Prehypertension. Management Seminar executive summary

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1 Hypertension Management Seminar executive summary Dr C P Ho Definition and classification of hypertension: JNC VII Hypertension is defined as blood pressure 140/90 mmhg Category Normal Systolic (mmhg) <120 Diastolic (mmhg) and <80 Prehypertension Stage 1 hypertension Stage 2 hypertension or or or 100 JNC VII. JAMA 2003;289:

2 Prevalence of hypertension*: North America and Europe Prevalence (%) Men Women Total United States Canada Europe Italy Sweden England Spain Finland Germany * BP 140/90 mmhg or treatment with antihypertensive medication Wolf-Maier K, et al. JAMA 2003;289:

3 Prevalence (%) Prevalence of hypertension: Asia China (2000/2001) Taiwan (1994) Men Women Total Hong Kong (1997) Singapore (1998) Malaysia (1996) Thailand (1991) Philippines (1999) Indonesia (1994) India (Mumbai, 1999) Japan ( ) Gu DF, et al. Hypertension 2002;40: ; Singh RB, et al. J Hum Hypertens 2000;14: ; Janus ED. Clin Exp Pharmacol Physiol 1997;24: ; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al. Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27: ; Muhilal H. Asia Pacific J Clin Nutr 1996;5: ; Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48: [in Japanese] Goals of treatment: JNC VII The SBP and DBP targets are <140/90 mmhg The primary focus should be on achieving the SBP goal In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmhg SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure JNC VII. JAMA 2003;289:

4 Treatment failures Study Blood pressure goal (mm Hg) Patients not achieving goal on active treatment (%) Reference HDFP <90 (DBP) HDFP, 1979 Australian Trial <90 (DBP) 36.1 ANBP, 1980 EWPHE <160/ Amery et al, 1991 IPPSH (SBP/DBP) 34.6 IPPSH, 1985 HAPPHY <90 (DBP) 23 Wilhelmsen et al, 1987 SHEP <95 (DBP) SHEP, 1991 <160 (SBP) Hypertension and cardiovascular disease 24-h average blood pressure is correlated with: Overall target organ damage score Left ventricular mass Impaired left ventricular function (Micro) albuminuria Brain damage Retinopathy Opsahl et al, 1988; Giaconi et al, 1989; Shimida et al, 1990; Hansen et al, 1992; White et al, 1993; Mancia et al,

5 Hypertensive kidney Kidney damage asymptomatic till late stage Viscous cycle to augment renal damage through the renin-angiotensin system Rate of damage predictable Treatment can reduce rate of progression 5

6 Hypertensive kidney Kidney damage asymptomatic till late stage Viscous cycle to augment renal damage through the renin-angiotensin system Rate of damage predictable Treatment can reduce rate of progression 6

7 The cost of cardiovascular diseases and stroke Heart Disease and Stroke Statistics 2006 Update, American Heart Association Millimetres matter A 2-mmHg reduction in DBP would result in a 6% reduction in the risk of CHD and a 15% reduction in the risk of stroke and TIAs DBP, diastolic blood pressure; CHD, coronary heart disease; TIA, transient ischaemic attack Cook NR, et al. Arch Intern Med 1995;155:

8 Millimetres matter For individuals years of age, each increment of 20 mmhg in systolic BP or 10 mmhg in diastolic BP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mmhg BP, blood pressure; CVD, cardiovascular disease JNC VII. JAMA 2003;289: h blood pressure profile in (dipper and non-dipper) Blood pressure (mm Hg) Sleep Non-dipper Dipper :00 11:00 15:00 19:00 23:00 3:00 7:00 Time of day Redman et al, 1976; Mancia et al, 1983; Kobrin et al, 1984; Baumgart et al, 1989; Imai et al, 1990; Portaluppi et al,

9 Blood pressure and target organ damage Current evidence suggests that: Measures of 24-h blood pressure more closely predict target organ damage than do clinic or casual measurements There is a higher incidence of cardiovascular complications when night-time blood pressure remains elevated Blood pressure variability is an additional and independent determinant of target organ damage The highest incidence of cardiovascular events occurs in the morning at (approximately) 24 h post dose Sokolow et al, 1966; Devereux et al, 1983; Devereux et al, 1987; Parati et al,1987; Mancia, 1990 Blood pressure and target organ damage Current evidence suggests that: Measures of 24-h blood pressure more closely predict target organ damage than do clinic or casual measurements There is a higher incidence of cardiovascular complications when night-time blood pressure remains elevated Blood pressure variability is an additional and independent determinant of target organ damage The highest incidence of cardiovascular events occurs in the morning at (approximately) 24 h post dose Sokolow et al, 1966; Pessina et al, 1985; Stanton et al, 1993; Veerman et al,

10 JNC-VI Hypertension Management Guidelines The optimal formulation should provide 24-hour efficacy with a once-daily dose with at least 50% of the peak effect remaining at the end of the 24 hours Agents with a duration of action beyond 24 hours are attractive because many patients inadvertently miss at least 1 dose of medication each week JNC-VI, 1997 The importance of nighttime blood pressure Dippers * (n=20) Nondippers (n=28) P value Fall in Cr Cl (ml/min.month) <0.01 Level of proteinuria (mg/24 h) Night-time BP vs Night-time BP vs proteinuria Cr Cl BP: Night vs Day: *>10%; <10% 390 r 2 =0.4 5 r 2 = <0.01 <0.001 <0.01 * Matched for age, sex, BMI, office BP, creatinin, lipids, antihypertensive R x Timio et al,

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12 2 Important Directions 1. Life-Style Management 2. Medical Therapy General issues when prescribing Prescribe drugs taken only once a day if possible. Prescribe non-proprietary drugs if these are appropriate and minimise cost. Give information about the benefits and side effects of drugs so that patients can make informed choices. 12

13 Drug treatment Key issues in updating the recommendations Beta-blockers: In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, particularly stroke. Betablockers were also less effective than an ACE inhibitor or a calcium channel blocker at reducing the risk of diabetes, particularly in patients taking a beta-blocker and a thiazide-type diuretic. Calcium-channel blockers or thiazide-type diuretics: These are the most likely drugs to confer benefit as firstline treatment for most patients aged 55 or older. Pharmacological interventions In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-ii receptor antagonist if an ACE inhibitor is not tolerated). 13

14 Pharmacological interventions In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese. 14

15 Beta-blocker Beta-blockers are no longer preferred as a routine initial therapy for hypertension But consider them for younger people, particularly: women of childbearing potential patients with evidence of increased sympathetic drive patients with intolerance of or contraindications to ACE inhibitors and angiotensin-ii receptor antagonists If a patient taking a beta-blocker needs a second drug, add a calcium-channel blocker rather than a thiazide-type diuretic, to reduce the patient s risk of developing diabetes. Beta-blocker If a patient s blood pressure is not controlled by a regimen that includes a beta-blocker (that is, it is still above 140/90 mmhg), change their treatment by following the flow chart above. If a patient s blood pressure is well controlled (that is,140/90 mmhg or less) by a regimen that includes a beta-blocker, consider long-term management at their routine review. There is no absolute need to replace the beta-blocker in this case. When withdrawing a beta-blocker, step down the dose gradually. Beta-blockers should not usually be withdrawn if a patient has a compelling indication for being treated with one, such as symptomatic angina or a previous myocardial infarction. 15

16 Pharmco-economic Analysis For 1st line treatment of essential hypertension (people at low risk of heart failure) Calcium Channel Blockers are the most cost effective option because they are associated with a low risk of diabetes and they also have a good effectiveness profile across the range of other cardiovascular disease risks. Target for blood pressure control in CKD With ACEI or ARB, reduce blood pressure to 130/80 mm Hg If urine protein >1 g/day, 120/75 mm Hg In type 2 diabetics, renal protection more clearly proven with ARB 16

17 Angiotensin converting enzymes inhibitor For the same degree of BP reduction, also reduce proteinuria Preservation of renal function (small study) Lisinopril (Zestril) slows renal deterioration Can be combined with verapamil or diltiazem Angiotensin Receptor Blocker Irbesartan Diabetic nephropathy Trial RENAAL Trial (Reduction of end-points in NIDDM with AA Losartan) Clear renoprotection in diabetic nephropathy in type 2 diabetics No head to head comparison with ACEI 17

18 Combination of ACEI and ARB therapy Candesartan 16 mg and Lisinopril 20 mg Microalbuminuria Study (CALM) Combination therapy afforded greater reductions in blood pressure and albuminuria than either treatment alone. More complete blockage of the renin angiotensin system K/DOQI Clinical practice guidelines Target Reduction of proteinuria <1 g/day blood pressure <130/80 mm Hg Start with ACEI/ARB Add Diuretics Add non-dihydropyridine (verapamil or diltiazem) Add ARB/ACEI 18

19 Dialysis outcome Blood pressure control Ca and phosphate control Hb around g/dl Nutrition of the patient, serum albumin >30 g/l Dialysis dose 19

20 How to improve dialysis outcome The most important determinant is the FREQUENCY of dialysis Provide quality dialysis Affordable Dialysis Three times per week Daily dialysis in home HD case 20

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