Establishing Preventive Cardiology Programs powerpoint_logo3

Epidemiology of Hypertension

Stanley S. Franklin, MD, FACP, FACC

Clinical Professor of MedicineUniversity of California at IrvineAssociate Medical DirectorUCI Heart Disease Prevention ProgramIrvine, California

Agenda: epidemiology of hypertension

• BP measurement

• Defining hypertension

• Why an important public health problem

• Calculating Global cardiovascular risk

• Intervention trials and meta-analyses

• Management strategies

• Barriers to treatment

• Prevention strategies

• BP measurement

• Defining hypertension

• Why an important public health problem

• Calculating Global cardiovascular risk

• Intervention trials and meta-analyses

• Management strategies

• Barriers to treatment

• Prevention strategies

BP Measurement

Nokolai Korotkoff, 1905

Ascultatory method of

blood pressure measurement

Noninvasive Blood Pressure Measurement

Methodologies- Auscultatory (K sound) - Mercury

- Aneroid

- Oscillometric

Locations Situations - Upper arm - Clinic/Office

- Wrist - Home

- Finger - Ambulatory

Defining hypertension

Defining Hypertension:

By the numbers?≥95 DBP160/95140/90130/85 >120/80

“A number at which the benefits of intervention exceed those of

inaction”

2098 Franklin #8

CV Mortality Risk Doubles withEach 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 pressureLewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

CVmortality

risk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105


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 Distribution of Hypertension Subtype in the Untreated Hypertensive Population by Age Hypertensive Population by Age (NHANES III)(NHANES III)

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

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

An Analysis of NHANES III Blood Pressure DataSummary: Hypertensives fall into one of two categories:

1. A smaller (26%), younger (age 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH)

2. A larger (74%), older (age 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH).

Summary: Hypertensives fall into one of two categories:

1. A smaller (26%), younger (age 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH)

2. A larger (74%), older (age 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH).

Franklin et al. Hypertension 2001;37: 869-874

Defining hypertension by

BP componentsSBPDBPPP

MAP

The BP Components of the Arterial Pulse Wave

75

125

Pre

ssu

re (

mm

Hg

)

Systolic Systolic pressurepressure

Diastolic Diastolic pressurepressure

Mean Mean pressurepressure

Diastolic decay Diastolic decay curvecurve

Dicrotic notchDicrotic notch(aortic valve (aortic valve

closes)closes)

Time

Pulse Pulse pressurpressuree

= 1/3 SBP + 2/3 DBP

*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)

10090-99

80-89

75-79

70-74<70

<120

120-139

140-159

160

Multiple Risk Factor Intervention Trial (MRFIT):

Effect of BP on CHD-Related Mortality (N=316,099)*

Death RateDeath Rateper 10,000per 10,000

Person-YearsPerson-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.

CH

D H

aza

rd R

ati

o/1

0 m

m H

g (

CI)

Age (y)

<50 50-59 600.0

0.4

0.8

1.2

1.6

2.0SBP (10 mm Hg) DBP (10 mm Hg)PP (10 mm Hg)

***

***

*** * ***

***

1.0


HemodynamicsCOPVR

Arterial stiffness

Hemodynamics of Arterial Blood Pressure

• Steady component (MAP = CO x PVR) (↑Resistance small art.) [MAP = 1/3(SBP) + 2/3(DBP)]

(Predominantly diastolic) (“Essential HTN”--young)

-- ↑VC or ↓VD responses -- ↑wall-to-lumen diameter -- Rarefaction (Art./Cap.)

• Pulsatile component (PP = SBP – DBP) (↑Stiffness large arteries) (↑CO and ↑SV) (Isolated systolic HTN) (Pathologic aging)

-- Disarray of elastin protein-- Abn. extracellular matrix-- ↑Collagen/Calcium depos.


StagingJNC VIJNC 7

2098 Franklin #19

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 VIJNC VISBP

(mm Hg)SBP

(mm Hg)DBP

(mm Hg)DBP

(mm Hg)SBP

(mm Hg)SBP

(mm Hg)DBP

(mm Hg)DBP

(mm Hg)

Optimal Normal80 <120<120 and 80and

Normal

Hi-normalPrehypertension

120-129

130-139120-139

80-84

or 85-89

and80-89or

Stage 1

Hypertension

Stage 1140-159 140-15990-99or 90-99or

Stage 2

Stage 3Stage 2

160-179

≥ 180≥ 160

100-109or

≥ 110or≥ 100or

CategoryCategory CategoryCategory

JNC 7JNC 7

BP CategoryBP Category PrevalencePrevalence

NormalNormal 39%39%

PrehypertensionPrehypertension 31%31%

HypertensionHypertension 30%30%

Prevalence of Blood Pressure Prevalence of Blood Pressure Categories in US Adults ≥20 Years of Categories in US Adults ≥20 Years of

Age Age (NHANES 1999-2000)(NHANES 1999-2000)

Prevalence of Blood Pressure Prevalence of Blood Pressure Categories in US Adults ≥20 Years of Categories in US Adults ≥20 Years of

Age Age (NHANES 1999-2000)(NHANES 1999-2000)

Greenland, Croft, Mensah (CDC). Arch Intern Med. 2004;164:2113fGreenland, Croft, Mensah (CDC). Arch Intern Med. 2004;164:2113f

Prehypertension …Prehypertension …Prehypertension …Prehypertension …

• Is Is notnot a disease, a disease,

• Is Is notnot “hypertension”, “hypertension”,

• Is Is notnot an indication for drug treatment of HTN, an indication for drug treatment of HTN,

• Does Does notnot have a BP goal, have a BP goal,

• DoesDoes predict a higher risk for developing CV predict a higher risk for developing CV

events,events,

• DoesDoes predict a higher risk for developing HTN, predict a higher risk for developing HTN,

• Should be an incentive to improve lifestyle Should be an incentive to improve lifestyle

practices for prevention of HTN and CVD.practices for prevention of HTN and CVD.

• Is Is notnot a disease, a disease,

• Is Is notnot “hypertension”, “hypertension”,

• Is Is notnot an indication for drug treatment of HTN, an indication for drug treatment of HTN,

• Does Does notnot have a BP goal, have a BP goal,

• DoesDoes predict a higher risk for developing CV predict a higher risk for developing CV

events,events,

• DoesDoes predict a higher risk for developing HTN, predict a higher risk for developing HTN,

• Should be an incentive to improve lifestyle Should be an incentive to improve lifestyle

practices for prevention of HTN and CVD.practices for prevention of HTN and CVD.

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 0.9170-179 6.8 1.2160-169 10.1 2.7150-159 19.5 6.2140-149 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 BP73.5%42.9%

30.6%

Why is HTN an importantPublic healthProblem?

2098 Franklin #24

Firstly, hypertension is very common In the adult population

Hypertension: Hypertension: How Big Is the Problem?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.Fields LE et al. Hypertension. 2004;44:398–404.

Prevalence of Hypertension in the US

411

21

44

5464 65

18-29 30-39 40-49 50-59 60-69 70-79 80+

Age

0

10

20

30

40

50

60

70

Per

cen

t H

yper

ten

sive

Based on NHANES III survey: 1988-1991HTN defined by BP >140/90 or treated

2098 Franklin #27

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

0

5

10

15

20

25

30

18–29 30–39 40–49 50–59 60–69 70–79 80+

Hyp

erte

nsi

ves

Wit

hin

Ag

e G

rou

p (

%)

Franklin SS. J Hypertension. 1999;17(suppl 5):S29-S36.

Age Groups (y)

47.4 million hypertensives47.4 million hypertensives

26.0% of US population26.0% of US population

26% 74%

1976-98 Cumulative Incidence of HTN 1976-98 Cumulative Incidence of HTN in Women and Men Aged 65 Yearsin Women and Men Aged 65 Years

1976-98 Cumulative Incidence of HTN 1976-98 Cumulative Incidence of HTN in Women and Men Aged 65 Yearsin Women and Men Aged 65 Years

Vasan, et al. JAMA.2002;287:1003Vasan, et al. JAMA.2002;287:1003

0 2 4 6 8 10 12 14 16 18 200

20

40

60

80

100

Risk of Hypertension Risk of Hypertension %%

Years of Follow-upYears of Follow-up

WomenWomen

MenMen

2098 Franklin #29

Trends in Prevalence of Hypertension in the US Population, by Race/Ethnicity,1988-2000

0

5

10

15

20

25

30

35

Pre

vale

nce

(%)

Non-Hispanic White Non-Hispanic Black Mexican American

1988-1991

1991-1994

1999-2000

0

5

10

15

20

25

30

35

Pre

vale

nce

(%)

Non-Hispanic White Non-Hispanic Black Mexican American

1988-1991

1991-1994

1999-2000

*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

0

10

20

30

40

50

60

70

Pre

vale

nce

(%)

UnitedStates

Canada Italy Sweden England Spain Finland Germany

Men Women On Treatment

0

10

20

30

40

50

60

70

Pre

vale

nce

(%)

UnitedStates

Canada Italy Sweden England Spain Finland Germany

Men Women On Treatment

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.

2098 Franklin #32

Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors

Ezzati et al. Ezzati et al. Lancet.Lancet. 2002;360:1347-1360. 2002;360:1347-1360.Attributable Mortality Attributable Mortality

(In thousands; total 55,861,000)(In thousands; total 55,861,000)

High mortality, developing regionHigh mortality, developing region

Lower mortality, developing regionLower mortality, developing region

Developed regionDeveloped region

00 8000800070007000600060005000500040004000300030002000200010001000

High blood pressureHigh blood pressure

TobaccoTobacco

High cholesterolHigh cholesterol

Unsafe sexUnsafe sex

High BMIHigh BMI

Physical inactivityPhysical inactivity

AlcoholAlcohol

Indoor smoke from solid fuelsIndoor smoke from solid fuels

Iron deficiencyIron deficiency

UnderweightUnderweight


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.

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.

Retinopathy Renal failurePeripheral vascular

disease

Complications of Hypertension:

LVH, CHD, HF

TIA, stroke

Hypertension Hypertension is a risk factoris a risk factor

Thirdly, there is considerablereduction in cardiovascular riskwith effective lowering of blood

pressure with therapy.

35%-40%

20%-25%

>50%

Average reduction in events

(%)

–60

–50

–40

–30

–20

–10

0Stroke

Myocardialinfarction Heart failure

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events

Fourthly, there is insufficientawareness, treatment andcontrol of hypertension.

0

10

20

30

40

50

60

70

80

Hypertension Awareness, Treatment, and Control: US 1976 to 2000*

NHANES III NHANES III (Phase 2) (Phase 2) 1991-19941991-1994

NHANES III NHANES III (Phase 1) (Phase 1) 1988-19911988-1991

51%51%

73%73% 68%68%

31%31%

55%55% 54%54%

10%10%

29%29% 27%27%

% A

du

lts

% A

du

lts

NHANES II NHANES II 1976-19801976-1980

NHANES NHANES 1999-20001999-2000

70%70%

59%59%

34%34%

Healthy People Healthy People

2000/2010 2000/2010

Control Control

Target = 50%Target = 50%

ControlControl

AwarenessAwareness

TreatedTreated

Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.

*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.

Awareness, Treatment, and Control of Hypertension by Various Populations

80

70

60

50

40

30

20

10

0

Pre

vale

nce

(%

)

Awareness Treatment Control,All Treated

Control, AllHypertensive§

69.573.9

57.8* 60.163.0

40.3†

55.6

44.6‡ 44.0‡

33.428.1

17.7†

Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

Calculating GlobalCardiovascular

Risk

2098 Franklin #41

Risk Factor Clustering With Hypertension

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

30MenWomen

17%19%

26% 27% 25% 24%22%

20%

8%12%

≥4

RiskFactors

(%)

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*NCEP-ATP III Definition: ≥3 of the Following*• Men: >102 cm (>40 in)

• Women: >88 cm (>35 in)

Fasting glucose

• ≥130/≥85 mm HgBlood pressure

HDL-C

• ≥150 mg/dLTriglycerides

Abdominal obesity (waist circumference)

• Men: <40 mg/dL

• Women: <50 mg/dL

• ≥100 mg/dL

Other CVD Risk Factors: JNC 7

Physical inactivity Cigarette smoking Age (older than 55 for men, 65 for women) Family history of premature CVD

(men under age 55 or women under age 65)

*Components of the metabolic syndrome in blue Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-. 2003;289:2560-25722572

Expert Panel on Detection, Evaluation, and Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Treatment of High Blood Cholesterol in Adults. JAMAJAMA. 2001;285:2486-2497.. 2001;285:2486-2497.

Age, yAge, y PointsPoints

20-3420-34 -9-935-3935-39 -4-440-4440-44 0045-4945-49 3350-5450-54 6655-5955-59 8860-6460-64 101065-6965-69 111170-7470-74 121275-7975-79 1313

11

22

55

TotalTotal AgeAge AgeAge AgeAge AgeAge AgeAgeCholesterolCholesterol 20-3920-39 40-4940-49 50-5950-59 60-6960-69 70-7970-79

<160<160 00 00 00 00 00160-199160-199 44 33 22 11 00200-239200-239 77 55 11 33 00240-279240-279 99 66 44 22 11

280280 1111 88 55 33 11

AgeAge AgeAge AgeAge AgeAge AgeAge20-3920-39 40-4940-49 50-5950-59 60-6960-69 70-7970-79

HDL mg/dLHDL mg/dL PointsPoints

6060 -1-150-5950-59 0040-4940-49 11

<40<40 22

Systolic BPSystolic BP IfIf IfIfmm Hgmm Hg UntreatedUntreated TreatedTreated

<120<120 00 00120-129120-129 00 11130-139130-139 11 22140-159140-159 11 22160160 22 33

Point TotalPoint Total 10-Year Risk, %10-Year Risk, %

<0<0 <1<100 1111 1122 1133 1144 1155 2266 2277 3388 4499 55

1010 661111 881212 10101313 12121414 16161515 20201616 2525

1717 3030

66

ATP-III: Framingham Point ScoresEstimate of 10-Year Risk for Men

NonsmokerNonsmoker 00 00 00 00 00SmokerSmoker 88 55 33 11 11

44

33

2098 Franklin #45

ESH/ESC Guidelines: Stratification of Risk to Quantify PrognosisESH/ESC Guidelines: Stratification of Risk to Quantify PrognosisESH/ESC Guidelines: Stratification of Risk to Quantify PrognosisESH/ESC Guidelines: Stratification of Risk to Quantify Prognosis

6252 M6252 M

Very high Very high added riskadded risk



High High added riskadded risk





Moderate Moderate added riskadded risk



Low Low added riskadded risk

Blood Pressure (mmHg)Blood Pressure (mmHg)

Other Risk FactorsOther Risk Factorsand Disease Historyand Disease History

No other risk factorsNo other risk factors

1-2 risk factors1-2 risk factors

ACCACC

Grade 1Grade 1SBP 140-159 SBP 140-159

or DBP 90-99or DBP 90-99

Grade 2Grade 2SBP 160-179 SBP 160-179

or DBP 100-109or DBP 100-109

Grade 3Grade 3SBP ≥ 180SBP ≥ 180

or DBP ≥ 110or DBP ≥ 110

3 or more risk factors3 or more risk factorsor TOD or diabetesor TOD or diabetes





Average Average riskrisk

Low Low added riskadded risk

LowLowadded riskadded risk

Average Average riskrisk

NormalNormalSBP 120-129SBP 120-129


High NormalHigh NormalSBP 130-139SBP 130-139


ACC: associated clinical conditions; TOD: target organ damage; SBP: systolic blood pressure; DBP: diastolic blood pressure ACC: associated clinical conditions; TOD: target organ damage; SBP: systolic blood pressure; DBP: diastolic blood pressure

2098 Franklin #46

:“Diabesity”

2098 Franklin #47

2098 Franklin #48

Advice from Woody Allen

“If I knew I would live this long I would have taken better care of myself”

“ Sudden Death is nature’s way of telling you to slow down”

“If I knew I would live this long I would have taken better care of myself”

“ Sudden Death is nature’s way of telling you to slow down”

______________________________________________________

______________________________________________________

____________________________________________________________

Intervention trialsAnd meta-analysis

2098 Franklin #51

•“Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.”

•“Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.”Paul Dudley White, 1931 Textbook of Cardiology.

2098 Franklin #52Messerli, F. H. Messerli, F. H. N Engl J MedN Engl J Med 1995 1995

Hypertension Intervention Trials: 1959-1970

Trial Severity of Hypertension

CV events/yr. In CTRL Group

CV events/yr: CTRL vs Ther. Group

Harrington, et al (1959)

Malignant Hypertension

90% Mortality 90% vs 50% (Mortality / Yr)

VA Coop. Study (1967)

Severe (DBP 115 mmHg) 187/121

29% 10:1 (1.5 Yr.)


Moderate (DBP 105-114 mmHg) 165/105

5.5% 3.5:1 (4.5 Yr.)

Trial Severity of Hypertension

CV events/yr. In CTRL Group

CV events/yr: CTRL vs Ther. Group

Harrington, et al (1959)

Malignant Hypertension

90% Mortality 90% vs 50% (Mortality / Yr)


Severe (DBP 115 mmHg) 187/121

29% 10:1 (1.5 Yr.)


Moderate (DBP 105-114 mmHg) 165/105

5.5% 3.5:1 (4.5 Yr.)

TOMHSTOMHSVA MONORxVA MONORx

CONVINCECONVINCEALLHAT ALLHAT ANBP2ANBP2

LIFELIFE

HAPPHYHAPPHYMAPHYMAPHY

INSIGHTINSIGHTNORDILNORDIL

CAPPPCAPPPSTOP-2STOP-2

VALUEVALUEASCOTASCOT

ACCOMPLISHACCOMPLISH

Clinical Trials in Hypertension

HR Black, 2003.HR Black, 2003.

1960s1960s 1970s1970s 1980s1980s 1990-19951990-1995 1996-19991996-1999 20002000 2001-20032001-2003 2004-20082004-2008

Should we treat Should we treat diastolic HBP?diastolic HBP?

What is the What is the best way to best way to treat HBP?treat HBP?

Should we treat Should we treat DBP in older DBP in older

persons?persons?

What is theWhat is the goal of goal of

treatment?treatment?

Should we Should we treat ISH in treat ISH in

older older persons?persons?

Can we Can we prevent prevent

hypertension?hypertension?

VA VA Cooperative Cooperative

StudiesStudiesMRC-1MRC-1

ANHBP-1ANHBP-1

EWPHEEWPHE

MRC-2MRC-2

STOP-1STOP-1

SCOPESCOPEHDFPHDFP HOTHOT

UKPDSUKPDS

Syst-EurSyst-EurSyst-ChinaSyst-China

SHEPSHEP TROPHYTROPHY

2098 Franklin #55

SHEP Trial of the elderly with ISH:Design

• N: 4736; 43% male

• Age: >60

• BP: SBP 160-219 and DBP <90

• Design: Placebo control, double blind• Active Rx: Chlorthalidone (atenolol as step 2)

• SBP difference: 12 mm Hg

• Duration: 4.5 years

• N: 4736; 43% male

• Age: >60

• BP: SBP 160-219 and DBP <90

• Design: Placebo control, double blind• Active Rx: Chlorthalidone (atenolol as step 2)

• SBP difference: 12 mm Hg

• Duration: 4.5 years

JAMA 1991;265:3255

2098 Franklin #56

SHEP Trial:Cardiovascular Disease Endpoints

JAMA 1991;265:3255

Placebo

Perindopril 4 mg/d

+3

HYVETHYVET

Perindopril 2 mg/d

Indapamide SR 1.5 mg/d

Placebo

Placebo

Placebo

ProtocolProtocol

+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

HR 95% CI P value

All stroke - 34% 0.46 - 0.95 0.025

Total mortality - 28% 0.59 - 0.88 0.001

Fatal stroke - 45% 0.33 - 0.93 0.021

Cardiovascular mortality - 27% 0.55-0.97 0.029

Heart failure - 72% 0.17-0.48 <0.001

Cardiovascular events - 37% 0.51-0.71 <0.001

HYVETtrial in the very elderly

Per Protocol

Beckett N. N Engl J Med. 2008;358: epub. March 31, 2008.

Blood PressureLowering

Effect

SpecificDrugEffect

Which is more important to minimize CV Events?

or

2098 Franklin #60

0.5 1.0 2.0

BP-Lowering Treatment TrialistsComparisons of Different Active Treatments

Relative Risk RR (95% CI)RR (95% CI)BP DifferenceBP Difference

(mm Hg)(mm Hg)

FavorsFavorsFirst ListedFirst Listed

FavorsFavorsSecond ListedSecond Listed

Major CV eventsMajor CV events

CV mortalityCV mortality

Total mortalityTotal mortality

1.02 (0.98, 1.07)1.02 (0.98, 1.07)2/02/0 ACEI vs D/BBACEI vs D/BB



1.04 (0.99, 1.08)1.04 (0.99, 1.08)1/01/0 CA vs D/BBCA vs D/BB

1.05 (0.97, 1.13)1.05 (0.97, 1.13)1/01/0 CA vs D/BBCA vs D/BB

0.99 (0.95, 1.04)0.99 (0.95, 1.04)1/01/0 CA vs D/BBCA vs D/BB

0.97 (0.95, 1.03)0.97 (0.95, 1.03)1/11/1 ACEI vs CAACEI vs CA



Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood Pressure Lowering Treatment Trialists’ Collaboration. LancetLancet. 2003;362:1527-1535.. 2003;362:1527-1535.

2098 Franklin #61

Managementstrategies

Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

National Heart, Lung, andBlood Institute

National High Blood PressureEducation Program

JNC 7: Appropriate BP Targets• For both CVD and kidney disease, systolic BP is far

more important than diastolic BP

• 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)

• Only a small fraction of hypertensives are achieving appropriate BP control

• Multiple antihypertensive agents are needed for most patients

• 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.

• For both CVD and kidney disease, systolic BP is far more important than diastolic BP

• 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)

• Only a small fraction of hypertensives are achieving appropriate BP control

• Multiple antihypertensive agents are needed for most patients

• 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.

JNC 7: Considerations for olderpersons with hypertension

This population has the lowest rates of BP control and the greatest absolute benefit with effective therapy.

Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.

More than two-thirds of people over 65 have HTN, i.e. ISH (Isolated systolic hypertension).

JNC 7: Considerations for special populations with hypertension

• Treatment generally similar for all demographic groups

• Socioeconomic factors and lifestyle important barriers to BP control

• Prevalence, severity of hypertension increased in blacks

• Treatment generally similar for all demographic groups

• Socioeconomic factors and lifestyle important barriers to BP control

• Prevalence, severity of hypertension increased in blacks

JNC 7. JAMA. 2003;289:2560-2672.

2098 Franklin #66

Intervention

Exercise

Weight reduction

Alcohol intake reduction

Sodium intake reduction

DASH diet

Intervention

Exercise

Weight reduction

Alcohol intake reduction

Sodium intake reduction

DASH diet

Lifestyle Interventions for Prevention or Treatment of Hypertension

Blood Pressure Effect

5-10 mm Hg (>30 min >3x/wk)

1-2 mm Hg/Kg

1 mm Hg/drink/d

1-3 mm Hg/40 mmol/d

3-10 mm Hg

Blood Pressure Effect

5-10 mm Hg (>30 min >3x/wk)

1-2 mm Hg/Kg

1 mm Hg/drink/d

1-3 mm Hg/40 mmol/d

3-10 mm Hg Adapted from Cushman et al. Endocrine Practice 1997;3:106 & Sacks, et al. NEJM 2001;334:3

2098 Franklin #67

Lifestyle Treatment Measures

Nonpharmacologic treatments are used for:

• Lowering blood pressure

• Reducing need for antihypertensive agents

• Minimizing associated risk factors

• Primary prevention of hypertension

Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug ChoicesInitial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed

With Compelling Indications

With Compelling Indications

Lifestyle ModificationsLifestyle Modifications

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved

Consider consultation with hypertension specialist

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 mm Hg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 2 Hypertension (SBP >160 or DBP >100 mm 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

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

Without Compelling Indications

JNC 7 Algorithm for Treatment of Hypertension

Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.

Barriers totreatment

Barriers to Controlling Hypertension

HealthcareSystem

Patients Providers

Colors of Salt

• White• Black• Red• Yellow• Green• Brown• Clear

• Table salt• Soy sauce• Catsup• Mustard• Pickles• Soups & gravies• Saline

Courtesy of Marty Grais, MD

2098 Franklin #72

The Initial Confrontation of the HTN Problem

• Upon making a diagnosis of HTN, tell patient the BP reading and what it should be (provide a written copy).

• Prepare patient for the probable necessity for polypharmacy to control BP with a minimum of side effects

• Advise Home BP measurement (135/85 mmHg is considered to be hypertensive).

• Upon making a diagnosis of HTN, tell patient the BP reading and what it should be (provide a written copy).

• Prepare patient for the probable necessity for polypharmacy to control BP with a minimum of side effects

• Advise Home BP measurement (135/85 mmHg is considered to be hypertensive).

Table 28. JNC 7 Report. Hypertension. 2003;42(6):1240.

Self-Measurement of BP

Provides information useful for:

1. assessing response to antihypertensive Rx

2. improving adherence with therapy

3. evaluating white-coat HTN

Home BP is more strongly related to target organ damage and has better prognostic accuracy than office BP.

Preventionstrategies

Strategies for Prevention of High Blood Pressure

General Population Strategy

Attempt to shift (downwards) the distribution of BP in entire population

Targeted Intensive Strategy

More intensive efforts to reduce BP in individuals/groups at highest risk of hypertension

High normal BP

Family history of hypertension

High risk groups

Environmental exposures that increase probability of hypertension

High weight High salt intake Alcohol consumption Physical inactivity

17% reduction in prevalence of hypertension

14% reduction in average annual incidence of stroke

6% reduction in average annual incidence of CHD

Estimated Effect of 2 mm Hg Reduction inAverage Diastolic BP in General Population

Cook N R et al., Arch Intern Med 1996

35-64 year old White Residents of United States

FollowingIntervention

BeforeIntervention

Whelton, PK, He J, Appel LA et al., JAMA 2002;288:1882-1888

• Epidemiology Summary:

– Increasing prevalence; world wide problem

– Blood pressure as a moving target

– ↑ PVR in the young, ↑ stiffness in the elderly

– Predominantly isolated systolic hypertension

– Consider special populations at increased risk

– Hypertension as a part of absolute global CV risk

– Population vs. high risk approaches for prevention

• Epidemiology Summary:

– Increasing prevalence; world wide problem

– Blood pressure as a moving target

– ↑ PVR in the young, ↑ stiffness in the elderly

– Predominantly isolated systolic hypertension

– Consider special populations at increased risk

– Hypertension as a part of absolute global CV risk

– Population vs. high risk approaches for prevention

Documents

Establishing Preventive Cardiology Programs powerpoint_logo3