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Hypertension
 

Hypertension

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    Hypertension Hypertension Presentation Transcript

    • Hypertension in Malaysia Assoc. Prof. Dr. Rashidi Ahmad MD(USM), MMed(EM)(USM),FADUSM, AM(Mal), Clinical Fellow (Cardio)(NHI) School of Medical Sciences, USM, KB, Kelantan
    • Objectives Understanding hypertension Magnitude of hypertension in Malaysia Best clinical practice (antihypertensive agents)
    • Definition Confirmed/based on the average of 2 or more readings taken at 2 or more visits to the doctor.
    • CUFF: Width should at least be 40% of the circumference of the arm
    • SITTING ARM SUPPORT IN STANDING KOROTKOFF PHASE: SBP 1 CLEAR TAPPING SOUNDS FIRST APPEAR DBP 5 THE DISAPPEARANCE OF SOUND
    • Important rules Check BP both arms – coarctation of aorta, arterial anomaly Lying & standing – postural drop in elderly, diabetics Beware of auscultatory gap
    • Pathophysiology
    • Keep thinking of secondary causes Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
    • IHD mortality versus blood pressure
    • O’Donnell, et al. J Hypertension, 1998; 16: 3
    • Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
    • Magnitude of HPT Affects about 50 million people in the US and approximately 1 billion worldwide. Prevalence increases with age: individuals who are normotensive at age 55 still face a 90% lifetime risk of developing HPT. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002;287:1003-10.
    • Chan 1997: 10% Lim,et al 1991: 13.8% Prevalence rates from Srinavas, et al Different years and 1998: 25.6% Different populations Nawawi 2002: 31.2% Liew, et al. 1997: 42.8%
    • Hypertension in Malaysia Prevalence: 25.7%. Men vs women - 26.3% vs 25.0%. 1 in 4 adults aged 25-64 years had HPT. Known hypertensives: 1.4 million Newly diagnosed:1.7 million. Chinese (31.0%), Malays (23.4%) and Indians (21.6%).
    • Prevalence of HPT by sex and race amongst Malaysian residents aged ≥ 18 years in 2006 (N=33,976) Sex, % (95% CI) Age (Years) Male Female Both sexes All races 33.3 (31.6, 32.8) 31.0 (30.3, 31.7) 32.2 (31.6, 32.8) Malay 33.7 (32.5, 34.8) 34.1 (33.1, 35.1) 33.9 (33.1 34.7) Chinese 35.0 (33.2, 36.8) 29.8 (28.2, 31.4) 32.4 (31.1, 33.8) Indians 30.9 (28.2, 33.8) 27.8 (25.6, 30.1) 29.4 (27.5,31.2) Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2) Bumi Sarawak 35.6 (31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)
    • Prevalence of HPT by sex and race amongst Malaysian residents aged ≥ 30 years in 2006 (N=24,796) Sex, % (95% CI) Age (Years) Male Female Both sexes All races 41.7 (40.7, 42.8) 43.4 (42.5, 44.4) 42.6 (41.8, 43.3) Malay 45.8 (44.4, 47.1) 51.2 (50.0, 52.4) 45.4 (44.3, 46.4) Chinese 47.4 (45.4, 49.4) 42.3 (40.4, 44.3) 40.6 (39.0, 42.1) Indians 44.1 (40.8, 47.4) 42.7 (39.9, 45.5) 40.0 (37.7, 42.3) Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2) Bumi Sarawak 35.6 ( 31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)
    • Rural vs Urban Rural 36.9% ( 35.9, 38.0) Urban 29.3% ( 28.5, 30.0)
    • The Malaysian Rule All hypertensives 64% 36% Aware 12% 88% Treated 74% 26% controlled
    • The ‘Malaysian Rule’ 100 All hypertensives 64 36 Aware 69 31 Treated 92 8 Controlled
    • Overall BP Control by ethnicity Indian 12.2% ( 10.0,14.7) Chinese 11.5% ( 10.1,12.9) Malays 7.0% ( 6.4,7.7)
    • Comparison with NHMS 11 ( > 30 years ) 1996 2006 Prevalence 33% 43% Aware 33 % 36% Diagnosed & Rx 23% 88% Rx and controlled 26% 26% Overall control 6% 8%
    • Hypertension Control in the Asia Pacific Region Prev Aware Treat Control Thailand (2003-4) 22.2% 28.6% 23.7% 8.6% China 2002 18.8% 30.2% 24.7% 6.1% Korea 2001 22.9% 30.2% 22.9% 10.7% Malaysia 2006 32.2% 35.8% 31% 8.2% USA 2004 29.9% 66.5% 53.7% 33.1%
    • Clinical Aspects – Current Status ( IHM MOH 2006 ) National Essential Hypertension Audit - rates of control Hospital with specialist 31.2% Hospital without specialist 26.6% Clinics with FMS/ MO 28.8% Clinics without FMS/MO 26.9%
    • Clinical Aspects – Current Status ( IHM MOH 2006 ) National Essential Hypertension Audit - rates of control by ethnicity Malay 24.3% Indian 30.8% Chinese 37.6% Others 30.8%
    • Clinical Aspects – Current Status ( IHM MOH 2006 ) National Essential Hypertension Audit - rates of control by age 30-39 19.4% 40-49 27.1% 50-59 29.1% >60 29.2%
    • Points to ponder! Patients’ non compliance Doctors not sure when to treat and what the treatment goals are Doctors not using the right drug/drugs Patients has undiagnosed secondary hypertension or complications of hypertension which makes optimum control difficult
    • What are the better ways to manage hypertensive patients in Malaysia?
    • Risk Stratification Co-existing Condition No RF TOD TOC Previous MI No TOD or or or No TOC RF (1 – 2) RF (≥ 3) Previous stroke BP Levels No TOC or or (mmHg) Clinical Diabetes atherosclerosis SBP 120 – 139 and/or Low Medium High Very high DBP 80 – 89 SBP 140 – 159 and/or Low Medium High Very high DBP 90 – 99 SBP 160 – 179 and/or Medium High Very high Very high DBP 100 – 109 SBP 180 – 209 and/or High Very high Very high Very high DBP 110 – 119 SBP ≥ 210 and/or Very high Very high Very high Very high DBP ≥ 120 Risk Level Risk of Major CV Event in 10 years Management Low < 10% Lifestyle changes Medium 10 – 20% Drug treatment and lifestyle changes High 20 – 30% Drug treatment and lifestyle changes Very high > 30% Drug treatment and lifestyle changes
    • First line therapy NICE / BHS ACEi / ARB/ diuretics/ CCB ESH/ESC ACEi /ARB/diuretics/CCB/Beta blockers WHO/ISH Low dose diuretics/ ACEi/CCB MSH ACEi / ARB/diuretics/CCB Chinese ACEi /ARB/diuretics/CCB/Beta blockers
    • Choice of anti-hypertensive drugs in patients with concomitant conditions Concomitant disease Diuretics β- ACEIs CCBs Peripheral ARBs blockers α-blockers Diabetes mellitus + +/- +++ + +/- ++ (without nephropathy) Diabetes mellitus (with ++ +/- +++ ++* +/- +++ nephropathy) Gout +/- + + + + + Dyslipidaemia +/- +/- + + + + Coronary heart disease + +++ +++ ++ + + Heart failure +++ +++# +++ +@ + +++ Asthma + - + + + + Peripheral vascular + +/- + + + + disease Non-diabetic renal ++ + +++ +* + ++ impairment Renal artery stenosis + + ++$ + + ++$ Elderly with no co-morbid +++ + + +++ +/- + conditions The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice +/- Use with care - Contraindicated * Only non-dihydropyridine CCB # Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated @ Current evidence available for amlodipine and felodipine only $ Contraindicated in bilateral renal artery stenosis
    • ESH/ESC Guidelines 2007 monotherapy vs combination therapy Mild BP elevation Choose between Marked BP elevation Low / moderate CV risk High / very high CV risk Conventional BP target Lower BP target Single agent Two-drug combination at low dose at low dose If goal BP not achieved Previous agent Switch to different agent Previous combination Add a third drug at full dose at low dose at full dose at low dose If goal BP not achieved Two-to three-drug Full dose Two-three-drug combination combination at full dose monotherapy at full dose ESH/ESC Guidelines 2007 J Hypertens. 2007;25:1105-1187
    • Newly diagnosed, uncomplicated patients with hypertension with no compelling indication First line monotherapy Blockers of the renin system ( ACEi, ARB ) Calcium channel blockers Diuretics
    • WHO/ISH JNC-6 Effects of diuretics and ß-blockers on cardiovascular mortality Treatment Treatment Better Worse Drug Dose No. RR (95% CI) Diuretics High 11 0.78 (0.62-0.97) Diuretics Low 4 0.76 (0.65-0.89) ß-blockers 4 0.89 (0.76-1.05) 0.4 0.7 1.0 RR (95% CI)
    • Combination therapy BP >160/90 mmHg Include diuretics as part of combination therapy (ACEI + Diuretic) Consider fixed dose combination if compliance is an issue
    • Malaysian Untreated Hypertensives (Acta Cardiol. 1999;54:277-282 ) NT HT SBP * 120 (112-130) 169(160- 180) DBP* 80 ( 78-82 ) 100 ( 100-110 ) MAP * 94 ( 91-97 ) 123 ( 119-130 ) PWV* 8.8 (8.3- 9.6) 11.7(10.9- 12.9 ) Our population most likely needs combination antihypertensive agents
    • Malaysian Untreated Hypertensives ( Asia Pacific J Pharmacol ; 1997 :89-95 ) NT HT Se Na * 142.18 +0.78 146.83+2.30 UNaV * 140.58+ 15.65 100.55+17.28 Se i Ca* 1.25 + 0.01 1.17+0.01 PRA 0.89+0.19 0.79+0.2 PRC 3.09+0.74 4.23+1.43 Se Aldo 275+21.51 257 + 16.22 “Malaysian hypertensives are salt retainers “ “ Malaysian hypertensives are normoreninaemic hypertensives “
    • Effective Combinations in Malaysia - Retrospective Review of Record ( Asia Pac J Pharmacol.; 2001:17-24 ) Diuretics No Diuretics ( n=100 ) ( n=100 ) SBP * 140 +2 151+3 DBP * 85+1 88+1 dSBP * 30+3 21+3 dDBP 13+2 13+2
    • Effective Combinations in Malaysia Diuretics No Diuretics Controlled 66% 38% p < 0.0001
    • What predicts BP control ? By univariate analysis Odds p Statin on admission 2.53 0.000 Presence of IHD 2.21 0.001 Diuretics on admission 2.12 0.002 ACE I on admission 1.97 0.006 > 2 drugs 1.92 0.007
    • What predicts BP control ? By multivariate analysis Odds p Statin on admission 1.79 0.030 Diuretics on admission 1.77 0.033
    • The Raub Heart Study Prevalence of Hypertension, Diabetes and Obesity 1993 1998 Males Hypertension 26.2 30.6 Diabetes 4.4 4.7 Obesity 3.1 5.2 Overweight 17.7 30.9 Females Hypertension 29.4 31.7 Diabetes 3.5 7.5 Obesity 10.5 12.3 Overweight 25.3 31.1
    • Blood pressure and vascular risk in diabetes Best evidence: 2000 UK Prospective Diabetes Study
    • UKPDS SBP UK Prospective Diabetes Study
    • Blood pressure reduction 165 Placebo Perindopril-Indapamide Average BP 155 during follow-up Mean Blood Pressure (mmHg) 145 Systolic 140.3 mmHg 135 134.7 mmHg 125 ∆ 5.6 mmHg (95% CI 5.2-6.0); p<0.001 115 105 95 85 Diastolic 75 77.0 mmHg ∆ 2.2 mmHg (95% CI 2.0-2.4); p<0.001 74.8 mmHg 65 R 6 12 18 24 30 36 42 48 54 60 Follow-up (Months)
    • All-cause mortality 10 Placebo Perindopril-Indapamide COVERSYL PLUS Cumulative incidence (%) 14% 5 Relative risk reduction 14%: 95% CI 2-25% p=0.025 0 0 6 12 18 24 30 36 42 48 54 60 Follow-up (months)
    • Conclusion Hypertension is getting more prevalent in Malaysia Awareness and control rates are still poor Understanding the profile of our patients is important for optimum management
    • A typical Malaysian Hypertensive - Back to Reality ! Diagnosed late Has other concomitant cardiovascular risk factors Has complications of hypertension including target organ damage and target organ complications BP not optimally controlled We have more works to do?
    • Thank You for Your Attention !