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2007
Hypertension
as a Public
Health Risk
January, 2007
Proportion of deaths attributable to leading
risk factors worldwide (2000)
High mortality, developing region
Lower mortality, developing region
Developed region
0
1
2
3
4
5
6
7
8
Attributable Mortality
(In millions; total 55,861,000)
et al. WHO
2000Program
Report. Recommendations
Lancet. 2002;360:1347-1360.
2007 Canadian Ezzati
Hypertension
Education
2
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
2007 Canadian Hypertension Education Program Recommendations
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Blood Pressure Distribution in the
Population According to Age
Men
Women
150
150
130
130
PP
110
80
80
70
70
30-39 40-49 50-59 60-69 70-79  80
Age
PP
110
30-39 40-49 50-59 60-69 70-79  80
PP=Pulse Pressure.
Age
Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension
1995;25:305-13
2007 Canadian Hypertension Education Program Recommendations
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Classification of Hypertension
(Pre Hypertension) 120-139 / 80-89
Category
Systolic
Diastolic
Optimal
<120
and / or
<80
Normal
<130
and / or
<85
High-Normal
130-139
and / or
85-89
Grade 1 (mild hypertension )
140-159
and / or
90-99
Grade 2 (moderate hypertension)
160-179
and / or
100-109
Grade 3 (severe hypertension)
 180
and / or
 110
Isolated Systolic Hypertension
(ISH)
140
and / or
<90
The category pertains to the highest risk blood pressure
*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.
2007 Canadian Hypertension Education Program Recommendations
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Blood Pressure and Risk of Stroke Mortality
Lancet 2002;360:
1903-13
2007 Canadian Hypertension Education Program
Recommendations
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Blood Pressure and Risk of IHD Mortality
2007 Canadian Hypertension Education Program Recommendations
Lancet 2002;360: 1903-13
7
Effect of SBP and DBP on
Age-Adjusted CAD Mortality: MRFIT
CAD Death Rate per 10,000 Person-years
80.6
48.3
43.8
37.4
31.0
25.8
38.1
34.7
25.3
24.6
25.2
24.9
23.8
16.9
20.6
10.3
13.9
11.8
12.6
12.8
8.8
8.5
160+
11.8
140-159
9.2
120-139
<120
100+
90-99
80-89
75-79
70-74
<70
Systolic BP
(mmHg)
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64.
2007 Canadian Hypertension Education Program Recommendations
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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)
(< 120)
N Engl J Med 2001;345:1291-7
2007 Canadian Hypertension Education Program Recommendations
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Ambulatory SBP mmHg
The Concept of Masked Hypertension
200
180
True
hypertensive
Masked HTN
160
140
135
True
Normotensive
120
White Coat HTN
100
100
120
140
160
180
200
Office SBP mmHg
From Pickering, Hypertension 1992
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The Prognosis of Masked Hypertension
Prevalence is approximately 10% in hypertensive patients.
CV events per 1000 patient-year
35
CV Events
30
25
20
15
10
5
0
Normal
23/685
White coat
24/656
Uncontrolled
41/462
Masked
236/3125
Bobrie et al. JAMA 2004;291:1342-9
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Cumulative hazard of stroke (%)
Cumulative hazard for stroke in 3 groups of subjects:
Normotensive, White-Coat Hypertension, and Ambulatory
hypertension
8
Ambulatory
hypertension
White-coat hypertension
7
6
Normotensive
group
5
4
3
2
p = 0.0013
1
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16
Time to stroke (years)
Verdecchia, P et al. Short- and Long-Term Incidence of Stroke in White-Coat Hypertension.
2007 Canadian45(2):203-208,
Hypertension Education
Hypertension.
FebruaryProgram
2005. Recommendations
12
Benefits of Treating Hypertension
• Younger than 60
– reduces the risk of stroke by 42%
– reduces the risk of coronary event by 14%
• Older than 60
–
–
–
–
reduces overall mortality by 20%
reduces cardiovascular mortality by 33%
reduces incidence of stroke by 40%
reduces coronary artery disease by 15%
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Correlation Between Reduction in SBP and
Stroke or MI
Stroke
Myocardial Infarction
Staessen et al. Lancet 2001;358:1305-15.
2007 Canadian Hypertension Education Program Recommendations
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Correlation Between Reduction in SBP
and Cardiovascular Mortality or Events
Cardiovascular mortality
Cardiovascular events
Staessen et al. Lancet 2001;358:1305-15.
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Benefits of Treating to Target
• Older than 60 with isolated systolic
hypertension
(SBP 160 mm Hg and DBP <90 mm Hg)
– 36% reduction in the risk of stroke
– 25% reduction in the risk of coronary events
Ref: adapted from SHEP, SYST-EUR, STONE studies.
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Effect of Long-Term Modest Reductions in
CV Risk Factors
10%
Reduction
in BP
+
10%
Reduction
in Total-C
=
45%
Reduction
in CVD
Emberson
et al. EurEducation
Heart J.
2004;25:484-491.
2007
Canadian Hypertension
Program
Recommendations
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Evaluating the Impact of Different Strategies
for CV Prevention on CV Risk Reduction.
Treating hypertension and other risk factors.
Treatment
Based on TC
(statin)
Treatment
Based on BP
(β-blocker,
diuretic)
Treatment Based on
Overall Absolute Risk
(ASA, statin, ACEI,
β-blocker, diuretic)
Predicted Reduction in
Major CVD (%)
0
-5
-10
-15
-6
-6
-9
-12
-30
-35
-10
-17
-20
-25
-8
Treatment thresholds
Top 10%
Top 20%
Top 30%
-40
-28
-37
2007
Canadian
Education
Program
Recommendations
Adapted
fromHypertension
Emberson et
al. Eur Heart
J. 2004;25:484-491.
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The Challenge In Canada
22% of Canadians 18-70 years of age have hypertension
50% of Canadians >65 years of age have hypertension
Hypertensive patients
who are treated
and BP controlled
Hypertensive patients
who are treated
but BP uncontrolled
21%
22%
Patients who are aware
but remain untreated
and BP uncontrolled
13%
9%
Diabetic patients
who are treated and
BP controlled
43%
Hypertensive patients
who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
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Results of a survey on awareness on
hypertension (Canada 2002)
67% of aware hypertensive patients believe
that their BP was their own primary
responsibility
Two thirds of these patients stated that high BP
was not a serious concern.
Thus the mandate to improve public awareness
of the consequences of hypertension is clear.
R. Petrella MD, Perspective in Cardiology, March 2002.
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The Canadian Hypertension Education
Program Objectives
• Develop evidence-based recommendations
for the management of hypertension
• Implement recommendations
• Evaluate impact of the program
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Leading diagnoses resulting in visits
to physician offices in Canada
Acute respiratory
tract infection
5
Routine medical
exams
10
Diabetes
15
Depression
20
Hypertension
Million visits/year
25
0
Source: IMS HEALTH Canada 2002. http://www.imshealthcanada.com/
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Changes in diagnosis of hypertension
in Canada
Hypertension Diagnosis by Gender
20
Percentage of Population
Post 1999 compared to pre
1999
• Doubling of the rate of
diagnosis of hypertension
• Closing of the gender gap
Females
Males &
Females
Males
15
10
1992
1994
1996
1998
2000
2002
2004
Year
Hypertension 2006;48:853-60
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Changes in the treatment of hypertension
Hypertension Treatrment by Gender
20
Females
Males & Females
Percentage of Population
Post 1999 compared to pre
1999
• Doubling of the rate of
treatment of hypertension
• Closing of the gender gap
Males
15
10
5
1992
1994
1996
1998
2000
2002
2004
Year
Hypertension 2006;48:853-60
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Changes in the proportion of those
diagnosed that are not treated
40
Percentage of Population
Post 1999 compared to pre
1999
• Marked decrease in
proportion of aware
hypertensives that are
untreated
• Closing of the gender gap.
Hypertensives who were Aware but not treated
by Gender
30
Females
20
Males &
Females
Males
10
1992
1994
1996
1998
2000
2002
2004
Year
Hypertension 2006;48:853-60
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2007 Canadian Recommendations for the
Management of Hypertension
A slide kit for medical education can be
downloaded from:
http://www.hypertension.ca
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