Transcript No Slide Title

Treatment of Mild to Moderate
Hypertension is Worthwhile*
* a useful question to have asked between 1970
and 1985, but not in 2011
*the most evidence-based statement in all of
medicine
50 year old European female
- BP averages 160/95 on multiple
readings
- BMI 25
- TC 6.1, HDL 1.2
- Non-smoker, non-diabetic
HYPERTENSION
BIG
PROBLEM
Hypertension specialists retired or died from the 1980’s – 1990’s.
Cardiologists deemed hypertension not to be an important specialty,
shut down the hypertension clinics, and devolved hypertension
management entirely to primary care
↓
Cardiologists and other medical specialists lost hypertension
management skills
↓
No-one left to educate medical students, trainee physicians and GP’s
↓
GP’s don’t know how to treat simple or complex hypertension and have
nowhere to refer their difficult patients
Because no-one in the Pharmac corridors of power is
interested in hypertension our patients are missing out on
badly needed modern (and some old) antihypertensive drug
therapies
Reserpine
Aldactazide
Amiloride
Minoxidil
Moxonidine
Eplerenone
Aliskerin
Combinations containing chlorthalidone rather than HCTZ
Modern fixed-dose combinations
• ACE-inhibitor – CCB
• ARB-CCB
• ACE-inhibitor – CCB – thiazide
• ARB – CCB – thiazide
We are not interested in prevention
Public awareness BP health risk - All time Low
99% of resource - High tech treatments and
complications
• Coronary angiography and intervention
• Cardiac surgery
• Stroke units and rehab ($450 million per year inpatient costs)
• Heart failure clinics
“Those who cannot remember
the past are doomed to repeat it”
George Santayana, philosopher
(1863-1952)
“They that sow the wind
shall reap the whirlwind”
Hosea 8:7
Increasing stroke numbers in New Zealand an
'epidemic' says leading AUT researcher
Tuesday 30 November 2010, 12:23PM
By AUT University
182 views
NORTH SHORE CITY
Urgent measures are needed to reduce the growing number of stroke victims in
New Zealand, says Professor Valery Feigin, Director of the new National Institute for
Stroke and Applied Neuroscience, which is officially being launched today by
Associate Minister of Health, the Hon Dr Jonathan Coleman at AUT’s North Shore
Campus.
Currently costing the country over $450 million per year in hospital and
rehabilitation-related costs alone, stroke incidence in New Zealand is the second
highest amongst developed countries and numbers are only increasing, says Feigin.
Increasing stroke numbers in New Zealand an
'epidemic' says leading AUT researcher
Tuesday 30 November 2010, 12:23PM
By AUT University
182 views
NORTH SHORE CITY
Urgent measures are needed to reduce the growing number of stroke victims in
New Zealand, says Professor Valery Feigin, Director of the new National Institute for
Stroke and Applied Neuroscience, which is officially being launched today by
Associate Minister of Health, the Hon Dr Jonathan Coleman at AUT’s North Shore
Campus.
NZ stroke rates
increasing and second
highest in OECD
Currently costing the country over $450 million per year in hospital and
rehabilitation-related costs alone, stroke incidence in New Zealand is the second
highest amongst developed countries and numbers are only increasing, says Feigin.
Journal of the New Zealand Medical Association, 15-February-2008 Vol 121
No 1269
Differences in cardiovascular mortality between
Australia and New Zealand according to
socioeconomic status: findings from the LongTerm Intervention with Pravastatin in Ischaemic
Disease (LIPID) Study
Ralph A H Stewart, Fiona M North, Katrina J Sharples, R John Simes, Andrew M Tonkin,
Harvey D White; for the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID)
Study Investigators
Abstract
Background Cardiovascular mortality is higher in New Zealand compared to Australia, but reasons for this difference are uncertain.
This study describes differences in cardiovascular risk factors and cardiovascular mortality in Australians and New Zealanders with
stable coronary artery disease stratified by socioeconomic status.
Journal of the New Zealand Medical Association, 15-February-2008 Vol 121
No 1269
Differences in cardiovascular mortality between
Australia and New Zealand according to
socioeconomic status: findings from the LongTerm Intervention with Pravastatin in Ischaemic
Disease (LIPID) Study
Ralph A H Stewart, Fiona M North, Katrina J Sharples, R John Simes, Andrew M Tonkin,
Harvey D White; for the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID)
Study Investigators
Cardiovascular mortality 40%
higher in NZ than Australia
Abstract
Background Cardiovascular mortality is higher in New Zealand compared to Australia, but reasons for this difference are uncertain.
This study describes differences in cardiovascular risk factors and cardiovascular mortality in Australians and New Zealanders with
stable coronary artery disease stratified by socioeconomic status.
Blood Pressure and Risk of Stroke Mortality
Lancet 2002;360:1903-13
Blood Pressure and Risk of Ischemic
Heart Disease (IHD) Mortality
Lancet 2002;360: 1903-13
Cardiovascular Mortality Risk
Increases as Blood Pressure Rises*
8x
8
Cardiovascular
Mortality Risk
7
6
5
4x
4
3
2x
2
1
0
115/75
135/85
155/95
175/105
Systolic/Diastolic Blood Pressure (mm Hg)
*Measurements
taken in individuals aged 40–69 years, beginning with a blood
pressure of 115/75 mm Hg.
Lewington S, et al. Lancet. 2002;360:1903-1913;
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Cumulative Incidence of Major
Cardiovascular Events (%)
Impact of High-Normal Blood Pressure on Risk of Major
Cardiovascular Events* in Men
16
Blood Pressure:
14
High-Normal
130–139/85–89 mm Hg
12
Normal
10
120–129/80–84 mm Hg
8
Optimal
6
<120/80 mm Hg
4
2
0
0
2
4
6
8
10
12
Time (Years)
*Defined as death due to cardiovascular disease or as having recognized
myocardial infarction, stroke, or congestive heart failure.
Vasan RS. N Engl J Med. 2001;345:1291-1297.
• Continuum of increasing CV risk from SBP
115mmHg
• CV mortality doubles for every 10/5 increase in BP
> 120/70mmHg
• High BP causes
- 35% of all cardiovascular deaths
- 50% of all stroke deaths
- 25% of all CAD deaths
- 50% of all congestive heart failure
- 25% of all premature deaths
- commonest cause of chronic kidney disease
What is “Mild to Moderate
Hypertension”???
No accepted medical
definition
JNC 7 Guidelines (JAMA 2003;289:2560-2572)
Classification of Blood Pressure
Category
SBP
DBP
Normal
< 120
or
< 80
Prehypertension
120-139
or
80-89
Stage 1
140-159
or
90-99
Stage 2
> 160
or
> 100
JNC 6 Guideline (Arch Int Med 1997;157:2413-16)
Classification of Blood Pressure
Category
SBP
DBP
Optimal
< 120
or
< 80
Normal
120-129
or
80-84
High normal
130-139
or
85-89
Stage 1
140-159
or
90-99
Stage 2
160-179
or
100-109
Stage 3
>179
or
> 109
I will arbitrarily define “Mild to
Moderate” Hypertension as:
140 – 179 systolic +/diastolic
90-109
The VA Cooperative Study, 1970
Cohort
380 men
Mean age 50 years
Eligibility Diastolic BP 90-114 mmHg
Design
Therapy
Duration
BP
change
Double blind; placebo
control
HCTZ, reserpine,
hydralazine
5.5 years (mean=3.8 yrs)
Diastolic BP -19 mmHg
VA Cooperative Study Group. JAMA. 1970;213:1143-1152.
Apart from the 1967 trial of treatment
of in individuals with severe
hypertension, the majority of RCT’s
of drug treatment in hypertension
have involved individuals broadly
within the “mild to moderate”
category
140-179/ 90-109
What do these RCT’s (total ~ 190 000 pts) of hypertension
drug treatment show?
Major cardiovascular events (MI, stroke, heart failure)
reduced by ave. 25%
(Stroke 40%, MI 15-20%, CHF 50%)
Relative risk reduction similar in all age groups
Arch Int Med 1993;153:578
BMJ 2008;336:1121
-
-
Basis for this is that active (pharmacological)
treatment is suggested if 5 year risk of
cardiovascular event is > 15%
But
“Isolated single risk factors” do not mandate
therapy unless extremely abnormal
(BP > 170/100, total cholesterol > 8mmol/l etc)
“Old Men
Making Rules
to Treat
Themselves”
CV Risk Factor Estimation Systems
System
Geographic Area
Age (yrs) Time Horizon
(yrs)
Framingham
Score
Assign
Q Risk
US
Europe
Scotland
General Practice
35-75
40-65
30-74
35-74
10
10
10
10
Procam
WHO/ISH
Reynolds
NZ CV Risk
Guideline
Europe
20-75
40-79
45-80
35-75
10
10
10
5
WHS-PHS2
New Zealand
50 year old European female
- BP averages 160/95 on multiple
readings
- BMI 25
- TC 6.1, HDL 1.2
- Non-smoker, non-diabetic
5 year risk 5-10%: therefore
No antihypertensives
No statin
Marma et al. Circ Cardiovasc Qual Outcomes 2010;3(1):8-14 (NHANES
survey 2003-2006 – US adults aged 20-79)
Short term cardiovascular risk
- low < 10% 10 year
- high >= 10% 10 years or diagnosed diabetes
Long term cardiovascular risk
- low < 39% lifetime
- high >= 39% lifetime
Population divided in to 3 groups
- low short term/ low long term (26%)
- low short term/ high long term (56%)
- high short term/ high long term (18%)
For example
50 year old female
- BP 160/95
- TC 6.1, HDL 1.2
- Non-smoker, non-diabetic
NZ Risk Score 5-10% 5years – no treatment
Lifetime cardiovascular risk – 50%
50 year old female
- BP 115/75
- TC 4, HDL 1.5
- Non-smoker, non- diabetic
NZ Risk Score <2.5% - no treatment
Lifetime cardiovascular risk – 8%
If we had the means to reduce the risk of
breast cancer in women at high lifetime
risk by 42% - would we employ it?
Causes of death in NZ women
- cardiovascular disease 40%
- breast cancer 5%
Journal of the New Zealand Medical Association, 19-February-2010, Vol 123
No 1309
Are at-risk New Zealand women
receiving recommended
cardiovascular preventive therapy?
Olivia Bupha-Intr, Sally B Rose, Beverley A Lawton, C Raina Elley,
Simon A Moyes, Anthony C Dowell
Abstract
Aim To determine whether use of cardiovascular medications by a sample of mid-life and older women is consistent with New
Zealand cardiovascular risk guidelines.
Method Retrospective analysis of risk factor data collected during the Women’s Lifestyle Study involving 1089 40–74 year old
women. Outcome measures included: 5-year cardiovascular (CVD) risk score calculated using the adjusted Framingham equation
and self-reported use of cardiovascular medications.
Results Seven percent (76/1089) of women had established CVD, and a further 3% (33/1089) had a risk score greater than 15%
(high risk). Of the 109 women at high risk (risk score ≥15% or established CVD); 36% (39/109) were taking aspirin, 55% (60/109)
were taking blood pressure-lowering medication, 45% (49/109) were taking lipid-lowering medications and 17% (19/109) were taking
all three medications. Triple therapy was being taken by 12% of women (4/33) for primary prevention (5-year risk score ≥15%) and
only 19.7% of women for secondary prevention (15/76).
Conclusion These results suggest that women at high-risk are not receiving cardiovascular medications as recommended by the
guidelines, reflecting a ‘treatment gap.’ Modifiable barriers to the management of women at risk for CVD need to be identified and
addressed to reduce cardiovascular morbidity and mortality among women.
Journal of the New Zealand Medical Association, 19-February-2010, Vol 123
No 1309
Are at-risk New Zealand women
receiving recommended
cardiovascular preventive therapy?
Olivia Bupha-Intr, Sally B Rose, Beverley A Lawton, C Raina Elley,
Simon A Moyes, Anthony C Dowell
Even the minimalistic
recommendations of the NZ CV risk
guideline are not being followed
Abstract
Aim To determine whether use of cardiovascular medications by a sample of mid-life and older women is consistent with New
Zealand cardiovascular risk guidelines.
Method Retrospective analysis of risk factor data collected during the Women’s Lifestyle Study involving 1089 40–74 year old
women. Outcome measures included: 5-year cardiovascular (CVD) risk score calculated using the adjusted Framingham equation
and self-reported use of cardiovascular medications.
Results Seven percent (76/1089) of women had established CVD, and a further 3% (33/1089) had a risk score greater than 15%
(high risk). Of the 109 women at high risk (risk score ≥15% or established CVD); 36% (39/109) were taking aspirin, 55% (60/109)
were taking blood pressure-lowering medication, 45% (49/109) were taking lipid-lowering medications and 17% (19/109) were taking
all three medications. Triple therapy was being taken by 12% of women (4/33) for primary prevention (5-year risk score ≥15%) and
only 19.7% of women for secondary prevention (15/76).
Conclusion These results suggest that women at high-risk are not receiving cardiovascular medications as recommended by the
guidelines, reflecting a ‘treatment gap.’ Modifiable barriers to the management of women at risk for CVD need to be identified and
addressed to reduce cardiovascular morbidity and mortality among women.
V mortality 40% higher on NZ than Australia and death from IHD 25% higher)
“A low dose thiazide diuretic remains
an acceptable option for first-line
therapy in many people without
contraindications or indications for
one of the other treatment options”
NZ CV Risk Guideline 2009
ACE inhibitor + Thiazide
vs
ACE inhibitor + CCB
ACCOMPLISH (NEJM 2008;359:2417-2428)
was a large (11 400) outcome study of high risk hypertensives > 55 yrs
and SBP > 160 . Many obese and 60% diabetic. Pts randomised to
Benazepril/HCTZ or Benazepril/Amlodipine combinations.
Primary endpoint – composite of death from cardiovascular causes,
nonfatal MI, nonfatal stroke, hospitalisation for angina, resuscitation after
cardiac arrest, and coronary revascularisation
Pts randomised from 2003.
Excellent BP control with 76% having BP at target at 18 months and few
dropouts for side effects. 50% obese 60% diabetes mellitus
www.hypertensiononline.org
Effects of Treatment on Systolic and Diastolic Blood Pressure over Time
Jamerson K et al. N Engl J Med 2008;359:2417-2428
Kaplan-Meier Curves for Time to First Primary Composite End Point
Jamerson K et al. N Engl J Med 2008;359:2417-2428
Hazard Ratios for the Primary Outcome and the Individual Components
Jamerson K et al. N Engl J Med 2008;359:2417-2428
Trial stopped early in October 2007 by data safety and monitoring
committee following interim analysis of 60% of expected information from
the trial.
Over a mean f/u of 39 months, cardiovascular morbidity/mortality was
reduced by 20% with the ACEI/CCB compared with the ACEI/HCTZ
“The benazepril-amlodipine combination was superior to the
benazepril hydrochlorothiazide combination in reducing
cardiovascular events in patients with hypertension who were at
high risk for such events”
www.hypertensiononline.org
The days of the primacy of diuretics in
hypertension may be numbered
Provisos:
they remain an extremely important part of combination
therapy and most regimens of > 2 drugs should contain a
thiazide
when used they need to be adequately dosed (..no outcome
studies have ever shown benefit with HCTZ 12.5mg daily)
Conclusions
“Mild to moderate hypertension” is the most important (remediable)
cause of cardiovascular disease and death
Most of the cardiovascular risks of mild to moderate hypertension can
be avoided by treating to target blood pressure – this has been
repeatedly demonstrated in multiple RCT’s involving hundreds of
thousands of patients
Aggressive management (at all ages) with a combination of lifestyle
intervention and pharmacotherapy is mandatory
Hypertension is poorly managed in New Zealand principally because
of a failure of clinical leadership in the cardiology and primary care
communities
The NZ cardiovascular Risk Guideline needs to be urgently updated
Waitemata Hypertension Clinic Risk Factor Management
Guideline
• No smoking at any time
•Fasting blood glucose < 5.5mmol/l
• Antihypertensive drug treatment of all (irrespective of age, gender,
smoking or lipid status) with sustained BP >= 140/90, and > =130/80
for diabetes, CKD,or history of MI, stroke or PVD
• Statins for all (irrespective of age, gender, BP or smoking status)
with LDL-C > 2.5mmol/l +/- TC/HDLC ratio > 4, and irrespective of
lipid profile in diabetics, CKD or history of MI, stroke or PVD
• Low dose aspirin in all over 50 on treatment for hypertension or
dyslipidaemia, and irrespective of age in all individuals with a history
of MI, stroke, or PVD