The Global Burden of Disease

The scale of the problem

Leading Causes of Death and Disability (DALY’s)

Rank Cause % Rank Cause %

1 Lower respiratory infections 8.2 1 Ischemic heart disease 5.9

2 Diarrhoeal diseases 7.2 2 Major depression 5.7

3 Perinatal conditions 6.7 3 Road traffic accidents 5.1

4 Major depression 3.7 4 Cerebrovascular disease 4.4

5 Ischemic heart disease 3.4 5 COPD 4.2

6 Cerebrovascular disease 2.8 6 Lower respiratory infections 3.1

7 Tuberculosis 2.8 7 Tuberculosis 3.0

8 Measles 2.7 8 War 3.0

9 Road traffic accidents 2.5 9 Diarrhoeal diseases 2.7

10 Congenital abnormalities 2.4 10 HIV 2.6

1990 2020

Global Burden of Disease Study, 1996

*

**

*

World Health Report 2002

Mortality due to leading global risk factors

Prevalence of ‘Hypertension’ by different cut points

0

5

10

15

20

50 60 70 80 90 100 110 120 130

Diastolic BP, mmHg

% o

f sc

reen

ed p

opul

atio

n

90 = 25.3%

95 = 14.5%

100 = 8.4%

105 = 4.7%

110 = 2.9%

115 = 1.4%

British Hypertension Society Guidelines for hypertension management 2004

(BHS-IV): summary

Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davies, Gordon T McInnes, John F Potter, Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the British Hypertension Society

BMJ Volume 328 13 March 2004 634-640.

BHS Guidelines

DefinitionsMeasurement

Risk assessmentEvaluation of hypertensive patients

Thresholds for interventionTreatment goals

Lifestyle measuresChoice of therapy

Meta-analysis of trials ABCD rule

Aspirin and statinsFollow up and implementation

Classification of blood pressure levels of the British Hypertension Society

Category Systolic blood pressure

(mmHg)

Diastolic blood pressure

(mmHg)

Blood Pressure

Optimal <120 <80

Normal <130 <85

High normal 130-139 85-89

Hypertension

Grade 1 (mild) 140-159 90-99

Grade 2 (moderate) 160-179 100-109

Grade 3 (severe) >180 >110

Isolated systolic hypertension

Grade 1 140-159 <90

Grade 2 >160 <90

Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device

• Use of properly maintain, calibrated, and validated device

• Measure sitting blood pressure routinely: standing blood pressure should be recorded at least at the initial estimation in elderly or diabetic patients

• Remove tight clothing, support arm at heart level, ensure arm relaxed and avoid talking during the measurement procedure

• Use of cuff of appropriate size

Continued

• Lower mercury column slowly (2mm per second)

• Read blood pressure to the nearest 2 mm Hg

• Measure diastolic blood pressure as disappearance of sounds (phase V)

• Take the mean of at least two readings, more recordings are needed if marked differences between initial measurements are found

• Do not treat on the basis of an isolated reading

Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device

Potential indications for the use of ambulatory blood pressure monitoring

• Unusual variability of blood pressure

• Possible white coat hypertension

• Informing equivocal treatment decisions

• Evaluation of nocturnal hypertension

• Evaluation of drug resistant hypertension

• Determining the efficacy of drug treatment over 24 hours

• Diagnosis and treatment of hypertension in pregnancy

• Evaluation of symptomatic hypotension

Cardiovascular risk assessment

Lifestyle measures

• Maintain normal weight for adults (body mass index 20-25kg/m2)

• Reduce salt intake to < 100mmol/day (<6g NaCI or < 2.4 g Na+/day)

• Limit alcohol consumption to < 3 units/day for men and < 2 units/day for women)

• Regular physical exercise (brisk walking rather than weightlifting) for > 30 minutes per day, ideally on most days of the week but at least on three days of the week.

• Consume at least five portions/day of fresh fruit and vegetables

• Reduce the intake of total and saturated fat

Thresholds and treatment for antihypertensive drug treatment

• Drug treatment should be started in all patients with sustained systolic blood pressures > 160mmHg or sustained diastolic blood pressures > 100mmHg despite non-pharmacological measures (A)

• Drug treatment is also indicated in patients with sustained systolic blood pressures 140-159mmHg or diastolic blood pressures 90-99mmHg if target organ damage is present, or there is evidence of established cardiovascular disease or diabetes, or if there is a 10 year cardiovascular disease risk of > 20% (B)

continued

Thresholds and treatment for antihypertensive drug treatment

• For most patients a target of < 140mmHg systolic blood pressure and <85mmHg diastolic blood pressure recommended (B). For patients with diabetes, renal impairment or established cardiovascular disease a lower target of < 130/80mmHg is recommended

180/110 160-179100-109

140-159 90-99

130-139 80-89

<130/85

160/100 140-159 90-99

<140/90

ReassessYearly

Re-measurein 5 years

Treat

Treat

Initial Blood Pressure

SEE NEXT SLIDE

140-159 90-99

Target organ damage orCVS complications or Diabetes or CV event risk 2%/year[>20% over 10 yrs ]

No target organ damageand

No CVS complicationsand

No diabetesand

CV event risk < 2%/year[<20% over 10 yrs ]

Treat Observe Reassess CV risk yearly

Drug treatment of hypertension

Diuretic

Beta-blocker

Calcium-channel blocker

ACE-inhibitor

(Alpha-blocker)

Angiotensin receptorblocker

Most hypertensives will need 2 drugs to control BP

Drug combinations may be synergistic

STROKEComparisons of different active treatments

RR (95% CI) Favours first listed

Favours second listed

0.5 1.0 2.0Relative Risk

BP difference(mm Hg)

1.09 (1.00,1.18) ACE vs. D/BB

0.93 (0.86,1.01) CA vs. D/BB

1.12 (1.01,1.25) ACE vs. CA

2/0

1/0

1/1

CORONARY HEART DISEASEComparisons of different active treatments

RR (95% CI)

Favours first listed

Favours second listed

BP difference(mm Hg)

0.5 1.0 2.0Relative Risk

0.96 (0.88,1.05)

1.01 (0.94,1.08)

0.98 (0.91,1.05)

ACE vs. CA

CA vs. D/BB

ACE vs. D/BB 2/0

1/0

1/1

HEART FAILUREComparisons of different active treatments

RR (95% CI)

Favours first listed

Favours second listed

BP difference(mm Hg)

0.5 1.0 2.0Relative Risk

1.07 (0.96,1.19)

ACE vs. CA

CA vs. D/BB

ACE vs. D/BB

1.33 (1.21,1.47)

0.82 (0.73,0.92)

2/0

1/0

1/1

MAJOR CARDIOVASCULAR EVENTS Comparisons of different active treatments

RR (95% CI)

Favours first listed

Favours second listed

BP difference(mm Hg)

0.5 1.0 2.0Relative Risk

ACE vs. CA

CA vs. D/BB

ACE vs. D/BB

0.97 (0.92,1.03)

1.04 (0.99,1.08)

1.02 (0.98,1.07)2/0

1/0

1/1

ALLHAT Design

High riskHypertensive

Patients42,515

Randomize

AmlodipineChlorthalidoneDoxazosinLisinopril

10,362 eligible forLipid lowering

Not eligible forLipid lowering

Randomize

Pravastatin Usual CareStudy completion January

2003

ALLHAT Primary Endpoint: CHD Death and Nonfatal MI

Relative Risk (95% Relative Risk (95% CI)CI)

FavorsFavorsChlorthalidoneChlorthalidone

Amlodipine 0.98 (0.90-1.07)Amlodipine 0.98 (0.90-1.07)

0.70.7 1.31.3

Lisinopril 0.99 (0.91-1.08)Lisinopril 0.99 (0.91-1.08)

Favors AmlodipineFavors AmlodipineFavors LisinoprilFavors Lisinopril

ALLHAT Collaborative Research Group. ALLHAT Collaborative Research Group. JAMAJAMA. 2002;288:2981-2997.. 2002;288:2981-2997.

High-riskHypertensive

High-riskHypertensive

Eligible forLipid Lowering

Atorvastatin10 mg

Atorvastatin10 mg

PlaceboPlacebo

Randomize DB

ASCOT: PROBE Design

Randomized

Amlodipine Perindopril

Doxazosin GITs

Atenolol Bendrofluazide Doxazosin GITs

Not Eligible forLipid Lowering

Expected Mean Follow-up: 5 Yrs

Fatal CHD + Non-Fatal MI

Expected Mean Follow-up: 5 Yrs

Fatal CHD + Non-Fatal MI

19342

10305

0

1

2

3

4

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Years

Cu

mu

lati

ve

Inc

ide

nc

e (

%)

36% reduction

HR = 0.64 (0.50-0.83)

Atorvastatin 10 mg Number of events 100

Placebo Number of events 154

p=0.0005

ASCOT study: Effect of atorvastatin on CHD

ASCOT study: Effect of atorvastatin on stroke

0

1

2

3

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Years

Cu

mu

lati

ve

Inc

ide

nc

e (

%)

27% rreduction

HR = 0.73 (0.56-0.96) p=0.0236

Atorvastatin 10 mg Number of events 89

Placebo Number of events 121

The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs

Younger (e.g.<55yr)and Non-Black

Older (e.g.55yr) or Black

Step 1

Step 2

Step 3

Step 4Resistant Hypertension

Add: either -blocker or spironolactone or other diuretic

A: ACE Inhibitor or angiotensin receptor blocker B: - blockerC: Calcium Channel Blocker D: Diuretic (thiazide)

A (or B*)

A (or B*)

A (or B*) C or D

C or D +

+ +C D

Adapted from: ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 8186

* Combination therapy involving B and D may induce more new onset diabetes compared with other combination therapies

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs

% of hypertensives with controlled BP

USA1

27%

England2

6%

<140/90 mm Hg

Canada3

16%

Australia4

19%

Zaire4

2.5%

India4

9%

Scotland4

17.5%

Spain4

20%

Finland4

20.5%

<160/95 mm Hg

Adapted from Mancia, 1997

Other medication for hypertensive patients

Primary prevention

(1) Aspirin: use 75mg daily if patient is aged >50 years with blood pressure controlled to <150/90mmHg and; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies cardiovascular disease risk chart)

(2) Statin: use sufficient doses to reach targets if patient aged up to at least 80 years, with a 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies risk chart) and with total cholesterol concentration >3.5mmol/l

(3) Vitamins – no benefit shown, do not prescribe

Secondary prevention (including patients with type 2 diabetes)

(1) Aspirin: use for all patients contraindicated

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration >3.5mmol/l

(3) Vitamins – no benefits shown, do not prescribe

Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg

Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg

Impact of structured algorithm