goals of hypertension management in clinical practice - ehs · goals of hypertension management in...
TRANSCRIPT
1
Goals Of Hypertension Goals Of Hypertension Management in Clinical Practice Management in Clinical Practice
Adel E. Berbari, MD, FAHA, FACP
Professor of Medicine and Physiology
Head Division of Hypertension and Vascular Medicine
World Hypertension League (WHL) MeetingWorld Hypertension League (WHL) Meeting
Head, Division of Hypertension and Vascular Medicine
American University of Beirut- Medical Center
Venue: Fairmont Heliopolis Hotel, Cairo- EgyptDate : Tuesday- April 8, 2008
Role of Physician /Health Care ProviderRole of Physician /Health Care Provider1.1. Lack of appreciation of definition of hypertension Lack of appreciation of definition of hypertension and and
importance of cardiovascular risk factors. importance of cardiovascular risk factors. 2.2. Excessive reliance on monotherapyExcessive reliance on monotherapy
Causes of Poor BP control Rates
3.3. Therapeutic inertiaTherapeutic inertiaReluctance to increase drug dose or to add additional Reluctance to increase drug dose or to add additional antihypertensive agents.antihypertensive agents.
Role of PatientRole of Patient1.1. Non adherence /non compliance with prescribed medicationsNon adherence /non compliance with prescribed medications2.2. Lack of persistenceLack of persistence
C ti ti f f di ti l f ifi dC ti ti f f di ti l f ifi dContinuation of use of medications only for a specified Continuation of use of medications only for a specified time periodtime period
Impact of antihypertensive regimenImpact of antihypertensive regimen1.1. Complexity of treatmentComplexity of treatment2.2. Drug associated side effectsDrug associated side effects3.3. Drug costDrug cost
2
10
12
14
16 R
isk
0
2
4
6
8
Rel
ativ
e
Increasing increments of blood pressure are Increasing increments of blood pressure are associated with increasing risk of cardiovascular associated with increasing risk of cardiovascular
mortality.mortality.
0115/75 135/85 155/95 175/105 195/115mm Hg mm Hgmm Hg mm Hg mm Hg
6
8
10
12
ncid
ence
(%
0
2
4
6
<120/<80 120-129/80-84 130-139/85-89
Cum
ulat
ive
In
SBP
DBP
Impact Impact of High Normal BP on Risk of CV Event Cumulative of High Normal BP on Risk of CV Event Cumulative 10 10 yr Incidence of First Cardiovascular Event According to yr Incidence of First Cardiovascular Event According to
BP Category at baseline BP Category at baseline
((Framingham Heart Study)Framingham Heart Study)
DBPBP Category Optimal Normal High Normal
3
S t li
Age Related Blood Pressure Changes
g)
160
140Males
Systolic
Diastolic
d Pr
essu
re (m
mH
120
100
140Females
Age in years
Blo
o
0 10 20 30 40 50 60 70 80
60
80
In Framingham Heart StudyIn Framingham Heart Study–– Gradual shift from DBP to SBP as Gradual shift from DBP to SBP as
cardiovascular risk predictorscardiovascular risk predictors–– In patients In patients younger than younger than 5050 yearsyears, , DBP major DBP major
predictorpredictor–– In patients In patients 50 50 –– 59 59 yearsyears, , SBP/DBP,SBP/DBP, equal equal
predictor predictor –– In patients In patients 60 60 years and olderyears and older, , coronary heart coronary heart
disease:disease:Positive Correlation with SBPPositive Correlation with SBPInverse Relation with DBP Inverse Relation with DBP
4
20
22
24
92
8883
75
68
DBP
at Baseline
12
14
16
1892
Risk of Death Risk of Death in Control (Untreated) Patients with Systolic (SBP) in Control (Untreated) Patients with Systolic (SBP) at Baseline and at Baseline and Fixed Levels of Diastolic (DBP) Fixed Levels of Diastolic (DBP) in Elderly (in Elderly (7070yrs)yrs)
Patients with Isolated Systolic HypertensionPatients with Isolated Systolic Hypertension
10
160 170 180 190 200 210 220
1.5
2
2.5
Rat
io
SBP
DBP PP
0
0.5
1
Haz
ard
Blood Pressure (mmHg)Adjusted hazard ratios for combined coronary heart disease and
cerebrovascular disease (CHD+CVD) events, SBP:Systolic Blood Pressure, DBP; Diastolic Blood Pressure; PP : Pulse Pressure
5
Systolic hypertension recently recognized as more important than diastolic hypertension:yp
- Cardiovascular risk factor- Therapeutic decision making in older
subjects- Poor hypertension control in 70 % of yp
treated patients due to inability of reaching goal SBP < 140 mmHg
Impact of Serum Chelesterol Levels on Risk of Heart Attacks
30
35
LOW RISK
• No Smoking
Normal
Hypertension
10
15
20
25
30
CH
D R
ISK
(%)
• Normal Glucose Tolerance
• No EKG-LVH195180165150 SB
P
0
5
185 210 235 260 285 310 335Serum Cholesterol (mg/dl)
C 150135120105
S
Data from Framingham study
6
Impact of Serum Cholesterol Levels on Risk of Heart Attacks
35
40 195
180
d Pr
essu
re HIGH RISK• Smoking• Glucose
Hypertension
15
20
25
30
CH
D R
ISK
% 135120
150165
105 Syst
olic
Blo
od Intolerance• EKG-LVH
0
5
10
185 210 235 260 285 310 335Serum cholesterol (mg/dl) Data from Framingham
study
Age 40 Years Age 60 YearsgSBP 180 mmHg
Age 60 Years SBP 120 mmHg
SimilarCardiovascular
Risk
7
35
40
ear
Determinants of CV Events risk during 20 years of successful antihypertensive treatment in middle aged subjects (modified from Alderman)
15
20
25
30
35
er 1
000
pers
ons
/ye
0
5
10
Rat
es p
e
Age >50 PP>60 Smoking Cholesterol DM LVH Heart Stroke> 6.34 Attack
EducationalProvider
Strategies to improve
compliance
Combinational approach to
improve compliance
Parthan et al. Exp Rev Pharmacoeconomics Outcomes Res 2006;6:325–36
BehaviouralAffective
8
ACCOMPLISH: Exceptional ControlRates with ACCOMPLISH: Exceptional ControlRates with Initial Combination TherapyInitial Combination Therapy
80.580
9075.6 71.8
Achieved Control RatesAchieved Control Rates
Con
trol
rate
(%)
Baseline Control Rates
N=8,067
20
30
40
50
60
70
37.6
21 0
44.4N=11,400
65.1
N=3,333
N=1,361
38.6
Jamerson ASH 2007
All Nordic U.S. African American
1021.0
Incidence of serious hypotensive episodes 1.8 % in 12.600 patients
Multiple Antihypertensive Agents are Needed Multiple Antihypertensive Agents are Needed to Reach BP Goalto Reach BP Goal
Trial (SBP achieved)
ASCOT-BPLA (136.9 mmHg)
( )ALLHAT (138 mmHg)IDNT (138 mmHg)
RENAAL (141 mmHg)UKPDS (144 mmHg)
ABCD (132 mmHg)MDRD (132 mmHg)
Average no. of antihypertensive medications1 2 3 4
Reproduced from Am J Med 116(5A), Bakris et al. pp. 30S–8. Copyright © 2004,with permission from Elsevier; Dahlöf et al. Lancet 2005;366:895–906
HOT (138 mmHg)AASK (128 mmHg)
9
Advantages of Fixed Versus Free Advantages of Fixed Versus Free Combinations of Two Antihypertensive DrugsCombinations of Two Antihypertensive Drugs
FixedFixed FreeFree
Si li it fSi li it fSimplicity of Simplicity of treatmenttreatment
++ ––
ComplianceCompliance ++ ––
EfficacyEfficacy ++ ++
TolerabilityTolerability +*+* ––
*Lower doses generally used in fixed-dose combinations+ = potential advantage*Lower doses generally used in fixed-dose combinations+ = potential advantage
TolerabilityTolerability ++
PricePrice ++ ––
FlexibilityFlexibility –– ++
Increased Persistence with FixedIncreased Persistence with Fixed--dose dose Combinations Compared with Individual Combinations Compared with Individual
ComponentComponent--based Therapybased Therapy
Fixed-dose combination
19%
54%
combination(Valsartan/HCTZ)
(n=8,150)
Free combination(Valsartan + HCTZ)
(n=561)
p<p<00..00010001
0% 20% 40% 60% 80%
Persistence (defined as patients remaining on treatmentfor a duration of 12 months)
Jackson et al. Value Health Suppl 2006;9:A363
10
Blood Pressure GoalsBlood Pressure Goals
Non diabetic DiabeticChronic kidney disease
(UAE ≥ 1G/D)
Coronary artery disease
< 140/90(or less if tolerated/
achievable
< 125/75< 130/80
Early/ aggressive
Antihypertensive
Delay
Prevent
Reverse
Protection
Futuretreatment.
BP related
Target organ damage
Morbidity
Mortality
Effects of early/aggressive antihypertensive treatment
11
-20
-10
0du
ctio
n (%
)
Primary end pointStrokeMI
-50
-40
-30
Ris
k R
ed All cause mortalityCHF hospitalization
Effect of prompt / better BP control withinEffect of prompt / better BP control within first 6 months of treatment on cardiovascular outcomes (SBP < 140mmHg)
(Value Clinical Trial)
BP ReductionBP Reduction Cardiovascular Cardiovascular ProtectionProtectionProtectionProtection
All classes of All classes of antihypertensive agentsantihypertensive agents
Calcium channel Calcium channel antagonistsantagonists
Angiotensin converting Angiotensin converting enzyme inhibitorsenzyme inhibitors
Angiotensin receptor Angiotensin receptor antagonistsantagonists
12
BP ReductionBP Reduction Cardiovascular Cardiovascular ProtectionProtection
All classes ofAll classes of Calcium channelCalcium channelAll classes of All classes of antihypertensive agentsantihypertensive agents
Calcium channel Calcium channel antagonistsantagonists
Angiotensin converting Angiotensin converting enzyme inhibitorsenzyme inhibitors
Angiotensin receptor Angiotensin receptor antagonistsantagonists
RenoprotectionRenoprotectionAngiotensin converting enzyme Angiotensin converting enzyme
inhibitorsinhibitorsAngiotensin receptor Angiotensin receptor
antagonistsantagonists
Antihypertensive Therapy
EffectivePreventionRegression
ManagementAssociated
Control CV
PreventionBP
Reduction
gTarget Organ
Damage
Associated Clinical
Conditions
CVRisk
Factors
New OnsetDiabetes