Download - Kolkata Final API 2010

8/6/2019 Kolkata Final API 2010

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Managing Hypertension

Beyond BP ControlRajeev Gupta, MD PhD FACC

Fortis Escorts Hospital, Jaipur 302017 &Rajasthan University of Health Sciences, Jaipur 302023 India


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20.3

16.9

9.3

8

6.7

9.9

6.4 6.25.4

7.1 7.1

4.75.4

65.2

4.5

0

5

10

15

20

25

Cardiovascular COPD Diarrhea Perinatal Respiratory TB Cancers Injuries

M ale F emale

Major Causes of Death in India: All AgesMillion Death Study 2001-2003

Million Death Study 2009

Analysis of cause of deaths in 1.1 million households and 113,692 personsin all the Indian States

%

CVDs caused 1.7-2.0 million deaths annually


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Cardiovascular Mortality in Different

Indian States: Million Death Study

Males Females

Mony P, et al. 2009https://tspace.library.utoronto.ca/bitstream/1807/18899/3/Mony_Prem%20kumar_200911_MSc_Thesis.pdf


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Burden of Risk FactorsMajor Population-wide Cardiovascular Risk

Factors

WHO. Global Health Risks. 2009


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Kaplan & Opie. Lancet 2006; 367:168-176Danaei G, et al. PLoS Med 2009; 6:e1000058

Hypertension: A Major Cardiovascular Risk Factor


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Risk Factors for AMI in South AsiansINTERHEART Study. Population Attributable Risks %

46.8

37.5

19.3

11.8

37.7

16.1

27.4

-4.6

21.4

36.2

23.9

12.5

33.3

19.6

25.2

15.8

12.2

45.9

-10

0

10

20

30

40

50

ApoB/ApoA1

Smoking

Hyperten

sion

Diabetes

HighWHR

Psychos

ocial

Exercise

Alcoh

ol

Fruits/Veg

South Asians

Others

Joshi PP, et al. JAMA 2007; 297:286-94


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Ten Risk Factors for StrokeINTERSTROKE Study: Population Attributable Risk

21.4

26.1

17.3

29.4

7.9

1.1 1.1

8.5

35.2

73.6

9.5

26.124.1

27.6

14.6

3.5

45.2

0

10

2030

40

50

60

70

Hypertension

Smoking

High

WHR

Diet

risk

Physical

Diabetes

Highalcohol

Psycho

Cardiac

ApoA/ApoB

Ischemic

Hemorrhage

ODonnel M, et al. Lancet 2010; 376:112-23


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1.9

0.5

3.6

0.4

5.6

2.6

3.8

4.1

3.4

1.6

7.1

2.42.6

4.3

0.3

5.4

0

1

2

3

4

5

6

7

8

1955 1965 1975 1985 1995 2005

Years

Delhi

Bombay

HaryanaHaryana

Rajasthan Rajasthan

U.P.

Punjab

Chandigarh

U.P.

Maharashtra

Rajasthan

Maharashtra

Himachal

Orissa

Orissa

Increasing Hypertension in IndiaRural populations: BP >160/95

r2=0.19

Percent

Prevalence

Gupta R, et al. J Human Hypertens 1996; 10:465-472


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1.2

4.2

3.1

4.3

6.4

15.5

14.1

10.911.6

13.1

9.2

0

2

4

6

8

10

12

14

16

18

1945 1955 1965 1975 1985 1995

Years

Calcutta

Kanpur

Bombay

Agra

Railways

Rohtak

Bombay

Ludhiana

Jaipur

Delhi

Jaipur

IncreasingHypertension in IndiaUrban populations: BP >160/95

r2=0.70

Percent

Prevalence

Gupta R, et al. J Hum Hypertension 1996;10:465-472


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29

44

31

34

25

3638

45

41

38

42

33

20

30

40

50

60

1993 1995 1997 1999 2001 2003 2005 2007

M en W omen

Jaipur

Mumbai

Delhi

Chennai

Jaipur

Mumbai

Jaipur

Recent Studies on Hypertension in IndiaUrban populations: BP >140/90

r2=0.37

Percent

Preval

ence

Gupta R. J Human Hypertens 2004; 18:73-78


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Risk Factor Trends in Urban RajasthanJaipur Heart Watch Studies 1992-2006

Gupta R, et al. Heart 2008; 94:16-26


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Lifetime Risk of HypertensionFramingham Heart Study

Vasan et al. JAMA 2002; 287:1003-10

Hypertension: The Neglected Disease of 21st Century

Lancet 2009


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.. Control of blood pressure is nolonger disputed & is supported by

most impressive evidence basemedicine in past and even today


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SBP Distribution & Mortality

Whelton PK et al. JAMA 2002; 288: 1882-8


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Cardiovascular Benefits of Reducing BP

0.36

0.490.43

0.38

0. 5 0 .5

0.43

0.54 0.530.5

0.60.64

0.67 0.670.7

0

0.2

0.4

0.6

0.8

1

40-49 50-59 60-69 70-79 80-89

S troke IHD V ascul ar

0.35

0.470.43

0.34

0.520.48

0.4

0.56

0.49 0.48

0.62 0.610.63

0.7 0.71

0

0.2

0.4

0.6

0.8

1

40-49 50-59 60-69 70-79 80-89

S tr ok e IHD V as c ular

Systolic BP

Diastolic BP

Hazard

ratio

Reduction of usual systolic BP (upper panel) and diastolic BP (lower panel) is associated

with a lower hazard ratios (hazard ratio


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Blood Pressure Goals & CVD Prevention

Goals: Reduce and preserve normal blood pressure

Increase rates of BP control

Promoters:

Physical activity, healthy diet, good medical care,medication, health insurance, diabetes control, weight loss.

Healthy food environments, stable income and workingconditions, health promotion and education

Barriers: Physical inactivity, high salt high fat diet, obesity, diabetes,

stress, lack of medical care, medication cost, tobacco use.

Lack of access to medical care, medications, and

recreation. Unemployment. Social stressors, social conflict.Centers Disease Control, USA 2007


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Lifestyle Modification Interventions

Modification SBP reduction (range)

Weight reduction 520 mmHg/10 kg weight loss

Adopt DASH eating plan 814 mmHg

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcoholconsumption

24 mmHg

Kaplan & Opie. Lancet 2006; 367:168-176


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Goals of Therapy: JNC-7 & BHS-4

Reduce CVD (CHD, stroke, diabetes, CHF) and

renal morbidity and mortality.

Treat to BP


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Beyond BP Control: Questions in

Hypertension Management

1. Are there drug-specific benefitsbeyond BP lowering?

2. Are we trying to prevent end pointsor the disease process?

3. Most effective therapeutic strategyto reduce overall CVD risk burden.

4. Improving adherence to therapy.


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Which is Better: ACEIs vs CCBs

William

s,B.JAmColl

Cardiol

2005;45:813-8

27


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Why are ACE Inhibitors Better?Benefits Beyond BP Control

Improvement in endothelial function

Reduction in oxidative stress

Decrease in vascular inflammation and adhesion

molecules

Inhibition of mitogenesis

Regression of atherosclerotic plaques and LVH

superior to older agents Inhibition of proteinuria superior to older agents

Reduction in new onset diabetes

Improvement in fibrinolysis


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Evidence Based Molecules for HypertensionABCD Rule: British NICE Guidelines 2006

Younger 55 yr or Black

Step 1 A Mono C or D

Step 2 A + C or D Two A + C or D

Step 3 A + C + D Multi drug A + C + D

Step 4 andResistant HTN

Add: either beta-blocker, alpha-blockeror spironolactone orother diuretic

Multi drugAdd: either beta-blocker,alpha-blocker orspironolactone or otherdiuretic

A= ACEI orARB

B= beta-blocker C= CCB D= Diuretic (THZ)

British NICE Guidelines. 2006


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Issues in High BP Management

1. Are there drug-specific benefits beyond

BP lowering?

2. Are we trying to prevent end points orthe disease process?

3. Most effective therapeutic strategy to

reduce overall CVD risk burden.4. Improving adherence to therapy.


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26% 25%

8%

Adapted fromKannel WB. Am J Hypertens. 2000;13:3S-10S.

Men Women

2 RFs

3 RFs

1 RF

NoAdditional

RFs 4 orMore RFs

27% 24%

12%

2 RFs

3 RFs

1 RF

NoAdditional

RFs 4 orMore RFs

>50% of Hypertension Occurs in Presence of 2 or More Risk Factors

CV Risk Factor Clustering With Hypertension

Framingham Offspring Study, Aged 18 to 74 Years

19% 22% 17% 20%


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Risk of CHD in Mild Hypertension by

Intensity of Associated Risk Factors

SBP 150-160 mm Hg + + + + + +

TC 240-262 mg/dL + + + + +

HDL-C 33-35 mg/dL + + + +

Diabetes + + +

Cigarette smoking + +

ECG-LVH +

42

36

30

24

18

12

6

0

46

1014

21

40

10-Yea r

Probability

of

Ev

ent

(%)

Kannel WB. Am J Hypertens. 2000;13:3S-10S.

Risk Factors


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The Polypill Concept

Majority of cardiovascular events occur in subjects withnormal risk factor levels.

To target prevention of intermediate and hard cardiovascularend-points in short- and long-term it is essential to shift the riskfactor continuum to lower levels.

Multiple risk factor interventions required to reduce acuteevents. Blood cholesterol and BP control is crucial.

Original polypill:

3 anti-hypertensives (diuretics, enalapril, atenolol)

Statin, aspirin and folic acid. Revised formulations

Clinical concernsLaw & Wald. BMJ 2002; 324:1570-6

Wald & Law. BMJ 2003; 326:1419-22

Combination Pharmacotherapy Working Group. Ann Intern Med 2005; 143:593-99


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Polypill Concept: Phase II Trial

TIPS. Lancet 2009; 373:1341-51.

Blood Pressure Lowering in


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Blood Pressure Lowering in

TIPS

TIPS. Lancet 2009; 373:1341-51.


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Beyond BP Control: Statins

Cholesterol Lowering Trialists Collaboration. Lancet 2005;366:1267-78


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Benefits of Statins in Hypertension

Pleiotropic effects Anti-inflammatory

Anti-oxidant

Anti-mitotic

Anti-atherosclerotic

Vasculoprotective effects Endothelial function

Vasodilatory mechanisms Protective interleukins

Others


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Lipid Lowering in TIPS

TIPS. Lancet 2009; 373:1341-51.

B d BP C l


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Beyond BP ControlAspirin in Primary Prevention

Antithrombotic Trialists Collaboration. Lancet 2009;373:1849-60


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Beyond BP Control: Folic Acid

Miller ER, et al. Am J Cardiol 2010;106:517-27


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Polypill: Projected Benefits for CHD & Stroke

TIPS. Lancet 2009; 373:1341-51.


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Issues in High BP Management

1. Are there drug-specific benefitsbeyond BP lowering?

2. Are we trying to prevent end pointsor the disease process?

3. Most effective therapeutic strategy

to reduce overall CVD risk burden.4. Improving adherence to therapy.


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Prevalence, Awareness, Treatment and Control of

Hypertension in Indian WomenMulticentric DST Study (4 urban, 5 rural sites; n=4608)

46.2

28.6

0

5

10

15

20

25

30

35

40

45

50

Prevalence Awareness Treatment Control

Urban Rural

56.8

24.6

35.7

46.5 28.310.2

Gupta R, Pandey RM, Misra A, et al. 2011

The Rule of Thirds (1/3)

%


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Hypertension Prevalence, Awareness, Treatment

and Control Status in IndiaParsi Community Study, Bombay (n=2879)

0

5

10

15

20

25

30

35

40

Prevalence Awareness Treatment Control

Bharucha & Kuruvilla. BMC Pub Health 2003; 3:e1

36.4%

51.5%

63.6%13.6%

Treatment

Gap, 36.4%

Compliance

Gap, 86.4%


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Determinants of Poor BP Control in India

Compliance with treatment** (Odds ratio 6.1,CI 3.9-12.6)

Life stress (life event score, 4 vs. 1)**

Smoking

Alcohol intake High body mass index

Others Age, gender

Educational status

Occupation

Marital status

Socioeconomic status

Joshi PP, et al. J Hum Hypertens 1996; 10:299-303** significant


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Compliance with BP Medicines in UK

Practice

Vrijens et al. BMJ 2008;336:1114-7


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Contributing Factors for Noncompliance

Misunderstandings about the medicationregimen

Complexity of the medication regimen

Adverse side effects

Concerns about taking medications

Patientphysician relationship

Financial and social reasons

Thrall et al; J Human Hypertens 2004; 18:596-8


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Strategies to Improve Compliance

Pharmacological therapy in hypertension Simplifying the medication regimen

Appropriate drug selection dependent on patientcharacteristics

Improved patientphysician communication Appropriate education

Behavioral strategiesfor example, self-monitoringof BP, diary, memory cues, rewards

Social supportfor example, family, health-careworkers, physicians

Continual monitoring of patient compliance by thephysician

Thrall et al; J Human Hypertens 2004; 18:596-8


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ABCDE Algorithm in HypertensionOur modification

Younger 50 yr

Step 1 A or B (if sympathetichyperactivity)

Mono A and/or C

Step 2 A (or B) + C or D orboth

Two Add D

Step 3 A or B, C and/or D, addE

Multidrug

A and C, and/or D, add Bor E

Concomitant

therapies

Statins Statins

A= ACE inhibitors/angiotensin receptor blockers; B= beta blockers;

C= calcium channel blockers; D= diuretics;

E= extra drugs (central adrenergic agonists, direct vasodilators, alpha blockers, etc)

Gupta & Guptha. Ind J Med Res 2011; In press.


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Improving Management in Primary Care

Integrated approach to prevention and management. Public policies are important, eg, tobacco control,

salt.

Opportunistic case finding for risk factorassessment, early disease detection, and

identification of high risk status

Combination of pharmacological and psychosocial

interventions, in a stepped care fashion needed.

Long term follow-up with regular monitoring, and

promoting adherence to treatment.

Beaglehole R, et al. Lancet 2008; 372:940-9


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Conclusions Hypertension is highly prevalent in India. There is

low awareness, treatment and control status.

Treatment is best achieved with combination of

lifestyle measures and drugs.

Two-drug combination is best option for BP control.

Global CVD risk reduction is required to prevent

events in all patients with hypertension.

Addition of statins (and NOT aspirin or folic acid) toconventional BP therapy is useful for risk reduction.

Compliance and adherence to treatment is a

major issue.


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1.18

2.04

2.58

1.59

0.5

1

1.5

2

2.5

1990 2000 2010 2020

No. in Millions

Million Death Study

1.9025-30%

GBD 1997 Projections

THANKS

Download - Kolkata Final API 2010

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