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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