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Welcome, Dear Friends

Welcome, Dear Friends. Pardons and Grants me heaven Even if I don't know a single letter about Crutz Feld Jacob’s Disease Tsutsugamushi Fever Criggler Nazzar Syndrome South American equine encephalitis and Many and much more rarer topics BUT ……. The Almighty.

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Welcome, Dear Friends

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  1. Dr.Sarma@works

  2. Dr.Sarma@works Welcome, Dear Friends

  3. Dr.Sarma@works Pardons and Grants me heaven Even if I don't know a single letter about Crutz Feld Jacob’s Disease Tsutsugamushi Fever Criggler Nazzar Syndrome South American equine encephalitis and Many and much more rarer topics BUT ……. The Almighty

  4. Dr.Sarma@works Will drag me to hell and will not pardon My ignorance of even the minute details of HT My indifference to apply the current knowledge My negligence in screening for HT, TOD My despondency about preventing TOD My inadequacy in maintaining my patients as normo-tensive as possible – (This is applicable to all common diseases) The Almighty

  5. Treatment of Hypertension A CLINICAL APPROACH Dr.Sarma RVSN, M.D., M.Sc (Canada) Consultant Physician and Chest Specialist, # 5, Jayanagar, Tiruvallur – 602 001 93805 21221, (044) 27660593

  6. Treatment of Hypertension A CLINICAL APPROACH Management of Hypertension Based on the latest recommendations of JNC VII, ISH, ESH, WHO

  7. Globally Renowned HT Societies • JNC VII – Joint National Committee on HT, USA • ISH – WHO International Society on HT • AHA – American Heart Association, USA • ACC – American College of Cardiologist • BHS – British Hypertension Society • NIHLB – National Inst. Heart Lung & Blood vessels • EHS – European Hypertension Society • CHS – Canadian Hypertension Society • NKF – National Kidney Foundation, USA • AKA – American Kidney Association, USA

  8. What is new in Hypertension?

  9. The Truth is HYPERTENSION What we record as B.P. It is only a marker of the bigger problem Hypertension is a multi-organ systemic disease The Problem is Hypertension is asymptomatic in 85% of cases

  10. The Truth is How to be wise in HT? It is wrong To consider Hypertension as an isolated disease Hypertension, DM, Dyslipidemia, Obesity often coexist They are the 4 pallbearers to the grave of CHD, CVD For all of them Primary and secondary prevention by TLC is the answer Afflicted with one, must be screened for all other thieves

  11. The Truth is Treatment Goal Goal BP Keep B.P. < 140/90 mm Hg in each patient This may be revised to 120/80 may be ? 110/70 MRFIT’s cut off values are 115/75 mm Hg It is essential to keep the B.P at or below the goal But, It also matters how the goal B.P. is achieved !

  12. As per JNC VII and ISH (WHO) 2004 What is normal B.P ? What is pre hypertension ? Definitions As per JNC VII and ISH (WHO) 2004 Normal SBP < 120 and DBP < 80 Pre HT SBP 120 to 139 mm Hg DBP 80 to 99 mm Hg

  13. What is stage 1 HT ? What is stage 2 HT ? Definitions Stage 1 SBP 140 to 159 DBP 90 to 99 Stage 2 SBP 160 and more DBP 100 and more

  14. JNC VII Classification

  15. Are the values same for Diabetics , CKD? Definitions No, for DM, IHD and CKD the criteria are more stringent The cut off values are 10 mm lower Stage 1 SBP 130 to 149 DBP 80 to 89 Stage 2 SBP 150 and more DBP 90 and more

  16. 25 DM 20 non-DM 15 Events/1000pt-years 10 5 0 <90 <85 <80 Target diastolic BP Hypertension Optimal Treatment (HOT) Study Reduction in CV events p=0.005 (DM) Lancet 1998; 351: 1755–62

  17. What is this rule of halves in HT ? Rule of Halves • For every 800 adults in the community • 400 are HT (either ↑ SBP or ↑ DBP or both) • Of them only 200 are diagnosed HT • Of them only 100 are started on treatment • Of them only 50 are on correct drug • Of them in only 25 the goal B.P. is attained • Means 25 ÷ 400 = 6% only have goal BP

  18. Under control (40%) (7.5% of the total hypertensives) Hypertensives (22%) Uncontrolled hypertension (60%) Normotensives (78%) How many are really Dx. and Rx.ed ?? Diagnosed HT Under treatment (50%) Un Rx. HT 37% 63% Undiagnosed HT A study from Europe on 23,339 patients

  19. Dr.Sarma@works Global Hypertension Control

  20. What is ISH ? – What percentage of 65+ aged have ISH ? Which is more harmful – ↑ SBP or DBP ? Why is ISH important ? Isolated Systolic Hypertension

  21. Relative prevalence of SBP and DBP 40 + yrs ISH S&DHT DHT Normal

  22. R R for CVD - SBP and DBP

  23. ISH is universal after 65+ Persons who are normo-tensive at age 55 have a 90% lifetime risk for developing HTN.

  24. 20 Stroke 15 Myocardial Infarction 10 5 0 HT- RR of stroke and MI Normotensives Hypertensives 5 Year Risk (%) 40 80 240 280 20 60 220 260 0 100 200 300 140 180 120 160 Systolic Blood Pressure (mmHg) Brown, M.J. Lancet 2000; 355: 659 - 660

  25. Is SBP more dangerous or DBP ?

  26. What is ISH ? – SBP 140+ , DBP < 90 What percentage of 65+ aged have ISH ? More than 90% Which is more harmful – ↑ SBP or DBP ? Of course ↑ SBP Why is ISH important ? Because of ↑↑ CVA and CHD mortality Isolated Systolic Hypertension

  27. Do you think we can control most of the patients of hypertension with – One drug Two drugs Three drugs Can’t control For adequate control of B.P. In most of the patients of hypertension Two drugs are required for adequate control More so if the initial BP is 20/10 above the goal

  28. Gone are the days of monotherapy It is the era of combination therapy Why is it so? Today’s Paradigm

  29. What are the so called CHD risk factors ? What are known as CHD risk equivalents ? What is Framingham risk score ? CVD Risk Factors

  30. Dr.Sarma@works Global Risk Profile and HT 25)

  31. HT combined with other CHD RF Framingham offspring study, subjects aged 17 – 84

  32. What are the so called CHD risk factors ? List discussed in previous slide What are known as CHD risk equivalents ? DM, PVD, CVA, Nephropathy, Retinopathy What is Framingham 10 CHD risk estimate ? 10 yearCHD risk estimate based on age, sex, smoking, TC, HDL, SBP, Rx. for HT see the program CVD Risk Factors

  33. Why is there TOD in HT ? What are the organs targeted for damage ? What is the basis of TOD ? What tests we need to do to assess HT ? Target Organ Damage

  34. Diseases Attributable to Hypertension Stroke Coronary heart disease Heart failure Cerebral hemorrhage Myocardial infarction Left ventricular hypertrophy Hypertension Chronic kidney failure Aortic aneurysm Hypertensive encephalopathy Retinopathy All Vascular Peripheral vascular disease Adapted from: Arch Intern Med 1996; 156:1926-1935.

  35. Target Organ Damage (TOD) • Heart • Left ventricular hypertrophy (LVH) • Angina or prior myocardial infarction (CHD) • Prior Coronary revascularization PTCA or CABG • Heart failure (Systolic / Diastolic dysfunction) • Brain • CVA Stroke or Transient Ischemic Attack (TIA) • Kidney : Chronic kidney disease and CRF • Vessels : Peripheral arterial disease PVD • Eyes : Hypertensive Retinopathy

  36. Dr.Sarma@works Atherosclerosis – Time line

  37. Endothelial NO Balance NO

  38. Target Organ Damage - Assessment • Routine Tests • Electrocardiogram, Echocardiography (desirable) • Urinalysis for proteinuria, Microalbuminuria • Blood glucose (F and PP), and Hematocrit • Serum Na and K, Creatinine or GFR, Calcium • Lipid Profile complete, Eye examination, ABI • Optional tests • X-Ray Chest PA • 24 hr. urine albumin excretion or ACR • More extensive testing is notgenerally indicated

  39. Why is there TOD in HT ? It is a disease of blood vessels. What are the organs targeted for damage ? Heart, brain, kidney, eye, peripheral vessel What is the basis of TOD ? ED, Arterial stiffness and Atherosclerosis What tests we need to do to assess TOD ? List discussed Target Organ Damage

  40. Paradigm Shift in HT Therapy It is not just ↓B.P. TODAY we must strive to • Alter the modifiable risk factors • Keep the SBP < 140 and DBP < 90 • Prevent or halt or reduce TOD – • LVH, CHD, CHF, CVA, CRF, PVD & Retino. • Prevent or control DM (as HT + DM is hazardous) • Prevent or control Dyslipidemia (Endothelial Dysf.) • Reduce morbidity and mortality • Improve QUALY – Quality Adjusted Life Years

  41. What is single most imp. predictor of CHD, HF, Death ? What time course of HT to LVH to LVF to death ? Can LVH be regressed at all ? Will drugs help to regress LVH and ↓TOD ? How important is Micro-albuminuria ? Target Organ Damage

  42. Normal weight 350 to 450 g

  43. Dr.Sarma@works Transverse Section of HEART - LVH 10 mm 25 mm

  44. Dr.Sarma@works Echocardiography of Heart - LVH

  45. ECG and Left Ventricular Hypertrophy

  46. Chest PA view of Heart - LVH C/T ratio > 50%

  47. Progression of HT to LVH to HF

  48. 1.00 0.99 Nomotensive-No LVH 0.98 Hypertensive-No LVH 0.97 Portion Surviving Normotensive-LVH 0.96 0.95 Hypertensive-LVH 0.94 0.93 0 2 4 6 8 10 12 14 16 18 Survival Time (Years) Survival Rate HT + LVH v/s NT + LVH Source : Am Hear J, 2000; 140 (6) : 848-856.

  49. Can LVH be reduced at all ?? LVH is the Single Most important predictor

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