-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
1/93
Impact of Blood Pressure Impact of Blood Pressure
The Importance of Achieving andThe Importance of Achieving andMaintaining Target GoalsMaintaining Target Goals
Dr Annuar RapaeeDr Annuar RapaeeMBBS(Malaya); MRCP(UK); AdvMCard(UKM); CCMR(GermanyMBBS(Malaya); MRCP(UK); AdvMCard(UKM); CCMR(Germany
AM; FNHAM; FAsCC;FACCAM; FNHAM; FAsCC;FACC
Consultant Cardiologist Serdang HospitalConsultant Cardiologist Serdang Hospital..
PMPL000701MYSG201004
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
2/93
Lecture Outline:Lecture Outline:
Burden of HypertensionBurden of Hypertension
What guidelines tell us ?What guidelines tell us ?
Choosing the ideal blood pressureChoosing the ideal blood pressure
Impact of blood pressure treatmentImpact of blood pressure treatment
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
3/93
Burden of Hypertension iBurden of Hypertension iMalaysiaMalaysia
PMPL000501MYSG201004
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
4/93
The prevalence of hypertension in Malaysians aged 30 yearsThe prevalence of hypertension in Malaysians aged 30 years
and above was 42.6% in 2006and above was 42.6% in 2006
Hypertension is a silent disease; 4.8 million individuals withHypertension is a silent disease; 4.8 million individuals with
hypertension in Malaysia, the majority of cases (64%) inhypertension in Malaysia, the majority of cases (64%) in
the country remain undiagnosed.the country remain undiagnosed.
Prevalence of Hypertension in MalaysiaPrevalence of Hypertension in Malaysia
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
5/93
2029 3039 4049 5059 6069 70
Prevalence of Hypertension by AgePrevalence of Hypertension by Age
and Genderand Gender
Age
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
6/93WHO World Health Report 2004
CV diseases
Cancer
Infectious andparasitic diseases
Other non-infectiousdiseases
Injuries
Respiratory diseases
Respiratory infections
Maternal and perinatal conditionsNutritional deficiencies
Cardiovascular Disease Leading Cause of GlobaCardiovascular Disease Leading Cause of Globa
MortalityMortality
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
7/93
Global Mortality : Risk FactorsGlobal Mortality : Risk Factors
Ezzati et al. Lancet. 2002;360:1347-1360
Attributable Mortality x 1000
High mortality, developing region
Lower mortality, developing region
Developed region
0 80007000600050004000300020001000
High blood pressure
Tobacco
High cholesterol
Unsafe sex
High BMI
Physical inactivity
Alcohol
Indoor smoke from solid fuels
Iron deficiency
Underweight
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
8/93
Cardiovascular Disease : AdmissionCardiovascular Disease : Admission
Government Hospital 1985 - 2000Government Hospital 1985 - 2000
Hypertensive Disease
Ischaemic Heart Disease
Disease of Pulmonary Circulation &other Forms of Heart Disease
Cerebrovascular Disease
Disease of Arteries, Veins, LymphaticVessels & Unspecified Disorders of theCirculatory System
Rheumatic Fever & Rheumatic Heart Disease
Data from MOH,
C di l Di D thCardiovascular Disease : Deaths
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
9/93
Cardiovascular Disease : DeathsCardiovascular Disease : Deaths
Government Hospital 1985 - 2000Government Hospital 1985 - 2000
6205
6058
5959
6221
6336
6574
6475
6535
6352
67157071
7249
7496
7307
7559
781
Data from MOH
Th C di l C i
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
10/93
Atherosclerosis
& LVH
Risk eg Hypertension
Remodelling VentricularDilation
CHF
End-stage
microvascular &heart disease
Death
MI
Adapted from Dzau et al.
The Cardiovascular ContinuumThe Cardiovascular Continuum
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
11/93
Hypertension : Increased CV RiskHypertension : Increased CV Risk
Framingham Heart Study
Coronary Disease Stroke Peripheral Artery
Disease
Cardiac Failure
BiennialA
ge-AdjustedRate
per
100
0
Kannel et al JAMA 1996
3 - 4 times2 times 3 - 4 times
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
12/93
20-74 75-84 85-94 95-104 105-160DBP, mm Hg
Risk of CV Events Increases with Diastolic BPRisk of CV Events Increases with Diastolic BP
Framingham study 38-year follow-upFramingham study 38-year follow-up
Kannel. Am J Cardiol 2000
0
10
20
30
40
50Age-adjusted annual rate Percent of events
0
10
20
30
40
50
Rate/1000 women Rate/1000 men
Events in women Events in men
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
13/93
Risk of CV Events Increases with Systolic BPRisk of CV Events Increases with Systolic BP
Framingham study 38-year follow-upFramingham study 38-year follow-up
74-119 120-139 140-159 160-179 180-300SBP, mm Hg
0
10
20
30
40
50Age-adjusted annual rate Percent of events
0
10
20
30
40
50
Kannel. Am J Cardiol 2000
Rate/1000 women Rate/1000 men
Events in women Events in men
f S CRi k f St k d C H t
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
14/93
Stroke CHD7 prospective observational studies 9 prospective observational studies
MacMahon et al. Lancet 1990
Risks of Stroke and Coronary HeartRisks of Stroke and Coronary Heart
Disease Increases with Diastolic BPDisease Increases with Diastolic BP
Approximate mean DBP, mm Hg
76 84 91 98 105
Relative risk of stroke
76 84 91 98 105
4.00
2.00
1.00
0.50
0.25
Relative risk of CHD
4.00
2.00
1.00
0.50
0.25
CV risk Doubles with Each BP Rise ofCV risk Doubles with Each BP Rise of
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
15/93
Lewington et al Lancet 2003
* Individuals aged 40-70 yrs, starting at BP 115/75
CV risk Doubles with Each BP Rise ofCV risk Doubles with Each BP Rise of
20/10 mmHg20/10 mmHg
C A t Di (CAD) i th M tCoronary Artery Disease (CAD) is the Most
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
16/93
Coronary Artery Disease (CAD) is the MostCoronary Artery Disease (CAD) is the Most
Common Cause of Morbidity and Mortality inCommon Cause of Morbidity and Mortality in
Patients with HypertensionPatients with Hypertension
* Individuals aged 40-70 years, starting at BP 115/75 mm Hg
CV mortality risk
Blood pressure (mm Hg)
0
1
2
3
4
5
6
7
8
115/75 135/85 155/95 175/105
Lewington et al. Lancet 2003JNC VII. JAMA 2003
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
17/93
Erdine. European Society of Hypertension Scientific Newsletter 2000
Hypertension Poorly Controlled WorldwideHypertension Poorly Controlled Worldwide
Percentage of Patients with Controlled BP (
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
18/93
Blood Pressure Control in MalaysiaBlood Pressure Control in Malaysia
Proportion of patients (%)
NHMS;1996
by MOH 21,000 subjects > 30yr - 33% HPT, only 23% on Rx and only 6% < 140/90 mmHg Manjung Hosp,Perak Hypertension Survey 2003
397 subjects, 98% > 30yr 22.9% HPT, 45% on Rx, 55% not aware and only 22.6% < 140/90 mmHgGHKL Physician clinic 2005
N=222 patients, 22.1% one drug,33.3% 2 drugs,34.2% 3 drugs, 8.1% 4 drugs.
10.8% BP140/90mmHg.
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
19/93
The Rule of HalvesThe Rule of Halves **********
Only 1/2 have been diagnosedOnly 1/2 have been diagnosed
Only 1/2 of those diagnosed have been treatedOnly 1/2 of those diagnosed have been treated
Only 1/2 of those treated are adequately controlledOnly 1/2 of those treated are adequately controlled
Thus, only 12.5% overall are adequately controlledThus, only 12.5% overall are adequately controlled
1999
HOImpact of HypertensionImpact of Hypertension
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
20/93
HOImpact of HypertensionImpact of Hypertension
Untreated or sub-optimally controlled hypertension leads toincreased cardiovascular, cerebrovascular and renalmorbidity and mortality
In persons older than 50 years, SBP > 140 mmHg is a muchmore important CVD risk factor than DBP
Risk of CVD beginning at 115/75 mmHg doubles with eachincrement of 20/10 mmHg Individuals who are normotensive at age 55 have a 90%
lifetime risk of developing hypertension
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
21/93
Lecture Outline:Lecture Outline:
Burden of HypertensionBurden of Hypertension
What guidelines tell us ?What guidelines tell us ?
Choosing the ideal blood pressureChoosing the ideal blood pressure
Impact of blood pressure treatmentImpact of blood pressure treatment
Blood Pressure has Multiple
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
22/93
Sympathetic nervous system
Renin-angiotensin system
Total body sodium
Patient 1 Patient 2 Patient 3
B. Waeber, March 2007, with permiss
Blood Pressure has MultipleRegulatory Pathways
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
23/93
Questions to be AnsweredQuestions to be Answered
What is high blood pressure?
Clinical evaluation - what should be done?
Which factors influence prognosis?
Do patients benefit from antihypertensive treatment?
CPG Management of HypertensionCPG Management of Hypertension
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
24/93
CPG Management of HypertensionCPG Management of Hypertension
CPG Management of HypertensionCPG Management of Hypertension
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
25/93
CPG Management of HypertensionCPG Management of Hypertension
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
CPG Management of HypertensionCPG Management of Hypertension
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
26/93
CPG Management of HypertensionCPG Management of Hypertension
CPG Management of HypertensionCPG Management of Hypertension
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
27/93
CPG Management of HypertensionCPG Management of Hypertension
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
JNC 7JNC 7
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
28/93
JNC 7JNC 7
JNC 7JNC 7
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
29/93
JNC 7JNC 7
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
JNC 7JNC 7
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
30/93
JNC 7JNC 7
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
31/93
The update of the NICE guideline on hypertension in
primary care was undertaken because recent large
clinical outcome trials had provided new information
about the pharmacological treatment of
hypertension.
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
June 2007June 2007
National Institute of Health and Clinical Excellence (NICE) NICE Clinical Guidelines (Published August 2004)
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
32/93
According to the new NICE guidelines for treatment ofhypertension of June 2006, calcium channel blockers or
thiazide-type diuretics are now recommended for initial
treatment in patients over 55 years of age and in black
patients of all ages.
ACE-inhibitors or Angiotensin-II Receptor Antagonists (if
ACE-inhibitors are not tolerated) are recommended for
younger patients.
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
June 2007June 2007
National Institute of Health and Clinical Excellence (NICE) NICE Clinical Guidelines (Published August 2004)
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
33/93
Beta-blockers are no longer considered apreferred routine initial therapy in the generalpopulation, but are still to be considered as initialtherapy in younger patients, e.g. those withincreased sympathetic drive and those withintolerance or contraindications to ACE-inhibitorsand angiotensin-II antagonists.
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
June 2007June 2007
National Institute of Health and Clinical Excellence (NICE) NICE Clinical Guidelines (Published August 2004)
UK NICE Guidelines for treatment of HypertensiUK NICE Guidelines for treatment of Hypertensi
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
34/93
UK NICE Guidelines for treatment of Hypertensiyp
June 2007June 2007
National Institute of Health and Clinical Excellence (NICE) NICE Clinical Guidelines (Published August 2004)
New (1999) WHO-ISH Definitions andNew (1999) WHO-ISH Definitions and
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
35/93
New (1999) WHO ISH Definitions andNew (1999) WHO ISH Definitions andClassification of BP LevelsClassification of BP Levels
Category Systolic BP Diastolic BP(mm Hg) (mm Hg)
Optimal BP
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
36/93
Clinical Evaluation - What Should Be Done?Clinical Evaluation - What Should Be Done?
Exclude secondary causes of hypertension
To ascertain the presence or absence of target organ damage
To assess lifestyle and identify other cardiovascular risk factors or concomdisorders that affect risk factors, prognosis and guide treatment
Such information is obtained from adequate history, physical
examination, laboratory investigations and other diagnostic
procedures
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
Clinical Evaluation - What Should Be Done?Clinical Evaluation - What Should Be Done?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
37/93
Risk factors of CVD
I. Used for risk stratification
II.Other factors adversely influencing
prognosis
Target organ damage (TOD)
Associated clinical conditions (ACC)
Clinical Evaluation - What Should Be Done?Clinical Evaluation - What Should Be Done?
1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
38/93
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
Decisions should not be made on BP alone, but also opresence of other risk factors, target organ damage, an
concomitant diseases, as well as on other aspects
patients personal, medical, social, economic, ethnic, an
cultural characteristics
1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians
More Than 80% of Patients with
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
39/93
40
30
20
10
0None
Hypertensiv
epatients(%)
1 2 3 4
Additional risk factors
Mancia et al. J Hypertens 2004;22:517Copyright 2004, with permission from Lippincott, Williams and Wilkins
o e a 80% o at e ts tHypertension Have Additional Risk Factors
14
40
32
12
2
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
40/93
Risk Factors for CVD
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
Major Risk Factors
Hypertension Cigarette Smoking Central Obesity
Physical Inactivity Dyslipidaemia Diabetes Mellitus Microalbuminurea Estimated GFR < 60 mL/min) Age (>55 years for men, >65 years for women)
Family History of Premature Cardiovascular Disease (
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
41/93
Risk Factors for CVD
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
Target Organ Damage
Heart Left Ventricular Hypertrophy Angina or Prior Myocardial Infarction
Prior Coronary Revascularization
Brain Stroke or Transient Ischaemic Attack
Chronic Kidney Disease
Peripheral Arterial DiseaseRetinopathy
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
42/93
Associated Clinical Conditions (ACC)
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
Cerebrovascular Disease Ischaemic Stroke Cerebral Haemorrhage Transient Ischaemic Attack (TIA)
Heart Disease Myocardial Infarction Angina Pectoris Coronary Revascularization Congestive Heart Failure
1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
43/93
Associated Clinical Conditions (ACC)
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
Renal Disease Diabetic nephropathy Renal Failure, Plasma Creatinine Concentration > 177 mmol/L (>2.0 mg/dL)
Vascular Disease
Dissecting Aneurysm Symptomatic Arterial Disease
Advanced Hypertensive Retinopathy Haemorrhages or Exudates Papillpedema
1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians
Stratifying Risk Quantifying PrognosisStratifying Risk Quantifying Prognosis
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
44/93
Stratifying Risk Quantifying PrognosisStratifying Risk Quantifying Prognosis
Clinical Practice Guidelines Management off Hypertension (3rd Edition Feb 2008)
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
45/93
Low risk =
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
46/93
Example 1:
65-year old man with diabetes, TIAs, and BP of 145/90 mm Hg
will have annual risk of major CVD event 20 times greater than
40-year old man with same BP but without diabetes or history ofCVD
gg
Which Factors Influence Prognosis?Which Factors Influence Prognosis?
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
47/93
Example 2:
40-year old man with BP of 170/105 mm Hg will have risk of
major CV event 2-3 times greater than man of same age with
BP of 145/90 mm Hg and similar other risk factors
gg
L t O tliLecture Outline:
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
48/93
Lecture Outline:Lecture Outline:
Burden of HypertensionBurden of Hypertension
What guidelines tell us ?What guidelines tell us ?
Choosing the ideal blood pressureChoosing the ideal blood pressure Impact of blood pressure treatmentImpact of blood pressure treatment
HO
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
49/93
The relationship between BP and risk of CVD
events is continuous, consistent and independent of
other risk factors.
The higher the BP, the greater is the chance of
heart attack, heart failure, stroke and kidney disease
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
HO
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
50/93
What physicians do in regards to
cardiovascular diseases is important
S Julius 1998
HO
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
51/93
Treatment adaptation of hypertensive patients not on target
Unchanged repeat84%
Dose increaseAddition
Switch
Based on 7 246 treated hypertensive patients whose diastolic bloodpressure was not on target in France, Germany, Italy, Spain and UK
Copyright 1992 CardioMonitor
, Taylor Nelson HealtS Julius 1998
HOBenefits of Lowering Blood PressureBenefits of Lowering Blood Pressure
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
52/93
Antihypertensive therapy reduces the incidence of
Stroke by 35 40%
Myocardial Infarction by 20 25%
Heart Failure by >50%
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
HOBenefits of Lowering Blood PressureBenefits of Lowering Blood Pressure
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
53/93
Antihypertensive therapy
In patients with Stage 1 hypertension and additional CV risk
factors, achieving 12mmHg reduction in SBP over 10 years
Prevents 1 death for 11 patients treated
In presence of CVD or target organ damage
Only 9 patients would require BP reduction to prevent 1 death
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
HOGoals of TherapyGoals of Therapy
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
54/93
JNC 7
The ultimate public health goal of Antihypertensive
therapy is the reduction of cardiovascular and renalmorbidity and mortality
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (August 2004)
HOIntensive BP Control Reduces CV RiskIntensive BP Control Reduces CV Risk
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
55/93
Relative Risk (95% CIs)Relative Risk (95% CIs)
1.01.0 1.251.25
More Intensive BPControl Better
Less Intensive BControl Better
0.50.5
StrokeStroke
Coronary Heart DiseaseCoronary Heart Disease
Heart FailureHeart Failure
BPLTTC Lancet 2003
Major CV EventsMajor CV Events
CV DeathCV Death
Total MortalityTotal Mortality
HO
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
56/93
Hypertension Optimal Treatment
A Landmark Study
A 3.8-Year International Study Of18,790 Patients
Malaysia was one of the
investigation centres
HOT Study, Hansson & Zanchetti, 1998)
HOPrimary Analysis of the HOT StudyPrimary Analysis of the HOT Study
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
57/93
to assess the relationship between major cardiovascularevents and three target diastolic blood pressures (< 90, 27 kg/m2
Treatment Flow Chart
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
76/93
Study Endpoints
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
77/93
Primary Endpoint
Time to first stroke
Prespecified Secondary Endpoints
All cardiovascular events
All cardiac events Death from any cause
Recruitment
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
78/93
Baseline Patient Characteristics
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
79/93
Difference in Blood Pressure
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
80/93
Difference in Blood Pressure
Reduction of 4.2/2.1 mmHg in the felodipine group
Primary Outcome27% RR in All Strokes
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
81/93
Lower incidences of CV events among felodipine
patients
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
82/93
patients
Secondary Outcomes
27% RR in total cardiovascular events
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
83/93
27% RR in total cardiovascular events
Secondary Outcomes31% RR in all cause death
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
84/93
Other Observations32% RR in coronary events
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
85/93
Other Observations
33% RR in cardiovascular death
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
86/93
33% RR in cardiovascular death
Felodipine ER was Well-Tolerated
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
87/93
Adverse events reported during treatment
Discussion
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
88/93
The FEVER study shows that in Chinese hypertensive patient
receiving a small dose of the diuretic hydrochlorothiazide (12.5 mgonce a day) the addition of a small dose of the calcium antagonistfelodipine (5 mg once a day), instead of placebo, is accompanied bya further SBP/DBP decrease of 4/2 mmHg (despite a more frequentadd-on therapy in the placebo group
Discussion
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
89/93
Marked reductions in
fatal and non-fatal stroke (27%, P = 0.001), total cardiovascular events (27%, P < 0.001),
total cardiac events (34%, P 0.012),
coronary events (32%, = 0.024), c
cardiac failure (30%, NS),
death by any cause(31%, = 0.006), cardiovascular death (17%, P = 0.019), and
cancer (36%, P = 0.017).
Relevant Clinical Conclusions FEVER
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
90/93
Even a small difference in SBP/DBP, amounting to
approximately 4/2 mmHg, can be associated withsubstantial reductions in the incidence of most types ofcardiovascular events in Chinese hypertensive patients
Relevant clinical conclusions FEVER
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
91/93
It substantiates and supports guidelines recommendations, andindicates that even small differences in the control of SBP just belowand just above the 140 mmHg goal (and DBP just below and above85 mmHg) are accompanied by substantial differences in outcomes.
SBP and DBP values achieved in the felodipine group of FEVERclosely correspond to the SBP/DBP values of 138.5/82.6 mmHg(138.1/82.3 mmHg) indicated as optimal blood pressures in the HOTstudy
Relevant Clinical Conclusions FEVER
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
92/93
FEVER shows the benefits of treating hypertension with a low-
dose combination of antihypertensive agents The results of FEVER directly show that adding a low
dihydropyridine dose to a low-dose thiazide diuretic furtherreduces blood pressure and cardiovascular outcomes
HO
-
8/4/2019 Impact of Blood Pressure - The Importance of Achieving and Maintaining Target Goals-2
93/93
THANK YOU