Hypertension update Which guideline to follow?

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Hypertension updateWhich guideline to follow? 

• Dr Sunita DodaniDepartment of Family
  MedicineAga Khan UniversityKarachi,
  PakistanFebruary 23,2003

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Presentation 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

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Presentation outline

• Hypertension Guidelines (Contd)
• Still Unanswered Questions
• What is needed in Pakistan
• Epidemiologic research
• Which guideline to follow?
• JNC VI guideline (1994)
• Risk stratification

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Worldwide 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)

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Epidemiological Transition Hypertension 

• 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

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Epidemiological 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

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World regions according to WHO

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Eastern 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

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The 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

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EMR. 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)

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Hypertension 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

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Hypertension 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

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Hypertension figures in Pakistan

• Prevalence of hypertension (PMRC)
• Rural

Female
Male
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Hypertension figures in Pakistan

• Prevalence of hypertension (PMRC)
• URBAN

Female
Male
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Early 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

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Hypertension 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

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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)

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Hypertension 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

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Hypertension 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

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Hypertension Guidelines

• Differences in the guidelines

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Hypertension 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.

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Hypertension 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

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Hypertension 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.

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Hypertension 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

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Hypertension 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

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Hypertension Guidelines

• which guideline to follow?
• Considering several meta analysis
• outcome data from major clinical trial
• strongest outcome data support the JNC VI
  recommendations

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Hypertension 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

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Hypertension 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

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Hypertension Guidelines

• Presentation available at
• http//www.pitt.edu/super1
• http//www.pitt.edu/super1/pakistan/pakistan.htm

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Presentation 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.

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Presentation 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.

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