Hypertension as a Public Health Risk

1
Hypertensionas a PublicHealth Risk
2
Whats New for 2009The Hypertensive Diabetic

• Patients with diabetes are at high cardiovascular
  risk
• Up to 80 of diabetic patients die of
  cardiovascular disease
• Most patients with diabetes have hypertension
• Between 35 and 75 of diabetic complications have
  been attributed to hypertension.
• Treatment of hypertension in patients with
  diabetes reduces total mortality, myocardial
  infarction, stroke, retinopathy and progressive
  renal failure rates.
• More intensive reduction in blood pressure
  reduces major cardiovascular events and total
  mortality by 25

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
3
Whats New for 2009The Hypertensive Diabetic

• 2/3rds of hypertensive diabetic patients have
  uncontrolled hypertension (gt 130/80 mmHg)
• There is underutilization of diuretic therapy in
  treating hypertension in diabetic patients. In
  general a diuretic is required for blood pressure
  control in multi drug regimes.
• A combination of lifestyle changes and 3 or more
  medications are often required.
• More intensive reduction in blood pressure in the
  hypertensive diabetic is one of a few medical
  interventions where the cost of treatment is less
  than the cost of the complications prevented.

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
4
Whats New for 2009

• Increased age on its own should not be a
  consideration in determining the need for
  antihypertensive drug therapy. Drug therapy for
  the elderly should be based on the same criteria
  as in younger adults however caution should be
  exercised in elderly patients who are frail or
  have postural hypotension.

5
Whats New for 2009

• The combination of an ACE inhibitor with an ARB
  is not recommended in patients with
• hypertension without compelling indications,
• coronary artery disease who do not have heart
  failure,
• prior stroke,
• non proteinuric chronic kidney disease or
• diabetes mellitus without micro albuminuria.

6
Whats New for 2009

• The use of the combination of an ACE inhibitor
  with an ARB should only be considered in selected
  and closely monitored people with advanced heart
  failure or proteinuric nephropathy.

7
Proportion of deaths attributable to leading risk
factors worldwide (2000)
Systolic blood pressure greater than 115 mmHg
WHO 2000 Report. Lancet. 20023601347-1360.
8
Hypertension as a Risk Factor

• Hypertension is a significant risk factor for
• cerebrovascular disease
• coronary artery disease
• congestive heart failure
• renal failure
• peripheral vascular disease
• dementia
• atrial fibrillation

9
Blood Pressure Distribution in the Population
According to Age
PPPulse Pressure.
Adapted from Third National Health and
Nutrition. Examination Survey, Hypertension
199525305-13
10
European Society of Hypertension Classification
of Blood Pressure
The category pertains to the highest risk blood
pressure ISHIsolated Systolic Hypertension. J
Hypertens 2007251105-87,
11
JNC (American) Classification of Blood Pressure
The category pertains to the highest risk blood
pressure ISHIsolated Systolic Hypertension.
JAMA 20032892560-72
12
Blood Pressure and Risk of Stroke Mortality
Lancet 20023601903-13
13
Blood Pressure and Risk of Ischemic Heart
Disease (IHD) Mortality
Lancet 2002360 1903-13
14
Effect of SBP and DBP onAge-Adjusted CAD
Mortality MRFIT
15
Impact of High-Normal Blood Pressure on the Risk
of Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT
HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE
mmHg
(130-139)
(121-129)
(lt 120)
N Engl J Med 20013451291-7
16
The Concept of Masked Hypertension
200
180
True hypertensive
Masked HTN
160
Home/Ambulatory SBP mmHg
140
True Normotensive
120
White Coat HTN
100
100
120
140
160
180
200
Office SBP mmHg
Derived from Pickering et al. Hypertension 2002
40 795-796.
17
The Prognosis of White Coat and Masked
Hypertension
Prevalence is approximately 10 of the adult
population
Odds Ratio of a Cardiovascular Event
J Hypertension 2007252193-2198
18
Long term follow-up of Normotensive, White-Coat
Hypertension, and Ambulatory hypertension
8
Ambulatory hypertension
White-coat hypertension
7
6
Normotensive group
5
Cumulative hazard of stroke ()
4
3
2
p 0.0013
1
0
0
1
2
3
16
15
14
13
12
11
4
10
5
6
7
8
9
Time to stroke (years)
Hypertension. 200545(2)203-208
19
Benefits of Treating Hypertension

• Younger than 60 (reducing BP 10/5-6 mmHg)
• reduces the risk of stroke by 42
• reduces the risk of coronary event by 14
• Older than 60 (reducing BP 15/6 mmHg)
• reduces overall mortality by 15
• reduces cardiovascular mortality by 36
• reduces incidence of stroke by 35
• reduces coronary artery disease by 18

Lancet 1990335827-38 Arch Fam Med 19954943-50

20
Benefits of Treating to Target

• Older than 60 with isolated systolic hypertension
• (SBP ?160 mm Hg and DBP lt90 mm Hg)
• 42 reduction in the risk of stroke
• 26 reduction in the risk of coronary events

Lancet 1997350757-64
21
Correlation Between Reduction in SBP and Stroke
or MI
22
Correlation Between Reduction in SBP and
Cardiovascular Mortality or Events
23
90 of Hypertensive Canadians have other
Cardiovascular Risk factors
Emberson et al. Eur Heart J. 200425484-491.
24
Treating hypertension and other risk factors
Adapted from Emberson et al. Eur Heart J.
200425484-491.
25
Challenges to Hypertension Management Public
Perceptions
44 of people could not identify a normal or a
high blood pressure 80 of people were unaware
of the association between hypertension and heart
disease 63 believed that hypertension was not a
serious condition 38 of people thought they
could control high blood pressure without the
help of a health professional
Can J Cardiol 200521589-93
26
The Canadian Hypertension Education Program (CHEP)

• Goal
• To reduce the burden of cardiovascular disease in
  Canada through optimized hypertension management
• Activities
• Regularly updated evidence-based recommendations
  for the management of hypertension
• Implementation of the recommendations
• Regular evaluation and revision of the program
• Assessment of patient outcomes

27
Leading diagnoses resulting in visits to
physician offices in Canada
25
20
Routine medical exams
Depression
Acute respiratory tract infection
15
Million visits/year
Diabetes
Hypertension
10
5
0
Source IMS HEALTH Canada 2002
28
2009 Canadian Hypertension Education Program
(CHEP)
Slide kits and supporting literature can be
downloaded from www.hypertension.ca/chep/ Patie
nt information and recommendations can be found
at www.hypertension.ca/bpc/ An extensive
electronic patient support for home blood
pressure measurement and lifestyle change can be
found at www.heartandstroke.ca/bp