The traditional method based on the mercury sphygmomanometer is being phased out, and the oscillometric technique using the upper arm is becoming the standard method for BP measurement, both in the clinic, at home and during 24 hour ambulatory recordings.
Slide Summary According to a meta-analysis of over 60 prospective studies, the risk of cardiovascular mortality doubles with each rise of 20 mm Hg in systolic blood pressure (BP) and 10 mm Hg in diastolic BP. Background In a meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline, the researchers found that between the ages of 40-69 years, each incremental rise of 20 mm Hg systolic BP and 10 mm Hg diastolic BP was associated with a twofold increase in death rates from ischemic heart disease and other vascular disease. The researchers also noted that when attempting to predict vascular mortality risk from a single BP measurement, the average of systolic and diastolic BP was “slightly more informative” than either alone, and that pulse pressure was “much less informative.” The seventh report Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) notes this study result as yet more information linking hypertension to high risk for cardiovascular events. Lewington S, Clarke R, Qizilbash H, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet . 2003;361:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.
07/22/10 Slide 8 Multiple Risk Factor Intervention Trial (MRFIT): Effect of BP on CHD- Related Mortality After an average of 12 years of follow-up, 6,327 deaths from coronary heart disease (CHD) occurred among the 316,099 men screened for entry into the Multiple Risk Factor Intervention Trial (MRFIT). 1 As the graph on this slide shows, the age-adjusted CHD death rate per 10,000 person-years was associated with increasing DBP above 70 mm Hg and increasing SBP above 110 mm Hg, with the greatest increases associated with rises in SBP. SBP was a stronger predictor of CHD death than DBP. SBP is the risk factor, DBP adds nothing to risk, and wide pulse pressure, even in young men, is the problem. Reference 1. Neaton JD, Wentworth D. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Arch Intern Med . 1992;152:56-64.
This slide shows the changes in classification of blood pressure from JNC VI to JNC 7. 1,2 “ Optimal” blood pressure in JNC VI became “normal” in JNC 7, while “normal” and “borderline” blood pressures in JNC VI were combined as “prehypertension” in JNC 7. 1,2 Stage 1 hypertension remained constant from JNC VI to JNC 7. 1,2 However, JNC 7 grouped JNC VI Stage 2 and Stage 3 hypertension into one stage (Stage 2). 1,2 This change reflected the fact that the approach to patient management for both former categories is similar. 1 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1997;157:2413-2446. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension . 2003;42:1206-1252.
Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA . 2003;290:199-206. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999-2000: a rising tide. Hypertension . 2004;44:398-404. Hypertension: How Big Is the Problem? Recent study used data from the National Health and Nutrition Examination Survey (NHANES) and the US Census Bureau to estimate hypertension burden, prevalence rates, and trends for adults from 1994 to 1998 to adults in 1999 to 2000 At least 65 million adults had hypertension in 1999 to 2000 Prevalence rate 31% Number of adults with hypertension increased by 30% for 1999 to 2000 compared to the 50 million for 1994 to 1998 Trends associated with increased: Obesity population Aging population Growing population
The Comparative Risk Assessment module of the World Health Organization (WHO)’s Global Burden of Disease 2000 study performed a systematic assessment of changes in population health that would result from modifying exposure to environmental and physiological health risk factors. The methodology used to determine the attributable mortality and attributable burden of disease due to each risk factor was a counterfactual analysis in which the contribution of 1 or a group of risk factors is estimated by comparing the current disease burden with the magnitude that would be expected in an alternative scenario characterized by a theoretical minimal exposure. In the case of high BP and cholesterol, the theoretical minimal exposures were levels of 115 mm Hg and 3.8 mmol/L, respectively. This analysis of the contribution of 26 selected risk factors to global disease burden found that high BP was the leading cause of mortality in both developing regions and developed regions of the world. The study looked at the impact of risk factors on mortality. High mortality, developing regions such as many countries in Africa and Southeast Asia. Lower mortality, developing regions such as Latin America and countries in the Western Pacific. Developed regions including Europe, Japan, and North America. In high mortality, developing regions, the leading causes of death were reported to be childhood and maternal undernutrition, including being underweight. However, despite the large contribution of communicable, maternal, perinatal, and nutritional conditions and their underlying risk factors to disease burden in the high mortality, developing regions, the “industrialized” risks of high BP, tobacco, and blood cholesterol levels also resulted in significant loss of life in these regions. Across developed regions, high BP, tobacco use, alcohol, high cholesterol, and high body mass index (BMI) were reported to be consistently the leading causes of loss of life. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347-1360. SLIDE
07/22/10 Hypertension is an important contributing risk factor for end-organ damage and subsequent increases in morbidity and mortality. The goal in treating hypertension is to prevent cardiovascular and renal complications. Even small elevations above optimal blood pressure (BP) values (<120/80 mm Hg) increase the likelihood of developing hypertension (BP ≥140/90 mm Hg) and incurring target-organ damage. Chronic elevations of BP lead to target-organ damage and the development of cardiovascular and renal diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, left-ventricular hypertrophy, and renal failure. Signs of target-organ damage herald a poorer prognosis and may present in the heart, blood vessels, kidneys, brain, or eyes. Later consequences include cardiac, cerebrovascular, vascular, and renal morbidities and death. Because of the complex nature of hypertension, it is not surprising that single antihypertensive agents normalize BP for less than a majority of hypertensive patients. Reference Cushman WC. J Clin Hypertens . 2003;5(suppl):14-22.
Awareness, treatment, and control rates of hypertension improved from the 1976-1980 NHANES II to the 1988-1991 NHANES III, phase 1. Awareness increased from 51% to 73%, treatment rate from 31% to 55%, and control rates from 10% to 29%. However, from the first phase of NHANES III (1988-1991) to the second phase (1991-1994); there was a plateauing of awareness, treatment, and control rates, as seen in this slide. In the most recent NHANES survey (1999-2000), rates of awareness, treatment, and control had increased again. Therefore, relative to 1976-1980, realization of the importance of BP has been on the rise. The present control rate of 34%, however, is still significantly short of the 2000/2010 goal of 50%. Definitions: With hypertension = systolic BP 140 or diastolic BP 90 mm Hg, or taking medication Aware hypertension = with hypertension and told by doctor Treated hypertension = taking hypertension medication Control hypertension = taking hypertension medication and systolic BP <140 and diastolic BP <90 mm Hg. Percentages are over population with hypertension (denominator). Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension . 1995;25:305-313. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA . 2003;289:2560-2572.
07/22/10 The National Health and Nutrition Examination Survey (NHANES) also evaluated the effect of race/ethnicity on awareness, treatment, and control of hypertension among various populations. Hypertension awareness, treatment, and overall control rates were lower in Mexican Americans ( P =.005, P <.001, and P <.001, respectively) than in non-Hispanic whites and non-Hispanic blacks. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA . 2003;290:199-206.
07/22/10 Like patients with diabetes, patients with the metabolic syndrome are at increased risk for CHD. Both diseases are associated with insulin resistance, a condition in which the normal actions of insulin are impaired. As with diabetes, obesity—particularly central, or abdominal, obesity—and a sedentary lifestyle are RFs for the development of insulin resistance. Moreover, patients with the metabolic syndrome have a higher risk of developing overt diabetes than do subjects without this condition. The clinical criteria used to identify patients with metabolic syndrome recommended by the National Cholesterol Education Program (NCEP) are shown on this slide. The diagnosis is established when 3 or more of these RFs are present. The presence of the metabolic syndrome substantially enhances the risk of CHD at any given low-density–lipoprotein cholesterol (LDL-C) level. Because the correlation between abdominal obesity and other metabolic syndrome RFs is stronger than the correlation between BMI and these RFs, the measurement of waist circumference is recommended as a simple method to identify the weight component of the metabolic syndrome. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Lakka H-M et al. JAMA . 2002;288:2709-2716.
07/22/10 Global risk assessment is the first step in CV risk management, and the intensity of risk-reduction therapy is based on the patient’s degree of absolute risk for CV events. This is because it is now understood that the impact of moderate elevations in several risk factors on CV morbidity and mortality is equivalent to large elevations in a single risk factor. The absolute global risk is determined by The Framingham Point Scores, which quantify the 10-year risk for developing CHD. The Framingham Point Scores for men and women take into account 6 risk factors—age (1), total serum cholesterol level (2), systolic BP and hypertension treatment status (3), serum HDL-C (4), and smoking status (5). Each risk factor is assigned a point value according to the Framingham Point Scores, and these values may be different for men and women. The 10-year risk for MI and coronary death measured in percent is estimated from the sum of the points (6). Point scores for men are shown here. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA . 2001;285:2486-2497.
07/22/10 Large-scale clinical trials have addressed a number of questions about the treatment of hypertension. The earliest trials, such as the VA Cooperative Studies, MRC1 and ANHBP 1, investigated whether to treat diastolic hypertension. Determining the goal of treatment was the question addressed by HDFP, HOT, and UKPDS, later trials. Whether to treat diastolic BP elevation in older patients was investigated in the EWPHE, MRC, STOP, and SCOPE studies. Whether to treat systolic BP elevation in older patients was answered by SHEP, Syst-Eur and Syst-China. Many trials have addressed the question “What is the best way to treat HBP?,” starting with HAPPHY, MAPHY, TOMHS, and the VA study, and more recently extending to INSIGHT, NORDIL, ALLHAT, ANBP2, CONVINCE, and LIFE. Trials under way are also investigating the best way to treat high BP (HBP)—VALUE, ACCOMPLISH—and whether we can prevent hypertension—TROPHY. *See reference list at end of slide set for all trial references.
Analyses for major CV events, CV mortality, and total mortality did not show significant differences among -blockers/diuretics, calcium antagonists, or ACEIs. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomized trials. Lancet . 2003;362:1527-1535.
07/22/10 In summary, the key messages regarding BP targets for clinicians treating patients with diabetes and hypertension are as follows: SBP is a far more important target than DBP for both CV and renal protection; it is a particularly crucial modulator of risk in older patients and those with diabetes or CKD. Clinicians should focus on reducing SBP to currently recommended levels—<140 mm Hg in all patients with hypertension; <130 mm Hg in higher risk patients, such as those with diabetes and/or CKD. Only a small fraction of treated hypertensives are currently achieving appropriate BP control based on data from national surveys. The failure to achieve intensive BP targets results in less than maximum benefit to these patients. Patients with diabetes, especially those with renal impairment, usually require at least 2 different antihypertensive agents to achieve goal BP; many require at least 3 agents.
07/22/10 The treatment of hypertension is generally similar across all demographic groups. Socioeconomic factors and lifestyle are important barriers to BP control in minority populations. The prevalence, severity, and impact of hypertension are increased in blacks, who also demonstrate a reduced BP response to certain types of antihypertensive monotherapy.
07/22/10 As recommended by JNC 7, hypertension treatment should start with lifestyle modifications. If the patient is not at goal BP of <140/90 mm Hg (<130/80 mm Hg for those with diabetes or chronic kidney disease), pharmacologic therapy should be initiated. Initial drug choices for patients without compelling indications should be a thiazide diuretic for most patients with stage 1 hypertension. Typically, combination therapy with 2 drugs is required for stage 2 hypertension. When use of a single drug fails to achieve the BP goal, addition of a second drug from a different class should be initiated. A 2-drug combination usually consists of a thiazide-type diuretic plus an ACEI, an ARB, a -blocker, or a CCB. Specific antihypertensives are designated for compelling indications (ie, HF, post-MI, high coronary artery disease [CAD] risk, diabetes, etc.). If a patient is still not at goal BP following the treatment algorithm, optimize the patient’s dosages or add additional drugs until goal BP is achieved. Also consider consulting with a hypertension specialist. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA . 2003;289:2560-2572.
07/22/10 In a global effort, patients, providers, and the healthcare system must make their contributions to get hypertension to goal.
Epidemiology of Hypertension Stanley S. Franklin, MD, FACP, FACC Clinical Professor of Medicine University of California at Irvine Associate Medical Director UCI Heart Disease Prevention Program Irvine, California
Agenda: epidemiology of hypertension <ul><li>BP measurement </li></ul><ul><li>Defining hypertension </li></ul><ul><li>Why an important public health problem </li></ul><ul><li>Calculating Global cardiovascular risk </li></ul><ul><li>Intervention trials and meta-analyses </li></ul><ul><li>Management strategies </li></ul><ul><li>Barriers to treatment </li></ul><ul><li>Prevention strategies </li></ul>
Defining Hypertension: By the numbers? ≥ 95 DBP 160/95 140/90 130/85 >120/80 “ A number at which the benefits of intervention exceed those of inaction”
CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment * *Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet . 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572. CV mortality risk SBP/DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75 135/85 155/95 175/105
Defining Hypertension: By subtype? IDH , SDH , ISH
<40 40-49 50-59 60-69 70-79 80+ Age (y) 17% 16% 16% 20% 20% 11% Distribution of Hypertension Subtype in the Untreated Hypertensive Population by Age (NHANES III) Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age . Franklin et al. Hypertension. 2001;37: 869-874 . Frequency of hypertension subtypes in all untreated hypertensives (%) } Diastolic Hypertension ISH (SBP 140 mm Hg and DBP <90 mm Hg) SDH (SBP 140 mm Hg and DBP 90 mm Hg) IDH (SBP <140 mm Hg and DBP 90 mm Hg) 0 20 40 60 80 100
An Analysis of NHANES III Blood Pressure Data <ul><li>Summary: Hypertensives fall into one of two categories: </li></ul><ul><li>1. A smaller (26%), younger (age 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH ) </li></ul><ul><li>2. A larger (74%), older (age 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH ). </li></ul>Franklin et al. Hypertension 2001;37: 869-874
Defining hypertension by BP components SBP DBP PP MAP
The BP Components of the Arterial Pulse Wave Pulse pressure = 1/3 SBP + 2/3 DBP 75 125 Pressure (mm Hg) Systolic pressure Diastolic pressure Mean pressure Diastolic decay curve Dicrotic notch (aortic valve closes) Time
Multiple Risk Factor Intervention Trial (MRFIT): Effect of BP on CHD-Related Mortality (N=316,099) * *Men aged 35-57 y followed for a mean of 12 y. Neaton JD, Wentworth D. Arch Intern Med . 1992;152:56-64. DBP (mm Hg) SBP (mm Hg) 100 90-99 80-89 75-79 70-74 <70 <120 120-139 140-159 160 Death Rate per 10,000 Person-Years
Blood Pressure and Risk for CHD by Age Groups: Results of a Single BP Component † Model † Adjusted for age, sex, and other risk factors * P <0.1, ** P <0.01, *** P <0.001 Franklin SS, et al. Circulation 2001;103:1245-1249. CHD Hazard Ratio/10 mm Hg (CI) Age (y) <50 50-59 60 0.0 0.4 0.8 1.2 1.6 2.0 SBP (10 mm Hg) DBP (10 mm Hg) PP (10 mm Hg) *** *** ** * * *** *** 1.0
Defining hypertension by Hemodynamics CO PVR Arterial stiffness
Hemodynamics of Arterial Blood Pressure <ul><li>Steady component </li></ul><ul><li>(MAP = CO x PVR) </li></ul><ul><li>(↑Resistance small art.) </li></ul><ul><li>[ MAP = 1/3(SBP) + 2/3(DBP)] </li></ul><ul><li>(Predominantly diastolic) </li></ul><ul><li>(“Essential HTN”--young) </li></ul><ul><li>-- ↑VC or ↓VD responses </li></ul><ul><li>-- ↑wall-to-lumen diameter </li></ul><ul><li>-- Rarefaction (Art./Cap.) </li></ul><ul><li>Pulsatile component </li></ul><ul><li>(PP = SBP – DBP) </li></ul><ul><li>(↑Stiffness large arteries) </li></ul><ul><li>(↑CO and ↑SV) </li></ul><ul><li>(Isolated systolic HTN) </li></ul><ul><li>(Pathologic aging) </li></ul><ul><li>-- Disarray of elastin protein </li></ul><ul><li>-- Abn. extracellular matrix </li></ul><ul><li>-- ↑Collagen/Calcium depos. </li></ul>
JNC Reclassification of BP Based on Risk Source for JNC VI: Arch Intern Med . 1997;157:2413-2446. Adapted with permission from Chobanian AV et al. Hypertension. 2003;42:1206-1252. JNC VI SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) DBP (mm Hg) Category Category JNC 7 Optimal Normal 80 <120 <120 and 80 and Normal Hi-normal Prehypertension 120-129 130-139 120-139 80-84 or 85-89 and 80-89 or Stage 1 Hypertension Stage 1 140-159 140-159 90-99 or 90-99 or Stage 2 Stage 3 Stage 2 160-179 ≥ 1 80 ≥ 1 60 100-109 or ≥ 110 or ≥ 100 or
Prevalence of Blood Pressure Categories in US Adults ≥20 Years of Age (NHANES 1999-2000) Greenland, Croft, Mensah (CDC). Arch Intern Med. 2004;164:2113f 30% Hypertension 31% Prehypertension 39% Normal Prevalence BP Category
Prehypertension … <ul><li>Is not a disease, </li></ul><ul><li>Is not “hypertension”, </li></ul><ul><li>Is not an indication for drug treatment of HTN, </li></ul><ul><li>Does not have a BP goal, </li></ul><ul><li>Does predict a higher risk for developing CV events, </li></ul><ul><li>Does predict a higher risk for developing HTN, </li></ul><ul><li>Should be an incentive to improve lifestyle practices for prevention of HTN and CVD. </li></ul>
Risk Pyramid: SBP and CHD Mortality for Men Screened in MRFIT Adapted from Stamler J et al. Arch Intern Med . 1993;153:598-615. Hypertension Control. WHO Technical Reports Series, 1996. No. 862. SBP (mm Hg) Excess CHD deaths (%) Men (%) 180 7.2 0.9 170-179 6.8 1.2 160-169 10.1 2.7 150-159 19.5 6.2 140-149 23.4 12.8 130-139 20.7 22.8 120-129 9.9 28.4 110-119 1.3 19.0 <110 0.0 6.1 High BP 73.5% 42.9% 30.6%
Why is HTN an important Public health Problem?
Firstly, hypertension is very common In the adult population
Hypertension: How Big Is the Problem? At Least 65 Million Americans have Hypertension Nearly 1 in 3 Adults (31%) in the US Has Hypertension Fields LE et al. Hypertension . 2004;44:398–404.
Age Distribution of Hypertensives in US Population: NHANES III and the 1991 Census 3.7 9.5 13 21.3 23.7 19.2 9.6 Hypertensives Within Age Group (%) Franklin SS. J Hypertension. 1999;17(suppl 5):S29-S36. Age Groups (y) 47.4 million hypertensives 26.0% of US population 26% 74% 0 5 10 15 20 25 30 18–29 30–39 40–49 50–59 60–69 70–79 80+
1976-98 Cumulative Incidence of HTN in Women and Men Aged 65 Years Vasan, et al. JAMA.2002;287:1003 Risk of Hypertension % Years of Follow-up Women Men
Trends in Prevalence of Hypertension in the US Population, by Race/Ethnicity,1988-2000 * p<0.01, ** p<0.001,compared to Non-Hispanic Whites within given time period; no significant trends across time periods within gender; analyses are age-adjusted to 2000 US population. Data from Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003; 290: 199-206. ** ** ** * *
Hypertension Prevalence and Treatment Among Persons 35-64 Years Old in 6 European Countries, Canada, and the United States Based on surveys of 1823 to 23129 respondents conducted from 1986 to 1999 (US NHANES III survey data from 1988-1994). Adapted from Wolf-Maier K et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003; 289: 2363-2369.
Secondly, hypertension is associated with considerable cardiovascular risk.
Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors Ezzati et al. Lancet. 2002;360:1347-1360. Attributable Mortality (In thousands; total 55,861,000) 0 8000 7000 6000 5000 4000 3000 2000 1000 High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight High mortality, developing region Lower mortality, developing region Developed region
Defining Hypertension: Is it a true risk factor or a risk marker ? A true risk factor is suspected of being causative of the disease process. A risk marker is associated with the disease process without being in the causal pathway.
Complications of Hypertension: TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; HF = heart failure. Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22. Hypertension is a risk factor Retinopathy Renal failure Peripheral vascular disease LVH, CHD, HF TIA, stroke
Thirdly, there is considerable reduction in cardiovascular risk with effective lowering of blood pressure with therapy.
Fourthly, there is insufficient awareness, treatment and control of hypertension.
Hypertension Awareness, Treatment, and Control: US 1976 to 2000* NHANES III (Phase 2) 1991-1994 NHANES III (Phase 1) 1988-1991 51% 73% 68% 31% 55% 54% 10% 29% 27% % Adults NHANES II 1976-1980 NHANES 1999-2000 70% 59% 34% Control Awareness Treated Chobanian et al. JAMA . 2003;289:2560-2572. Healthy People 2000/2010 Control Target = 50%
Awareness, Treatment, and Control of Hypertension by Various Populations * P <.01; † P <.001; ‡ P <.05 (for the difference among groups within the same survey phase [non-Hispanic whites as the referent for race/ethnicity]). § Includes all survey participants with hypertension, whether treated or not. Source: National Health and Nutrition Examination Survey 1999-2000 data. Data are weighted to the US population. Hajjar I, Kotchen TA. JAMA. 2003;290:199-206. 80 70 60 50 40 30 20 10 0 Prevalence (%) Awareness Treatment Control, All Treated Control, All Hypertensive § 69.5 73.9 57.8* 60.1 63.0 40.3 † 55.6 44.6 ‡ 44.0 ‡ 33.4 28.1 17.7 † Non-Hispanic Whites Non-Hispanic Blacks Mexican Americans
Risk Factor Clustering With Hypertension Risk factor clustering with hypertension, ages 18–74 years. Framingham offspring. Kannel WB. Am J Hypertens . 2000. 0 1 2 3 5 0 10 15 20 25 30 Men Women 17 % 19% 26 % 27% 25 % 24% 22% 20% 8% 12 % ≥ 4 Risk Factors (%) Number of Risk Factors
BP is a risk marker for “The Metabolic Syndrome” *Diagnosis is established when ≥3 of these risk factors are present. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. NCEP-ATP III Definition: ≥3 of the Following* <ul><li>Men: >102 cm (>40 in) </li></ul><ul><li>Women: >88 cm (>35 in) </li></ul>Fasting glucose <ul><li>≥ 130/≥85 mm Hg </li></ul>Blood pressure HDL-C <ul><li>≥ 150 mg/dL </li></ul>Triglycerides Abdominal obesity (waist circumference) <ul><li>Men: <40 mg/dL </li></ul><ul><li>Women: <50 mg/dL </li></ul><ul><li>≥ 100 mg/dL </li></ul>
Other CVD Risk Factors: JNC 7 <ul><li>Physical inactivity </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Age (older than 55 for men, 65 for women) </li></ul><ul><li>Family history of premature CVD </li></ul><ul><li>(men under age 55 or women under age 65) </li></ul>*Components of the metabolic syndrome in blue Chobanian et al. JAMA . 2003;289:2560-2572
ATP-III: Framingham Point Scores Estimate of 10-Year Risk for Men Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Age, y Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 1 2 5 Total Age Age Age Age Age Cholesterol 20-39 40-49 50-59 60-69 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 1 3 0 240-279 9 6 4 2 1 280 11 8 5 3 1 Age Age Age Age Age 20-39 40-49 50-59 60-69 70-79 HDL mg/dL Points 60 -1 50-59 0 40-49 1 <40 2 Systolic BP If If mm Hg Untreated Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2 160 2 3 Point Total 10-Year Risk, % <0 <1 0 1 1 1 2 1 3 1 4 1 5 2 6 2 7 3 8 4 9 5 10 6 11 8 12 10 13 12 14 16 15 20 16 25 17 30 6 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 4 3
ESH/ESC Guidelines: Stratification of Risk to Quantify Prognosis 6252 M Very high added risk Very high added risk Very high added risk High added risk Very high added risk Very high added risk High added risk High added risk Moderate added risk Moderate added risk Moderate added risk Low added risk Blood Pressure (mmHg) Other Risk Factors and Disease History No other risk factors 1-2 risk factors ACC Grade 1 SBP 140-159 or DBP 90-99 Grade 2 SBP 160-179 or DBP 100-109 Grade 3 SBP ≥ 180 or DBP ≥ 110 3 or more risk factors or TOD or diabetes Very high added risk High added risk High added risk Moderate added risk Average risk Low added risk Low added risk Average risk Normal SBP 120-129 or DBP 80-84 High Normal SBP 130-139 or DBP 85-89 ACC: associated clinical conditions; TOD: target organ damage; SBP: systolic blood pressure; DBP: diastolic blood pressure
Advice from Woody Allen <ul><li>“ If I knew I would live this long I would have taken better care of myself” </li></ul><ul><li>“ Sudden Death is nature’s way of telling you to slow down” </li></ul>______________________________________________________ ______________________________________________________ ____________________________________________________________
<ul><li>“ Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” </li></ul>Paul Dudley White, 1931 Textbook of Cardiology.
Clinical Trials in Hypertension HR Black, 2003. 1960s 1970s 1980s 1990-1995 1996-1999 2000 2001-2003 2004-2008 Should we treat diastolic HBP? What is the best way to treat HBP? Should we treat DBP in older persons? What is the goal of treatment? Should we treat ISH in older persons? Can we prevent hypertension? TROPHY TOMHS VA MONORx CONVINCE ALLHAT ANBP2 LIFE HAPPHY MAPHY INSIGHT NORDIL CAPPP STOP-2 VALUE ASCOT ACCOMPLISH VA Cooperative Studies MRC-1 ANHBP-1 EWPHE MRC-2 STOP-1 SCOPE HDFP HOT UKPDS Syst-Eur Syst-China SHEP
SHEP Trial of the elderly with ISH : Design <ul><li>N: 4736; 43% male </li></ul><ul><li>Age: > 60 </li></ul><ul><li>BP: SBP 160-219 and DBP <90 </li></ul><ul><li>Design: Placebo control, double blind </li></ul><ul><li>Active Rx: Chlorthalidone (atenolol as step 2) </li></ul><ul><li>SBP difference: 12 mm Hg </li></ul><ul><li>Duration: 4.5 years </li></ul>JAMA 1991;265:3255
Placebo Perindopril 4 mg/d +3 HYVET Perindopril 2 mg/d Indapamide SR 1.5 mg/d Placebo Placebo Placebo Protocol +6 +9 +12 +18 +24 +60 mo. 0 – 1 – 2 double-blind goal BP: <150/80 mmHg Beckett NG et al, NEJM. 2008; 358: 1887-98 open FU Age 80-105 with stage 2 HTN
HYVET trial in the very elderly Per Protocol Beckett N. N Engl J Med . 2008;358: epub. March 31, 2008. 0.51-0.71 0.17-0.48 0.55-0.97 0.33 - 0.93 0.59 - 0.88 0.46 - 0.95 95% CI 0.029 - 27% Cardiovascular mortality - 37% - 72% - 45% - 28% - 34% HR <0.001 <0.001 0.021 0.001 0.025 P value All stroke Total mortality Fatal stroke Heart failure Cardiovascular events
Blood Pressure Lowering Effect Specific Drug Effect Which is more important to minimize CV Events? or
BP-Lowering Treatment Trialists Comparisons of Different Active Treatments 0.5 1.0 2.0 Relative Risk RR (95% CI) BP Difference (mm Hg) Favors First Listed Favors Second Listed Major CV events CV mortality Total mortality Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet . 2003;362:1527-1535. 1.02 (0.98, 1.07) 2/0 ACEI vs D/BB 1.03 (0.95, 1.11) 2/0 ACEI vs D/BB 1.00 (0.95, 1.05) 2/0 ACEI vs D/BB 1.04 (0.99, 1.08) 1/0 CA vs D/BB 1.05 (0.97, 1.13) 1/0 CA vs D/BB 0.99 (0.95, 1.04) 1/0 CA vs D/BB 0.97 (0.95, 1.03) 1/1 ACEI vs CA 1.03 (0.94, 1.13) 1/1 ACEI vs CA 1.04 (0.98, 1.10) 1/1 ACEI vs CA
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS National Heart, Lung, and Blood Institute National High Blood Pressure Education Program
JNC 7: Appropriate BP Targets <ul><li>For both CVD and kidney disease, systolic BP is far more important than diastolic BP </li></ul><ul><li>Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease) </li></ul><ul><li>Only a small fraction of hypertensives are achieving appropriate BP control </li></ul><ul><li>Multiple antihypertensive agents are needed for most patients </li></ul><ul><li>Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD. </li></ul>
JNC 7: Considerations for older persons with hypertension <ul><li>This population has the lowest rates of BP control and the </li></ul><ul><li>greatest absolute benefit with effective therapy. </li></ul><ul><li>Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. </li></ul><ul><li>More than two-thirds of people over 65 have HTN, i.e. ISH </li></ul><ul><li>(Isolated systolic hypertension). </li></ul>
JNC 7: Considerations for special populations with hypertension <ul><li>Treatment generally similar for all demographic groups </li></ul><ul><li>Socioeconomic factors and lifestyle important barriers to BP control </li></ul><ul><li>Prevalence, severity of hypertension increased in blacks </li></ul>JNC 7. JAMA . 2003;289:2560-2672.
<ul><li>Intervention </li></ul><ul><li>Exercise </li></ul><ul><li>Weight reduction </li></ul><ul><li>Alcohol intake reduction </li></ul><ul><li>Sodium intake reduction </li></ul><ul><li>DASH diet </li></ul>Lifestyle Interventions for Prevention or Treatment of Hypertension <ul><li>Blood Pressure Effect </li></ul><ul><li>5-10 mm Hg ( > 30 min > 3x/wk) </li></ul><ul><li>1-2 mm Hg/Kg </li></ul><ul><li>1 mm Hg/drink/d </li></ul><ul><li>1-3 mm Hg/40 mmol/d </li></ul><ul><li>3-10 mm Hg </li></ul>Adapted from Cushman et al. Endocrine Practice 1997;3:106 & Sacks, et al. NEJM 2001;334:3
Lifestyle Treatment Measures <ul><li>Nonpharmacologic treatments are used for: </li></ul><ul><li>Lowering blood pressure </li></ul><ul><li>Reducing need for antihypertensive agents </li></ul><ul><li>Minimizing associated risk factors </li></ul><ul><li>Primary prevention of hypertension </li></ul>
JNC 7 Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Chobanian et al. JAMA . 2003;289:2560-2572. Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed With Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved Consider consultation with hypertension specialist Stage 2 Hypertension (SBP > 160 or DBP > 100 m m Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140 -159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB, or combination Without Compelling Indications
Barriers to Controlling Hypertension Healthcare System Patients Providers
Colors of Salt <ul><li>White </li></ul><ul><li>Black </li></ul><ul><li>Red </li></ul><ul><li>Yellow </li></ul><ul><li>Green </li></ul><ul><li>Brown </li></ul><ul><li>Clear </li></ul><ul><li>Table salt </li></ul><ul><li>Soy sauce </li></ul><ul><li>Catsup </li></ul><ul><li>Mustard </li></ul><ul><li>Pickles </li></ul><ul><li>Soups & gravies </li></ul><ul><li>Saline </li></ul>Courtesy of Marty Grais, MD
The Initial Confrontation of the HTN Problem <ul><li>Upon making a diagnosis of HTN , tell patient the BP reading and what it should be (provide a written copy). </li></ul><ul><li>Prepare patient for the probable necessity for polypharmacy to control BP with a minimum of side effects </li></ul><ul><li>Advise Home BP measurement (135/85 mmHg is considered to be hypertensive). </li></ul>Table 28. JNC 7 Report . Hypertension . 2003;42(6):1240.
Self-Measurement of BP <ul><li>Provides information useful for: </li></ul><ul><ul><li>assessing response to antihypertensive Rx </li></ul></ul><ul><ul><li>improving adherence with therapy </li></ul></ul><ul><ul><li>evaluating white-coat HTN </li></ul></ul><ul><li>Home BP is more strongly related to target organ damage and has better prognostic accuracy than office BP. </li></ul>
Whelton, PK, He J, Appel LA et al., JAMA 2002;288:1882-1888
<ul><li>Epidemiology Summary: </li></ul><ul><ul><li>Increasing prevalence; world wide problem </li></ul></ul><ul><ul><li>Blood pressure as a moving target </li></ul></ul><ul><ul><li>↑ PVR in the young, ↑ stiffness in the elderly </li></ul></ul><ul><ul><li>Predominantly isolated systolic hypertension </li></ul></ul><ul><ul><li>Consider special populations at increased risk </li></ul></ul><ul><ul><li>Hypertension as a part of absolute global CV risk </li></ul></ul><ul><ul><li>Population vs. high risk approaches for prevention </li></ul></ul>