Title: Hypertension update Which guideline to follow?
1Hypertension updateWhich guideline to follow?Â
- Dr Sunita DodaniDepartment of Family
MedicineAga Khan UniversityKarachi,
PakistanFebruary 23,2003
2Presentation outline
- World Wide Epidemic Some Figures
- Epidemiological Transition Hypertension
- Data From Developing Countries
- EMRO Work
- Statistics From Pakistan NHSP
- Hypertension Guidelines
- Currently available guidelines
- Similarities in guidelines
- Differences in guidelines
3Presentation outline
- Hypertension Guidelines (Contd)
- Still Unanswered Questions
- What is needed in Pakistan
- Epidemiologic research
- Which guideline to follow?
- JNC VI guideline (1994)
- Risk stratification
4Worldwide Epidemic Some Figures
- affect all ages, but primarily occurs in adults.
- 20 prevalence,approximately 690m people have
hypertension world wide - major risk factor for stroke, coronary heart
disease and kidney failure - 30 of deaths worldwide (15 million) are due to
cardiovascular diseases - 5 million deaths / year worldwide due to strokes
alone, with another 30 million suffering from its
disabling effects. -
- (Geneva, Switzerland November 15-16, 1999)
5Epidemiological Transition HypertensionÂ
- Developing countries experiencing rapid health
transition, escalating relative and absolute
burdens of CVD - Determinants of transition
- a) demographic (increased life expectancy)
- b) lifestyle changes
- c) urbanization, industrialization and
globalization
6Epidemiological Transition Hypertension
(Contd)
- In developing countries ,steady increase in
hypertension prevalence over the last 50 years,
more in urban than in rural areas
(WHO report 2002) - WHO Regions
7World regions according to WHO
8Eastern Mediterranean region (EMR)
- (Jordan, Iran, Srilanka, Pakistan, Egypt Oman,
Saudi Arabia , Bangladesh etc) - Paucity of large, authentic, epidemiological
studies - Limited data available in the form of small
studies - Majority of studies done have shortcomings
- differing examination techniques differing
diagnostic criteria - screening blood pressure values used
9The studies are not representative of the
total population Limited to single centers or
single community
EMR (cont'd)
- Majority of third world countries lack
- sufficient national estimates of the
- prevalence of hypertension
- In developing countries ,steady increase
- in hypertension prevalence over the last 50
- years, more in urban than in rural areas
10EMR. Some prevalence figures
- Saudi Arabia 10-15
- (EMRO bulletin 2001)
- Riyadh city 15.4 (27 unaware)
- Bangladesh (gt 70 yrs) 65
- (multi center trail, hypertension study
group, 2000) - Egypt (national estimates) 26
- gt 70 yrs 56.6
- (Ibrahim MM , Cairo university Egypt,
1998) - Iran(population based) 18
- (Sarraf-Zadegan N, East Mediterr
Health J 1999) -
11Hypertension figures in Pakistan
- National Health Survey of Pakistan
- 1990-1994
- Some data available, some in re-analysis phase
- 10.8 million hypertensives (pop 91m,1991)
- 5.5 million men
- 5.3 million women
- 12 million hypertensives (pop 130m,1998)
- 17.9 (? 15 yrs)
- 21.5.. Urban
- 16.2.. Rural
12Hypertension figures in Pakistan
- NHSP ( 1990-1994)
- 58 (? 65 yrs females)
- 1 in every 3 Pakistanis (gt45 yrs)
- Prevalence is lower in females than males at
younger ages, but exceed after 35-44 yrs of age - (This cross over is at later age in US
population) - gt3 of the hypertensive patients have BP
controlled to the conventional recommendations of
under 140/ 90 mmHg
13Hypertension figures in Pakistan
- Prevalence of hypertension (PMRC)
- Rural
Female
Male
14Hypertension figures in Pakistan
- Prevalence of hypertension (PMRC)
- URBAN
Female
Male
15Early detection,awareness treatment
- (Need for guidelines)
- help to limit the subjective element in decision
making assist clinicians to provide better care
- define the best clinical decisions and the
minimal level of acceptable care in order to
ensure appropriate quality - formulated based upon the evidence collected from
available literature, and agreement among experts
in areas where literature is deficient
16Hypertension Guidelines
- Several guidelines for the management of
hypertension were published in the last few years - Many were recent revisions and updated versions
of old ones, modified according to new evidence
from clinical trials - Provided answers to many clinical questions. a)
Isolated systolic hypertension in the - elderly is dangerous should be
- treated
- b) aggressive lowering of blood pressure is
- required in patients with risk
factors
17 Hypertension Guidelines
- JNC VI 1994
- Hypertension Detection and Follow-up Program
(HDFP) - WHO/ISH 1999
- British hypertension Society 1999
- Medical Research Council (MRC)
- Canadian Cardiac Society 1999
- Local
- Pakistan hypertension league 1998
- (First Report of National Task Force)
-
-
18Hypertension Guidelines
- These four major guidelines are based on the
strong evidence from almost the same literature
and the large randomized mega trials, they agree
and disagree on a number of important issues
19Hypertension Guidelines
- These guidelines agree on many aspects
- 1. All guidelines agree upon the definition of
hypertension. - 2. The type of routine tests needed for the
evaluation of hypertensive patients - 3. The need for global risk assessment the
target blood pressure - 4. The importance of life style modification
- 5. Individualization of antihypertensive therapy
- 6. Need for indefinite follow-up
20Hypertension Guidelines
- Differences in the guidelines
21Hypertension Guidelines
- Still Unanswered Questions
- how to avoid over treatment of patients at very
low risk? - what is the best simple approach for accurate
cardiovascular risk assessment? - Decisions to initiate therapy are based on the
absolute cardiovascular risk profile of the
hypertensive patient - ? risk assessment are based on the Framingham
data - ? risk scoring equations are incomplete
complicated - ? do not account for racial and genetic
differences.
22Hypertension Guidelines
- Still Unanswered Questions
- management of patients with uncomplicated mild
hypertension - ? duration period of observation
- ? the number of office visits
- ? blood pressure measurements
- ? the average blood pressure threshold during
the period of monitoring - role of ambulatory blood pressure is not settled
- how to adjust for racial, genetic, geographic,
age gender and socioeconomic differences
23Hypertension Guidelines
- Still Unanswered Questions
- optimal blood pressure reduction
- ? what is the desired level of blood pressure
- ? It is not necessarily the same level in all
- individuals.
- ? Race, age and gender may influence our target
- blood pressure.
- ? We might need more aggressive reduction in
- blood pressure in special groups, e.g.,
diabetics, - blacks and patients with end-organ damage.
24Hypertension Guidelines
- Population dataPriorities in Epidemiologic
research - define the magnitude of the hypertension problem
in Pakistan with evidenced based data - prevalence among different age groups, geographic
areas, socioeconomic classes and the influence of
factors like gender, ethnicity - Its risk factors e.g. Obesity, excessive salt
intake, alcohol intake, psychosocial stress, low
levels of education, poor SES, should be
recognized examined
25Hypertension Guidelines
- Epidemiologic research
- the type and prevalence of hypertensive
cardiovascular complications. might be influenced
by environment, race and other demographic
characteristics - identify the susceptible groups which are most
vulnerable to complications - How close are these complications related to the
level of blood pressure and what are the other
mechanisms involved - develop methods to improve detection and control
of hypertension
26Hypertension Guidelines
- which guideline to follow?
- Considering several meta analysis
- outcome data from major clinical trial
- strongest outcome data support the JNC VI
recommendations
27Hypertension Guidelines
Table 1 Classification of Blood Pressure
Diastolic
Systolic
Category
(mm Hg)
(mm Hg)
Normal Values of Blood Pressure
Optimal
less than 120
less than 80
Normal
less than 85
less than 130
High normal
130 - 139
85 - 89
Stages of Hypertension
(Mild)
140 - 159
90 - 99
Stage 1
Stage 2
(Moderate)
100 - 109
160 - 179
Stage 3
(Severe)
180 or higher
110 or higher
28Hypertension Guidelines
- Risk factors stratification
- In populations in individual patients, the
benefit from antihypertensive treatment is
determined by the absolute cardiovascular risk - Blood pressure by itself is a very weak predictor
of risk or benefit from treatment - simple but accurate risk assessment tools for
estimating cardiovascular risk, similar to that
in the New Zealand guidelines
29Hypertension Guidelines
- Presentation available at
- http//www.pitt.edu/super1
-
- http//www.pitt.edu/super1/pakistan/pakistan.htm
30Presentation references
- Ramsay LE. Williams B, Johnston GD, et al.
Guidelines for management of hypertension report
from the third working party of the British
Hypertension Society. J Hum Hypertens 1000
13569-592. - Fieldman RD, Campbell N, Larochell P. Burgess ED,
et al. 1999 Canadian recommendations for the
management of hypertension CMAJ 1999 161 (12
suppl) S1-S17 - Joint National Committee on Prevention,
Detection, Evaluation, and treatment of High
Blood Pressure. The Sixth report. Arch Intern Med
1997 1572413-2446.
31Presentation references
- Carretero OA. Oparil S. Essential hypertension
Part II treatment. Circulation 2000
101446-453. - Reddy KS. Implementation of international
guidelines on hypertension the Indian
experience.Clin Exp Hypertens. 1999 Jul-Aug21
(5-6)693-701. - OBrien E. Critical appraisal of the JNC VI,
WHO/ISH and BHS guidelines for essential
hypertension.Expert Opin Pharmacother. 2000
May1(4)675-82.
32THANKYOU