM et al. JAMA. 1997;277:739-745.
    54. 54. Diuretics versus β -blockers Trials in elderly: Diuretics or  -Blockers Diuretics  -Blockers
    55. 55. <ul><li> -Blockers are reported to compare poorly with diuretics in reducing CV events and strokes </li></ul>Diuretics versus β -blockers
    56. 56. Conclusion
    57. 57. Diuretics: The cornerstone of hypertension treatment 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 They enhance the antihypertensive efficacy of all other antihypertensive drugs
    58. 58. Conclusion 1. The ALLHAT study JAMA. 2002; 288: 2981-2997 2. JNC - VII Report, JAMA , 2003;289:2560-2572
    59. 59. THANK YOU

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