hypertension
TRANSCRIPT
Hypertension in Malaysia
Assoc. Prof. Dr. Rashidi Ahmad
MD(USM), MMed(EM)(USM),FADUSM,
AM(Mal), Clinical Fellow (Cardio)(NHI)
School of Medical Sciences, USM, KB, Kelantan
Objectives
Understanding hypertension
Magnitude of hypertension in Malaysia
Best clinical practice (antihypertensive agents)
Definition
Confirmed/based on the average of 2 or more readings taken at 2 or more visits to the doctor.
CUFF:Width should at least be 40% of the
circumference of the arm
ARM SUPPORT IN STANDING
SITTING
KOROTKOFF PHASE:
1 CLEAR TAPPING SOUNDS FIRST APPEAR
5 THE DISAPPEARANCE OF SOUND
SBP
DBP
Important rules
Check BP both arms – coarctation of aorta, arterial anomaly
Lying & standing – postural drop in elderly, diabetics
Beware of auscultatory gap
Pathophysiology
Keep thinking of secondary causes
Sleep apneaDrug-induced or related causes
Chronic kidney diseasePrimary aldosteronismRenovascular disease
Chronic steroid therapy and Cushing’s syndromePheochromocytoma
Coarctation of the aortaThyroid or parathyroid disease
IHD mortality versus blood pressure
O’Donnell, et al. J Hypertension, 1998; 16: 3
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
Magnitude of HPT
Affects about 50 million people in the US and approximately 1 billion worldwide.
Prevalence increases with age: individuals who are normotensive at age 55 still face a
90% lifetime risk of developing HPT.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72.
Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002;287:1003-10.
Lim,et al1991: 13.8%
Srinavas, et al1998: 25.6%
Liew, et al.1997: 42.8%
Nawawi2002: 31.2%
Chan1997: 10%
Prevalence rates fromDifferent years and
Different populations
Hypertension in Malaysia
Prevalence: 25.7%.
Men vs women - 26.3% vs 25.0%.
1 in 4 adults aged 25-64 years had HPT.
Known hypertensives: 1.4 million
Newly diagnosed:1.7 million.
Chinese (31.0%), Malays (23.4%) and Indians (21.6%).
Prevalence of HPT by sex and race amongst Malaysian residentsaged ≥ 18 years in 2006 (N=33,976)
Sex, % (95% CI)Age (Years)
Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)
Bumi Sarawak 35.6 (31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)
Male Female Both sexes
All races 33.3 (31.6, 32.8) 31.0 (30.3, 31.7) 32.2 (31.6, 32.8)
Malay 33.7 (32.5, 34.8) 34.1 (33.1, 35.1) 33.9 (33.1 34.7)
Chinese 35.0 (33.2, 36.8) 29.8 (28.2, 31.4) 32.4 (31.1, 33.8)
Indians 30.9 (28.2, 33.8) 27.8 (25.6, 30.1) 29.4 (27.5,31.2)
Prevalence of HPT by sex and race amongst Malaysian residents aged ≥ 30 years in 2006 (N=24,796)
Sex, % (95% CI)Age (Years)
Indians 44.1 (40.8, 47.4) 42.7 (39.9, 45.5) 40.0 (37.7, 42.3)
Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)
Bumi Sarawak 35.6 ( 31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)
Male Female Both sexes
All races 41.7 (40.7, 42.8) 43.4 (42.5, 44.4) 42.6 (41.8, 43.3)
Malay 45.8 (44.4, 47.1) 51.2 (50.0, 52.4) 45.4 (44.3, 46.4)
Chinese 47.4 (45.4, 49.4) 42.3 (40.4, 44.3) 40.6 (39.0, 42.1)
Rural vs Urban
Rural 36.9% ( 35.9, 38.0)
Urban 29.3% ( 28.5, 30.0)
The Malaysian Rule
All hypertensives
64% 36% Aware
12% 88% Treated
74% 26% controlled
The ‘Malaysian Rule’
100 All hypertensives
64 36 Aware
69 31 Treated
92 8 Controlled
Overall BP Control by ethnicity
Indian 12.2% ( 10.0,14.7)
Chinese 11.5% ( 10.1,12.9)
Malays 7.0% ( 6.4,7.7)
Comparison with NHMS 11 ( > 30 years )
1996 2006
Prevalence 33% 43%
Aware 33 % 36%
Diagnosed & Rx 23% 88%
Rx and controlled 26% 26%
Overall control 6% 8 %
Hypertension Control in the Asia Pacific Region
Prev Aware Treat Control
Thailand (2003-4) 22.2% 28.6% 23.7% 8.6%
China 2002 18.8% 30.2% 24.7% 6.1%
Korea 2001 22.9% 30.2% 22.9% 10.7%
Malaysia 2006 32.2% 35.8% 31% 8.2%
USA 2004 29.9% 66.5% 53.7% 33.1%
Clinical Aspects – Current Status ( IHM MOH 2006 )
National Essential Hypertension Audit - rates of control
Hospital with specialist 31.2%Hospital without specialist 26.6%Clinics with FMS/ MO 28.8%Clinics without FMS/MO 26.9%
Clinical Aspects – Current Status ( IHM MOH 2006 )
National Essential Hypertension Audit- rates of control by ethnicity
Malay 24.3%Indian 30.8% Chinese 37.6%Others 30.8%
Clinical Aspects – Current Status ( IHM MOH 2006 )
National Essential Hypertension Audit - rates of control by age
30-39 19.4%40-49 27.1%50-59 29.1%>60 29.2%
Points to ponder!
Patients’ non compliance
Doctors not sure when to treat and what
the treatment goals are
Doctors not using the right drug/drugs
Patients has undiagnosed secondary hypertension or complications of hypertension which makes optimum control difficult
What are the better ways to
manage hypertensive patients
in Malaysia?
Co-existing Condition
BP Levels(mmHg)
No RFNo TODNo TOC
TODor
RF (1 – 2)No TOC
TOCor
RF (≥ 3)or
Clinical atherosclerosis
Previous MIor
Previous strokeor
Diabetes
SBP 120 – 139 and/or DBP 80 – 89
Low Medium High Very high
SBP 140 – 159 and/or DBP 90 – 99
Low Medium High Very high
SBP 160 – 179 and/orDBP 100 – 109
Medium High Very high Very high
SBP 180 – 209 and/orDBP 110 – 119
High Very high Very high Very high
SBP ≥ 210 and/orDBP ≥ 120
Very high Very high Very high Very high
Risk Level Risk of Major CV Event in 10 years Management
Low < 10% Lifestyle changes
Medium 10 – 20% Drug treatment and lifestyle changes
High 20 – 30% Drug treatment and lifestyle changes
Very high > 30% Drug treatment and lifestyle changes
Risk Stratification
First line therapy
NICE / BHS ACEi / ARB/ diuretics/ CCB
ESH/ESC ACEi /ARB/diuretics/CCB/Beta blockers
WHO/ISH Low dose diuretics/ ACEi/CCB
MSH ACEi / ARB/diuretics/CCB
Chinese ACEi /ARB/diuretics/CCB/Beta blockers
Choice of anti-hypertensive drugs in patients with concomitant conditions
Concomitant disease Diuretics β-blockers
ACEIs CCBs Peripheralα-blockers
ARBs
Diabetes mellitus (without nephropathy)
+ +/- +++ + +/- ++
Diabetes mellitus (with nephropathy)
++ +/- +++ ++* +/- +++
Gout +/- + + + + +
Dyslipidaemia +/- +/- + + + +
Coronary heart disease + +++ +++ ++ + +
Heart failure +++ +++# +++ +@ + +++
Asthma + - + + + +
Peripheral vascular disease
+ +/- + + + +
Non-diabetic renal impairment
++ + +++ +* + ++
Renal artery stenosis + + ++$ + + ++$
Elderly with no co-morbid conditions
+++ + + +++ +/- +
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice+/- Use with care- Contraindicated* Only non-dihydropyridine CCB# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated@ Current evidence available for amlodipine and felodipine only$ Contraindicated in bilateral renal artery stenosis
ESH/ESC Guidelines 2007monotherapy vs combination therapy
ESH/ESC Guidelines 2007 ESH/ESC Guidelines 2007 J HypertensJ Hypertens. 2007;25:1105. 2007;25:1105--11871187
Single agentSingle agentat low doseat low dose
TwoTwo--drug combinationdrug combinationat low doseat low dose
If goal BP not achievedIf goal BP not achieved
If goal BP not achievedIf goal BP not achieved
Previous agentPrevious agentat full doseat full dose
Switch to different agentSwitch to different agentat low doseat low dose
Previous combinationPrevious combinationat full doseat full dose
Add a third drugAdd a third drugat low doseat low dose
TwoTwo--to threeto three--drugdrugcombination at full dosecombination at full dose
Full doseFull dosemonotherapymonotherapy
TwoTwo--threethree--drug combinationdrug combinationat full doseat full dose
Mild BP elevationMild BP elevationLow / moderate CV riskLow / moderate CV riskConventional BP targetConventional BP target
Marked BP elevationMarked BP elevationHigh / very high CV riskHigh / very high CV riskLower BP targetLower BP target
Choose betweenChoose between
Newly diagnosed, uncomplicated patients with hypertension with no compelling indication
First line monotherapy
Blockers of the renin system ( ACEi, ARB )
Calcium channel blockers
Diuretics
WHO/ISH JNC-6
Effects of diuretics and ß-blockers on cardiovascular mortality
Treatment Treatment Better Worse
Drug Dose No. RR (95% CI)
0.4 0.7 1.0 RR (95% CI)
Diuretics High 11 0.78 (0.62-0.97)
Diuretics Low 4 0.76 (0.65-0.89)
ß-blockers 4 0.89 (0.76-1.05)
Combination therapy
BP >160/90 mmHg
Include diuretics as part of combination therapy (ACEI + Diuretic)
Consider fixed dose combination if compliance is an issue
Malaysian Untreated Hypertensives(Acta Cardiol. 1999;54:277-282 )
NT HT
SBP * 120 (112-130) 169(160- 180)DBP* 80 ( 78-82 ) 100 ( 100-110 )MAP * 94 ( 91-97 ) 123 ( 119-130 ) PWV* 8.8 (8.3- 9.6) 11.7(10.9- 12.9 )
Our population most likely needs combination antihypertensive agents
Malaysian Untreated Hypertensives( Asia Pacific J Pharmacol ; 1997 :89-95 )
NT HT
Se Na * 142.18 +0.78 146.83+2.30
UNaV * 140.58+ 15.65 100.55+17.28
Se i Ca* 1.25 + 0.01 1.17+0.01
PRA 0.89+0.19 0.79+0.2
PRC 3.09+0.74 4.23+1.43
Se Aldo 275+21.51 257 + 16.22
“Malaysian hypertensives are salt retainers “
“ Malaysian hypertensives are normoreninaemic hypertensives “
Effective Combinations in Malaysia- Retrospective Review of Record
( Asia Pac J Pharmacol.; 2001:17-24 )
Diuretics No Diuretics( n=100 ) ( n=100 )
SBP * 140 +2 151+3DBP * 85+1 88+1 dSBP * 30+3 21+3 dDBP 13+2 13+2
Effective Combinations in Malaysia
Diuretics No Diuretics
Controlled 66% 38%
p < 0.0001
What predicts BP control ?
By univariate analysisOdds p
Statin on admission 2.53 0.000Presence of IHD 2.21 0.001Diuretics on admission 2.12 0.002ACE I on admission 1.97 0.006
> 2 drugs 1.92 0.007
What predicts BP control ?
By multivariate analysis
Odds p
Statin on admission 1.79 0.030
Diuretics on admission 1.77 0.033
The Raub Heart Study
Prevalence of Hypertension, Diabetes and Obesity
1993 1998MalesHypertension 26.2 30.6Diabetes 4.4 4.7Obesity 3.1 5.2Overweight 17.7 30.9FemalesHypertension 29.4 31.7Diabetes 3.5 7.5Obesity 10.5 12.3Overweight 25.3 31.1
Blood pressure and vascular risk in diabetes Best evidence: 2000
UK Prospective Diabetes Study
UKPDS
SBP
UK Prospective Diabetes Study
Blood pressure reduction
165
∆ 2.2 mmHg (95% CI 2.0-2.4); p<0.001
∆ 5.6 mmHg (95% CI 5.2-6.0); p<0.001
Diastolic
Systolic
PlaceboPerindopril-Indapamide
Mea
n B
lood
Pre
ssur
e (m
mH
g)
65
75
85
95
105
115
125
135
145
155
R 6 12 18 24 30 36 42 48 54 60
140.3 mmHg134.7 mmHg
Average BP during follow-up
77.0 mmHg74.8 mmHg
Follow-up (Months)
All-cause mortality
0
10
0 6 12 18 24 30 36 42 48 54 60
PlaceboPerindopril-Indapamide
COVERSYL PLUS
Relative risk reduction 14%: 95% CI 2-25%
p=0.025
5
14%
Cu m
ula t
ive
inci
d enc
e (%
)
Follow-up (months)
Conclusion
Hypertension is getting more prevalent in Malaysia
Awareness and control rates are still poor
Understanding the profile of our patients is important for optimum management
A typical Malaysian Hypertensive- Back to Reality !
Diagnosed late
Has other concomitant cardiovascular risk factors
Has complications of hypertension including target organ damage and target organ complications
BP not optimally controlled
We have more works to do?
Thank You for Your Attention !