Hypertension: Revisited by Prof. Mohammad Ishaq Professor of Cardiology Karachi Institute of Heart Diseases President Pakistan Hypertension League Symposium Theme: Prevent Heart Diseases – Save Lives World Hypertension.
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Slide 1
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 2
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 3
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 4
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 5
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 6
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 7
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 8
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 9
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 10
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 11
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 12
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 13
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 14
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 15
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 16
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 17
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 18
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 19
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 20
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 21
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 22
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 23
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 24
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 25
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 26
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 27
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 28
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 29
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 30
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 31
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 32
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 33
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 34
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 35
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 36
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 37
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 38
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 39
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 40
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 41
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 42
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 2
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 3
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 4
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 5
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 6
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 7
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 8
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 9
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 10
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 11
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 12
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 13
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 14
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 15
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 16
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 17
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 18
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 19
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 20
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 21
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 22
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 23
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 24
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 25
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 26
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 27
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 28
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 29
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 30
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 31
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 32
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 33
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 34
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 35
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 36
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 37
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 38
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 39
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 40
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 41
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.
Slide 42
Hypertension: Revisited
by
Prof. Mohammad Ishaq
Professor of Cardiology
Karachi Institute of Heart Diseases
President Pakistan Hypertension League
Symposium Theme: Prevent
Heart Diseases – Save Lives
World Hypertension Day 2010 Theme:
Healthy Weight – Healthy Blood Pressure
PAKISTAN HYPERTENSION LEAGUE(PHL)
Found June 1997, Karachi
Changing patterns of death
Infectious, maternal, perinatal
and nutritional conditions
Chronic diseases and
injuries
Millions of Deaths
60
40
20
0
1990
2020
1990
2020
Global Burden of Disease Project, 1996
Risk of Hypertension (%)
Lifetime Risk of Developing Hypertension Among Adults at 65
Years of Age*
100
80
60
Men
Women
40
20
0
0
2
4
6
8
10
Years
*Residual lifetime risk of developing hypertension among adults
at 65 years of age with a blood pressure <140/90 mm Hg.
Vasan RS, et al. JAMA. 2002;287:1003-1010.
12
14
16
18
20
Global Burden: Prevalence
Over 20% of adult population.
I Billion world wide
55 million in USA.
12 million in Pakistan.
120 million in SAARC region.
70% the hypertension fall into stage 1
Complications of Hypertension:
End-Organ Damage
Hypertension
Hemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
LVH, CHD, CHF
Peripheral
Vascular
Disease
Renal Failure,
Proteinuria
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
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.
12
Age-adjusted annual
incidence of CHD per 1000
Blood Pressure and Risk for
Coronary Heart Disease in Men
60
60
50
50
40
40
Age 65-94
30
30
20
20
Age 35-64
10
10
0
0
<120 120- 140- 160- 180+
139 159 179
Systolic blood pressure (mmHg)
Age 65-94
Age 35-64
<75
758595- 105+
84
94
104
Diastolic blood pressure (mmHg)
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at
baseline
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative Risk of
Stroke Death
9
8
7
6
5
4
3
2
1
0
Risk of Stroke Death According to
Blood Pressure (mm Hg): MRFIT
†
Systolic Blood Pressure (SBP)
Diastolic Blood Pressure (DBP)
†
1
2
3
4
DBP
<112
<71
112
71
*
5
6
*
7
*
*
8
118
76
121
79
125
81
129
84
MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; †P < 0.001.
Stamler J, et al. Arch Intern Med. 1993;153:598-615;
He J, Whelton PK. Am Heart J. 1999;138(Pt 2):211-219.
9
10
(Highest 10%)
Decile
(Lowest 10%)
SBP
†
†
*
†
132
86
137
89
142
92
≥151
≥98
Systolic BP and CV Death in MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic (n=342,815)
Diabetic (n=5,163)
<120
120-139
140-159
160-179
180-199
Systolic BP (mmHg)
BP= blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
200
Risk of CHD Death
According to SBP and DBP in MRFIT
Relative risk of
CHD mortality
4
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
3
2
1
0
Decile
SBP (mmHg)
DBP (mmHg)
1
2
3
4
5
6
7
8
(lowest 10%)
<112
112-
118-
121-
125-
129-
132-
137-
<71
76-
79-
81-
84-
86-
89-
71-
CHD=coronary heart disease
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
9
10
(highest 10%)
142>151
92-
>98
Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor
Incidence of ESRD per 100,000
Person-Years (%)
Intervention Trial*
100
White Men (n = 300,645)
80
83.1
Black Men (n = 20,222)
60
37.2
40
27.3
15.8
20
5.4
0
26.2
5.4
<117
117-123
9.1
124-130
14.2
131-140
Systolic Blood Pressure (mm Hg)
*The
original cohort of 332,544 men included 11,677 men in other ethnic groups
whose data are excluded from this comparison.
ESRD = end-stage renal disease
Klag MJ, et al. JAMA. 1997;277:1293-1298.
32.4
>140
Cardiovascular Mortality
Rate per
10,000 Person-Years
Diabetes Increases Hypertension-Related Cardiovascular
Risk: MRFIT
250
225
200
175
150
125
100
75
50
25
0
Nondiabetic Men (n = 342,815)
Diabetic Men (n = 5,163)
<120
120139
140159
160179
Systolic Blood Pressure (mm Hg)
MRFIT = Multiple Risk Factor Intervention Trial
Stamler J, et al. Diabetes Care. 1993;16:434-444.
180199
≤200
Hypertension Increases the Risk of Symptomatic
Peripheral Artery Disease
Odds Ratio
(95% CI)
1
Male Gender
Age/10 Years
Diabetes
Smoking
Hypertension
Dyslipidemia
Hyperhomocysteinemia
Race (Asian/Hispanic/Black vs. White)
C-Reactive Protein
Renal Insufficiency
CI = confidence interval
Norgren L , et al. J Vasc Surg. 2007;45(Suppl 1):S5A-S67A.
2
3
4
Factors in the development & Evolution
of Hypertension
A. NON MODIFIABLE
Age
Sex
Ethnicity
Heredity
B. MODIFIABLE
Salt & K Intake
Alcohol Excess
Contraceptives
NSAIDS
Sedentary Living
Obesity
Socio economic factors
Management of Hypertension
Individual Hypertensive: Treatment
Community control: Life style modification
Effects of
Lifestyle Modifications
on Blood Pressure
Recommended Lifestyle Modifications and Their Individual
Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Lifestyle Modifications
on Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or more
lifestyle modifications are used concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
Weight Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
-5
Measures*
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA. 1992;267:1213-1220.
Copyright © 1992, American Medical Association. All rights reserved.
Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-and- Vegetables
Diet
132
Diastolic Blood Pressure (mm
Hg)
Systolic Blood Pressure (mm
Hg)
Control Diet
130
128
126
124
122
Combination
Diet*
88
86
84
82
80
78
0
1
2
3
4
5
6
7
8
0
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and low in saturated
and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997, Massachusetts
Medical Society. All rights reserved.
1
2
3
4
5
6
Week of Intervention
7
8
Greater Restriction of Sodium Intake Lowers Diet-Reduced Blood
Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood Pressure
(mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
120
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001, Massachusetts Medical
Society. All rights reserved.
Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
170
Systolic
Blood Pressure
160
150
†
‡
140
130
mm Hg
mm Hg
Exercise Group
100
†
‡
90
80
120
110
110
Diastolic
Blood Pressure
141.2 144.4
Baseline
136.2 137.9
Week 6
137.6 131.3
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
70
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Baseline Value (mm Hg ± SD)
Changes in Systolic Blood
Pressure (mm Hg)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
91–120
min/wk
>120
min/wk
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Decreasing Dietary Salt Intake Reduces Systolic Blood
Pressure
Dietary Approaches to Stop Hypertension Trial
136
Systolic Blood
Pressure (mm Hg)
*
134
132
*
130
*
*
128
*
126
124
High-Salt
Diet†
1
2
3
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
4
Central obesity: a driving force for
cardiovascular disease & diabetes
Front
Back
28
“Balzac” by Rodin
A continuing epidemic: 2 of 3 adults are
overweight or obese
National Health and Nutrition Examination Surveys 1999-2004
US adults ≥20 years of age
70
60
50
Patients 40
(%)
30
Overweight
Obesity
20
10
0
1999-2000
Overweight = BMI 25-29.9 kg/m2
Obesity = BMI ≥30 kg/m2
2001-2002
2003-2004
Year of survey
Ogden CL et al. JAMA. 2006;295:1549-55.
29
13 year old boy weighing
11.2kg
more than normal
runs 33% increased
probability of a
cardiovascular event
before the age of 60
30
OBESITY – ASIA PASIFIC REGION
WHO, International Task Force
BMI >23
BMI >25
Over Weight
Obesity
Associations of adiposity with CVD
Insulin resistance
Dysglycemia
Hypertension
Dyslipidemia
CAD
White = visceral fat area (VFA)
Black = subcutaneous (sc) fat
32
Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.
Left ventricular
dysfunction
Sleep apnea
syndrome
Central adiposity: Better marker of CVD than
BMI
N = 8802 HOPE Study participants
1.5
P = 0.14
P = 0.003
P = 0.0127
BMI, WHR,
WC tertiles
1
Adjusted
RR of CVD
death
First
Second
Third
0.5
0
BMI
(kg/m2)
WHR
WC = waist circumference
WHR = waist/hip ratio
33
Dagenais GR et al. Am Heart J. 2005;149:54-60.
WC
(cm)
34
Insulin Resistance: Associated
Conditions
35
A new vital sign: Waist
circumference
Abdominal
adiposity
Coronary
heart disease
Hypertension
Dyslipidemia
RISK
Dysglycemia
Adapted from Després J-P et al. BMJ. 36
2001;322:716-20.
Intra-abdominal adiposity is a major contributor to
increased cardiometabolic risk
IAA = high risk fat
Associated with
inflammatory markers
(C-reactive protein)
Dyslipidaemia
Free fatty
acids
Insulin
resistance
Inflammation
Secretion of
adipokines
(↓ adiponectin)
IAA: intra-abdominal adiposity
37
Kershaw EE et al, 2004; Lee YH et al, 2005;
Boden G et al, 2002
Increased
cardiometabolic
risk
Prevalence of Obesity in Pakistan
BMI >25 25-44 Years
Effect of Weight Loss on Blood Pressure in Overweight or Obese
Subjects by Gender
Trials of Hypertension Prevention Phase I
Mean Change (mm Hg)
Systolic
Blood Pressure
Diastolic
Blood Pressure
0
0
-1
-1
-1.1
-2
-2.0
-3
-2
-3
-3.1
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
-2.8
Men
Women
-4
Summary
The risk of fatal and nonfatal CV and renal
events (stroke, CAD, ESRD is closely linked
to both systolic and diastolic blood pressure
Central obesity is a major & rising C.V risk
factor
CV and renal risks are exaggerated in
patients with diabetes mellitus
Life style modifications are crucial in BP
prevention & control at community level
Summary
Among hypertensive patients, the extent to
which cardiovascular and renal events are
reduced is closely linked to the extent to
which blood pressure is reduced
Evidence from clinical trials supports the
current recommendations to reduce blood
pressure to 130/80 mm Hg in patients who
have diabetes, chronic kidney disease, and
coronary artery disease
Summary
Modification of unhealthy lifestyle practices
can lower B P among hypertensive patients,
regardless of age, ethnicity, or gender. These
practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular aerobic
exercise program.
Lifestyle modifications can augment B P
reduction caused by antihypertensive drugs.