Transcript Classification of blood pressure levels of the British
The Global Burden of Disease
The scale of the problem
Leading Causes of Death and Disability (DALY’s)
1990 Rank Cause % 1 2 3 4 5 6 7 Lower respiratory infections 8.2
Diarrhoeal diseases Perinatal conditions Major depression Ischemic heart disease Cerebrovascular disease Tuberculosis 8 9 Measles Road traffic accidents 10 Congenital abnormalities 7.2
6.7
3.7
3.4
2.8
2.8
2.7
2.5
2.4
2020 Rank Cause % 1 2 3 4 5 6 7 Ischemic heart disease Major depression Road traffic accidents Cerebrovascular disease COPD Lower respiratory infections 3.1
Tuberculosis 8 9 War Diarrhoeal diseases 10 HIV 5.9
5.7
5.1
4.4
4.2
3.0
3.0
2.7
2.6
Global Burden of Disease Study, 1996
Mortality due to leading global risk factors
* * *
World Health Report 2002
*
Prevalence of ‘Hypertension’ by different cut points
20 15 10 5 90 = 25.3% 95 = 14.5% 100 = 8.4% 105 = 4.7% 110 = 2.9% 115 = 1.4% 0 50 60 70 80 90 100 Diastolic BP, mmHg 110 120 130
British Hypertension Society Guidelines for hypertension management 2004 (BHS-IV): summary
Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davies, Gordon T McInnes, John F Potter, Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the British Hypertension Society BMJ Volume 328 13 March 2004 634-640.
BHS Guidelines
Definitions Measurement Risk assessment Evaluation of hypertensive patients Thresholds for intervention Treatment goals Lifestyle measures Choice of therapy Meta-analysis of trials ABCD rule Aspirin and statins Follow up and implementation
Classification of blood pressure levels of the British Hypertension Society
Category Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood Pressure Optimal Normal High normal Hypertension Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe) Isolated systolic hypertension Grade 1 Grade 2 <120 <130 130-139 140-159 160-179 >180 140-159 >160 <80 <85 85-89 90-99 100-109 >110 <90 <90
Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device
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Use of properly maintain, calibrated, and validated device
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Measure sitting blood pressure routinely: standing blood pressure should be recorded at least at the initial estimation in elderly or diabetic patients
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Remove tight clothing, support arm at heart level, ensure arm relaxed and avoid talking during the measurement procedure
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Use of cuff of appropriate size Continued
Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device
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Lower mercury column slowly (2mm per second)
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Read blood pressure to the nearest 2 mm Hg
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Measure diastolic blood pressure as disappearance of sounds (phase V)
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Take the mean of at least two readings, more recordings are needed if marked differences between initial measurements are found
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Do not treat on the basis of an isolated reading
Potential indications for the use of ambulatory blood pressure monitoring
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Unusual variability of blood pressure
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Possible white coat hypertension
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Informing equivocal treatment decisions
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Evaluation of nocturnal hypertension
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Evaluation of drug resistant hypertension
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Determining the efficacy of drug treatment over 24 hours
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Diagnosis and treatment of hypertension in pregnancy
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Evaluation of symptomatic hypotension
Cardiovascular risk assessment
Lifestyle measures
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Maintain normal weight for adults (body mass index 20-25kg/m 2 )
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Reduce salt intake to < 100mmol/day (<6g NaCI or < 2.4 g Na+/day)
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Limit alcohol consumption to < 3 units/day for men and < 2 units/day for women)
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Regular physical exercise (brisk walking rather than weightlifting) for > 30 minutes per day, ideally on most days of the week but at least on three days of the week.
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Consume at least five portions/day of fresh fruit and vegetables
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Reduce the intake of total and saturated fat
Thresholds and treatment for antihypertensive drug treatment
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Drug treatment should be started in all patients with sustained systolic blood pressures > 160mmHg or sustained diastolic blood pressures > 100mmHg despite non-pharmacological measures (A)
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Drug treatment is also indicated in patients with sustained systolic blood pressures 140-159mmHg or diastolic blood pressures 90-99mmHg if target organ damage is present, or there is evidence of established cardiovascular disease or diabetes, or if there is a 10 year cardiovascular disease risk of > 20% (B)
continued
Thresholds and treatment for antihypertensive drug treatment
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For most patients a target of < 140mmHg systolic blood pressure and <85mmHg diastolic blood pressure recommended (B). For patients with diabetes, renal impairment or established cardiovascular disease a lower target of < 130/80mmHg is recommended
Initial Blood Pressure
180/110 160-179 100-109 140-159 90-99 130-139 80-89 <130/85 Treat
160/100 140-159 90-99 <140/90 Treat Reassess Yearly Re-measure in 5 years SEE NEXT SLIDE
140 159 90-99 Target organ damage or CVS complications or Diabetes or CV event risk
2%/year [>20% over 10 yrs ] No target organ damage and No CVS complications and No diabetes and CV event risk < 2%/year [<20% over 10 yrs ] Treat Observe Reassess CV risk yearly
Drug treatment of hypertension
Diuretic ACE-inhibitor Calcium-channel blocker Beta-blocker Angiotensin receptor blocker (Alpha-blocker)
Most hypertensives will need
2 drugs to control BP Drug combinations may be synergistic
STROKE
Comparisons of different active treatments BP difference (mm Hg) Favours first listed Favours second listed ACE vs. D/BB CA vs. D/BB ACE vs. CA 2/0 1/0 1/1 RR (95% CI) 1.09 (1.00,1.18) 0.93 (0.86,1.01) 1.12 (1.01,1.25) 0.5
1.0
Relative Risk 2.0
CORONARY HEART DISEASE
Comparisons of different active treatments BP difference (mm Hg) Favours first listed Favours second listed RR (95% CI) ACE vs. D/BB 2/0 CA vs. D/BB ACE vs. CA 1/0 1/1 0.98 (0.91,1.05) 1.01 (0.94,1.08) 0.96 (0.88,1.05) 0.5
1.0
Relative Risk 2.0
HEART FAILURE
Comparisons of different active treatments BP difference (mm Hg) Favours first listed Favours second listed RR (95% CI) ACE vs. D/BB 2/0 CA vs. D/BB ACE vs. CA 1/0 1/1 1.07 (0.96,1.19) 1.33 (1.21,1.47) 0.82 (0.73,0.92) 0.5
1.0
Relative Risk 2.0
MAJOR CARDIOVASCULAR EVENTS
Comparisons of different active treatments BP difference (mm Hg) Favours first listed Favours second listed RR (95% CI) ACE vs. D/BB 2/0 CA vs. D/BB ACE vs. CA 1/0 1/1 0.5
1.0
Relative Risk 2.0
1.02 (0.98,1.07) 1.04 (0.99,1.08) 0.97 (0.92,1.03)
High risk Hypertensive Patients 42,515
ALLHAT Design
Randomize Amlodipine Chlorthalidone Doxazosin Lisinopril 10,362 eligible for Lipid lowering Randomize Pravastatin Usual Care Not eligible for Lipid lowering
Study completion January 2003
ALLHAT Primary Endpoint: CHD Death and Nonfatal MI
Relative Risk (95% CI) Amlodipine 0.98 (0.90-1.07) Lisinopril 0.99 (0.91-1.08)
0.7
Favors Amlodipine Favors Lisinopril
1.3
Favors Chlorthalidone
ALLHAT Collaborative Research Group.
JAMA
. 2002;288:2981-2997.
ASCOT: PROBE Design
High-risk Hypertensive 19342 Randomized Amlodipine
Perindopril
Doxazosin GITs Atenolol
Bendrofluazide
Doxazosin GITs 10305 Randomize DB Eligible for Lipid Lowering Atorvastatin 10 mg Placebo Not Eligible for Lipid Lowering Expected Mean Follow-up: 5 Yrs Fatal CHD + Non-Fatal MI
4 3 ASCOT study: Effect of atorvastatin on CHD Atorvastatin 10 mg Placebo Number of events Number of events 100 154
36% reduction
2 1 HR = 0.64 (0.50-0.83) p=0.0005
0 0.0
0.5
1.0
1.5
2.0
Years 2.5
3.0
3.5
ASCOT study: Effect of atorvastatin on stroke 3 Atorvastatin 10 mg Placebo Number of events Number of events 89 121
27% rreduction
2 1 HR = 0.73 (0.56-0.96) p=0.0236
0 0.0
0.5
1.0
1.5
2.0
Years 2.5
3.0
3.5
The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs
Younger (e.g.<55yr) and Non-Black Older (e.g.
55yr) or Black Step 1 Step 2 A (or B*) A (or B*) + C or D C or D Step 3 A (or B*) + C + D Step 4 Resistant Hypertension Add: either
-blocker or spironolactone or other diuretic A: ACE Inhibitor or angiotensin receptor blocker C: Calcium Channel Blocker B:
b
- blocker D: Diuretic (thiazide) * Combination therapy involving B and D may induce more new onset diabetes compared with other combination therapies Adapted from: ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 81
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Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
<140/90 mm Hg
USA 1
27% % of hypertensives with controlled BP
Canada 3
16%
Finland 4
<160/95 mm Hg
Spain 4 Australia 4
20.5% 20% 19%
England 2
6%
Scotland 4
17.5%
India 4
9%
Zaire 4
2.5%
Adapted from Mancia, 1997
Other medication for hypertensive patients
Primary prevention (1) Aspirin : use 75mg daily if patient is aged >50 years with blood pressure controlled to <150/90mmHg and; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies cardiovascular disease risk chart) (2) Statin : use sufficient doses to reach targets if patient aged up to at least 80 years, with a 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies risk chart) and with total cholesterol concentration >3.5mmol/l (3) Vitamins – no benefit shown, do not prescribe
Secondary prevention (including patients with type 2 diabetes)
(1) Aspirin : use for all patients contraindicated (2) Statin : use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration >3.5mmol/l (3) Vitamins – no benefits shown, do not prescribe
Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg
Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg Impact of structured algorithm