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Hypertension And Old And New

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10th Post Graduate Course PAFP Pangasinan Chapter

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Hypertension And Old And New

  1. 1. The Relationship of Systolic and Diastolic Blood Pressure to Cardiovascular Disease Risk: Observational Data
  2. 2. Hypertension Awareness, Treatment, and Control: US 1976 to 2000 NHANES, National Health and Nutrition Examination Survey. Chobanian AV et al. JAMA. 2003;289:2560-2572. Incidence (%) NHANES II 1976-1980 NHANES III (Phase 1) 1988-1991 NHANES III (Phase 2) 1991-1994 NHANES 1999-2000
  3. 3. Prevalence of Hypertension in the United States* † *Based on NHANES 1999  2000 data. Hypertension is defined as blood pressure  140/90 mmHg or antihypertensive treatment. † Low reliability due to large relative error. Fields et al. Hypertension . 2004:44;398-404 . Hypertension Prevalence Age
  4. 4. Hypertension Prevalence by Age and Race/Ethnicity in Men and Women Hypertension Prevalence Based on NHANES 1999-2000. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Non-Hispanic White Non-Hispanic Black Mexican American Hajjar I, Kotchen TA. JAMA. 2003;290:199-206. Age, y Men Women Age, y
  5. 5. Lifetime Risk of Developing Hypertension Among Adults Aged 55 to 65 Years* *Residual lifetime risk of developing hypertension among adults aged 55 to 65 years with a blood pressure <140/90 mmHg. Risk of Hypertension (%) Years Men Women Vasan RS, et al. JAMA . 2002; 287:1003-1010. Copyright 2002, American Medical Association.
  6. 6. Mortality According to Blood Pressure in Men Age 50 to 69 Society of Actuaries. Blood Pressure Study, 1939. Ratio (%) of actual to expected mortality Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
  7. 7. Blood Pressure and Risk for Coronary Heart Disease in Men Age-adjusted annual incidence of CHD per 1000 Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at baseline Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Age 65-94 Age 35-64 Age 65-94 Age 35-64 Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
  8. 8. Risk of CHD Death According to SBP and DBP in MRFIT Relative risk of CHD mortality He J, et at. Am Heart J. 1999;138:211-219. Copyright 1999, Mosby Inc. <112 <71 Decile 112- 71- 118- 76- 121- 79- 125- 81- 129- 84- 132- 86- 137- 89- 142- 92- > 151 > 98 (lowest 10%) (highest 10%) SBP (mmHg) DBP (mmHg) Systolic blood pressure (SBP) Diastolic blood pressure (DBP) CHD=coronary heart disease 1 2 3 4 5 6 7 8 9 10
  9. 9. Risk of Stroke Death According to Blood Pressure: MRFIT Relative Risk of Stroke Death <112 <71 1 2 3 4 5 6 7 8 9 10 Decile 112  71  118  76  121  79  125  81  129  84  132  86  137  89  142  92  ≥ 151 ≥98 (Lowest 10%) (Highest 10%) SBP (mmHg) DBP (mmHg) Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) Stamler J, et al. Arch Intern Med . 1993;153:598-615; He J, Whelton PK. Am Heart J . 1999;138(Pt 2):211-219. MRFIT, Multiple Risk Factor Intervention Trial.
  10. 10. Isolated Systolic Hypertension and CVD Risk in Framingham Heart Study Age-adjusted annual CVD event rate per 1000 Wilking SV et al. JAMA. 1988;260:3451-3455. Men Women ISH BP  160/<95 mmHg BP <140/95 mmHg 82 43 33 2.4 18 2.5 CVD=cardiovascular disease ISH=isolated systolic hypertension P<0.001 for difference between both men and women with ISH and blood pressure (BP) <140/95 mmHg
  11. 12. Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies
  12. 13. Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies <ul><li>STOP-2 (1999) </li></ul><ul><ul><li>The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes </li></ul></ul><ul><li>INSIGHT (2000) </li></ul><ul><ul><li>The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications </li></ul></ul><ul><li>NORDIL (2000) </li></ul><ul><ul><li>The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death </li></ul></ul><ul><li>ARIC (2000) </li></ul><ul><ul><li>In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes </li></ul></ul><ul><ul><li>Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk </li></ul></ul>
  13. 14. STOP-2 <ul><li>The S wedish T rial in O ld P atients With Hypertension- 2 (STOP-2) was a prospective, randomized trial enrolling 6,614 patients, 70-84 years old, with hypertension (systolic BP  180 mmHg, diastolic BP  105 mmHg, or both) </li></ul><ul><li>Patients were assigned to treatment with conventional antihypertensive drugs (n=2,213), ACE inhibitors (n=2,205), or calcium channel blockers (n=2,196) </li></ul><ul><li>Endpoints were fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease </li></ul><ul><li>719 patients (10.9%) had diabetes at baseline </li></ul>Hansson L, et al. Lancet. 1999;354:1751-1756.
  14. 15. STOP-2 Change in Supine Blood Pressure From Baseline* Change in BP from baseline (mmHg) Hansson L, et al. Lancet. 1999;354:1751-1756. *Among patients who survived at least 24 months
  15. 16. STOP-2 Frequency of Events Per 1000 Patient Years Events per 1000 patient years Hansson L, et al. Lancet. 1999;354:1751-1756. P=0.018 P=0.025
  16. 17. Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies <ul><li>STOP-2 (1999) </li></ul><ul><ul><li>The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes </li></ul></ul><ul><li>INSIGHT (2000) </li></ul><ul><ul><li>The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications </li></ul></ul><ul><li>NORDIL (2000) </li></ul><ul><ul><li>The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death </li></ul></ul><ul><li>ARIC (2000) </li></ul><ul><ul><li>In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes </li></ul></ul><ul><ul><li>Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk </li></ul></ul>
  17. 18. INSIGHT <ul><li>The I nternational N ifedipine GITS S tudy: I ntervention as a G oal in H ypertension T reatment (INSIGHT) was a prospective, randomized trial that enrolled 6,321 patients, 55-80 years old, with hypertension (BP  150/95 mmHg, or systolic BP  160 mmHg) and at least one additional risk factor </li></ul><ul><li>Patients were randomized to the calcium channel blocker nifedipine (n=3,157) or to the diuretic combination HCTZ + amiloride (n=3,164) </li></ul><ul><li>The primary outcomes were cardiovascular death, myocardial infarction, heart failure, and stroke </li></ul><ul><li>1,302 patients (20.6%) had type 1 or type 2 diabetes at baseline </li></ul>Brown MJ, et al. Lancet. 2000;356:366-372.
  18. 19. INSIGHT Endpoints Brown MJ, et al. Lancet. 2000;356:366-372. Percent of patients with event *Cardiovascular death, myocardial infarction, heart failure, and stroke P=0.017
  19. 20. Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies <ul><li>STOP-2 (1999) </li></ul><ul><ul><li>The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes </li></ul></ul><ul><li>INSIGHT (2000) </li></ul><ul><ul><li>The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications </li></ul></ul><ul><li>NORDIL (2000) </li></ul><ul><ul><li>The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death </li></ul></ul><ul><li>ARIC (2000) </li></ul><ul><ul><li>In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes </li></ul></ul><ul><ul><li>Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk </li></ul></ul>
  20. 21. NORDIL <ul><li>The NOR dic DIL tiazem (NORDIL) Study was a prospective, randomized, open-label study that enrolled 10,881 patients, 50-74 years old, with diastolic blood pressure  100 mmHg </li></ul><ul><li>Patients were assigned to a non-dihydropyridine calcium channel blocker, diltiazem (n=5,410), or to diuretics, beta-blockers, or both (n=5,471) </li></ul><ul><li>Average follow-up was 4.5 years </li></ul><ul><li>The combined primary endpoint was fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death </li></ul><ul><li>727 patients (6.7%) had type 2 diabetes at baseline </li></ul>Hansson L, et al. Lancet. 2000;356:359-365.
  21. 22. NORDIL Change in Blood Pressure From Baseline* *For patients in study for at least 24 months Hansson L, et al. Lancet. 2000;356:359-365. Change in BP from baseline (mmHg) P<0.001
  22. 23. NORDIL Event Rates Per 1000 Patient Years Hansson L, et al. Lancet. 2000;356:359-365. Event rate per 1000 patient years *Fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death TIA=transient ischemic attack P=0.04
  23. 24. NORDIL Event Rates Per 1000 Patient Years in Diabetics Hansson L, et al. Lancet. 2000;356:359-365. Event rate per 1000 patient years P=NS for primary endpoint and components *Fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular death TIA=transient ischemic attack
  24. 25. Old and New Antihypertensive Therapy and Diabetes: Important Findings of 4 Major Studies <ul><li>STOP-2 (1999) </li></ul><ul><ul><li>The ACE inhibitors, enalapril and lisinopril, and the calcium channel blockers (CCBs), felodipine and isradipine, were not superior to diuretics and beta-blockers in treating cardiac outcomes </li></ul></ul><ul><li>INSIGHT (2000) </li></ul><ul><ul><li>The CCB nifedipine was not superior to the diuretic combination HCTZ + amiloride in preventing overall cardiovascular or cerebrovascular complications </li></ul></ul><ul><li>NORDIL (2000) </li></ul><ul><ul><li>The CCB diltiazem was not superior to treatment based on diuretics and/or beta-blockers in preventing the primary combined endpoint of all stroke, myocardial infarction, and other cardiovascular death </li></ul></ul><ul><li>ARIC (2000) </li></ul><ul><ul><li>In hypertensive patients, the use of beta-blockers appeared to increase the risk of developing diabetes </li></ul></ul><ul><ul><li>Thiazide diuretics, ACE inhibitors, and CCBs did not pose an increased risk </li></ul></ul>
  25. 26. ARIC <ul><li>The A therosclerosis R isk I n C ommunities (ARIC) Study is an ongoing observational study of clinical and subclinical atherosclerotic vascular disease in 15,792 patients, 45-64 years old, from 4 geographical communities in the United States </li></ul><ul><li>An interim analysis was conducted on 12,550 nondiabetic subjects enrolled in the ARIC study </li></ul><ul><li>The risk of developing diabetes was assessed relative to the absence (n=8,746) or presence (n=3,804) of hypertension and according to the type of antihypertensive therapy used </li></ul>Gress TW, et al. N Engl J Med. 2000;342:905-912.
  26. 27. ARIC Substudy Baseline Characteristics Gress TW, et al. N Engl J Med. 2000;342:905-912. Copyright 2000 Massachusetts Medical Society. All rights reserved. No hypertension n=8,746 Hypertension n=3,804 P value Age (yrs) 53.3 55.3 <0.001 Female (%) 55.5 55.6 0.91 Serum glucose (mg/dl) 97.6 101.0 <0.001 Serum insulin (pmol/liter) 68.4 97.8 <0.001 Systolic BP (mmHg) 113.2 134.4 <0.001 Diastolic BP (mmHg) 69.9 80.9 <0.001 Coronary artery disease (%) 3.1 6.2 <0.001 Peripheral vascular disease (%) 0.5 1.2 <0.001 History of stroke (%) 0.7 2.6 <0.001 Hypercholesterolemia (%) 18.9 24.6 <0.001 Renal insufficiency (%) 2.4 5.7 <0.001
  27. 28. ARIC Substudy Incidence of Diabetes Mellitus Incidence rates per 1000 person-years Gress TW, et al. N Engl J Med. 2000;342:905-912.
  28. 29. Summary: Old and New Antihypertensive Therapy in Diabetes <ul><li>Both older and newer antihypertensive agents reduce cardiovascular risks in diabetes </li></ul><ul><li>Superiority of a single class of antihypertensive agents in diabetes has not been established unequivocally </li></ul><ul><li>In diabetics with specific co-morbid conditions, newer antihypertensive agents have demonstrated small incremental benefits in several large treatment trials </li></ul><ul><li>Adverse effects with certain antihypertensive agents have been demonstrated in diabetes </li></ul><ul><ul><li>CCBs with long duration of action have not showed consistent adverse effects </li></ul></ul>
  29. 30. THANK YOU

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